Consultant physicians working with patients - Royal College of ...

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2 Specialties Geriatric medicineDay hospitalsA high-turnover day hospital might expect to see 600new patients a year in a 30-place unit. Each consultantshould expect to have responsibility for around 12–15patients at any one time. The consultant should holdinterdisciplinary case conferences every one to twoweeks.Services beyond the base hospitalThese may include clinics at other hospitals, outreachclinics, domiciliary work and hospice work.Work to maintain and improve the quality of careThis work encompasses duties in clinical governance,professional self-regulation, continuing professionaldevelopment (CPD) and education, and the training ofothers. For many consultants at various times in theircareers, it may include an educational role, research,clinical management and provision of specialist adviceat local, regional and national levels.The BGS has produced detailed guidance on clinicalgovernance and the amount of time that is required tofulfil these requirements. Generally, a lead clinician inclinical governance needs one session of PA, whileparticipation in clinical governance would needabout 0.25 PA. This does not include any timerequired for revalidation, CPD or participation inappraisal, which are mandatory activities for allconsultants.Leadership roles and development of the serviceDepartments of geriatric medicine are expected to takean active role in the development of services for olderpeople in primary and secondary care. Such work fordesignated individuals should be recognised in thejob-planning process, alongside other managementduties such as running the department and takingresponsibility for the delivery of teaching, clinicalgovernance and the research agenda for a group ofgeriatricians.Academic geriatric medicineAcademic geriatricians usually make a significantcontribution to the NHS service for older people buthave fewer clinical PAs to allow for universitycommitments, which include teaching and research.Their job plans should reflect this mix of university andNHS work. Consultant geriatricians teach not onlyundergraduate medical students but also otherdisciplines. Many NHS geriatricians teach andundertake research when there is no academicdepartment. All academic and NHS geriatricians have aresponsibility for the postgraduate training of higherspecialist trainees in geriatric medicine, whichculminates in the award of a Certificate of Completionof Training (CCT).7 Opportunities for integrated careThere is a growing awareness of the scope for geriatricmedicine to integrate throughout healthcare services.As referred to in other sections, the importance ofgeriatrician involvement in other areas of communitycare, such as care homes rather than just the traditionalcommunity hospitals, is becoming apparent. The newterm ‘interface geriatrics’ describes the ability toperform a comprehensive geriatric assessment at thefront door of the general hospital to ensure that an olderperson is placed appropriately in order to receive thecare they need. This might be in an acute medical bed,accommodation within a community facility, or care athome with either domiciliary or early outpatient careand therapy.Geriatrician involvement with older orthopaedicpatients has been shown to improve both mortality andmorbidity, and there is clear scope for similarinvolvement to be extended throughout any surgeryfor older people, whether elective or emergencyprocedures.8 Workforce requirements for the specialtyIn 2009, there were 1,205 consultant geriatricians; anincrease of 8.5% on 2008. Half of the workforce aged50 years and under was female compared to 20% forconsultants aged 55 years and over. In the next fiveyears, it is expected that 12.4% of all consultants willreach 65 years and are likely to retire. The majority ofconsultants (86.2%) work full time. The averagenumber of PAs per week was 11.5, with the actualnumber of PAs worked being 12.4.The number of trainee posts stood at 508 in 2009,a drop of 15 from 2008. Just under half (49.6%) oftrainees were women and 34% of all trainees hadchildren. The impact of the European Working TimeDirective has been mixed, with 63.7% of traineesreporting a reduction in the quality of training but37.4% saying it has improved their work balance. Theaverage frequency of on-call work was one in 10 forweekdays and one in 11 on weekends.C○ Royal College of Physicians 2013 123
Consultant physicians working with patientsThe ratio by which the population is served by awhole-time equivalent (WTE) consultant geriatricianvaries considerably across the country – from the lowestratio in Wales, Yorkshire and Humber, and Scotland,with one geriatrician per 46,000 of the population,compared to the highest ratio of 76,000 to 86,000 in theEast and West Midlands. 7To care for the population older than 75 years, the BGShas recommended that there should be a minimum ofone WTE geriatrician per 50,000 population (one WTEfor 4,000 people older than 75 years), although thenumbers needed are likely to increase further with theincreasing age and frailty of the population.9 Consultant work programme/specimenjob planTable 3 provides an example of a consultant job plan.10 Key points for commissioners1 Providing excellent care for older people results inexcellent care for younger patients; the converse israrely true.2 Geriatrician input early in a patient’s hospitalstay (in the A&E department or clinical decisionunit) leads to better care in the best environmentfor that person. This could be at home withsupport, in a community setting, or in the acutefacility.3 Geriatric medicine is the parent specialty forstroke, and the vast majority of post-strokerehabilitation is undertaken by geriatricians withan interest in the condition.4 Improved and increased levels of care taking placein the community cannot be achieved withoutteams led by geriatricians working closely withprimary care and other providers.Table 3 Example of a job planActivity Workload Programmed activities (PAs)Direct clinical careAcute ward rounds (including interdisciplinarymeetings and interviewing relatives)Rehabilitation ward rounds (includinginterdisciplinary meetings and interviewing relatives)20–25 patients 2–320 patients 1–2Intrahospital liaison or domiciliary visits 0.5General or geriatric medicine clinicNumbers will depend on casemix and theavailability of specialty trainees1.0Specialist clinic, day hospital, other subspecialty work 1.0Post-take ward round or on-call work 1.0Patient-related administration 1.0Total number of direct clinical care PAs7.5–9.5 on averageSupporting professional activities (SPAs)Work to maintain and improve the quality ofhealthcareOther NHS responsibilitiesExternal dutiesEducation and training, appraisal,departmental management and servicedevelopment, audit and clinicalgovernance, CPD and revalidation,researcheg medical director, clinical director, leadconsultant in specialty, clinical tutorwork for deaneries, royal colleges,specialist societies, Department of Healthor other government bodies, etc2.5 on averageLocal agreement with trustLocal agreement with trust124 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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