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

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2 Specialties HaematologyHaematologyDr Mike Galloway Consultant haematologist1 Description of the specialty Haematologists provide an interpretative andadvisory service based on laboratory results andHaematologists are both clinicians and laboratorydirect the appropriate referral of patients withspecialists who engage in the following activities:abnormal laboratory results within an acceptabletimeframe. This may involve providing support and working within a specialty clinical team, taking full written advice to the GP to allow care to be managedclinical responsibility for patients with a wide range in the primary-care setting.of haematological disorders (see Table 1) providing interpretation of laboratory results and Clinical serviceadvising other hospital clinicians and GPs on Clinical referrals come from primary, secondary orappropriate clinical managementtertiary care. The level of subspecialisation varies, and providing professional direction and having clinical many haematologists have a subspecialty interest inresponsibility for the haematology and transfusion addition to their commitment to laboratory and generallaboratoryhaematology. providing a laboratory, clinical and consultativeservice 24 hours a day.Haematological malignancyThe British Committee for Standards in HaematologyHaematologists undergo general professional training (BCSH) has defined three major levels of care for patientsin medicine followed by specialist training in all aspects with haematological malignancies (see Table 2). 2of clinical and laboratory haematology. Many undertake The National Institute for Health and Care Excellencea period in research. Most develop further expertise in (NICE) Guidance on cancer services recommendsone or more subspecialties.that patients with haematological cancers are managedby multidisciplinary haemato-oncology teams servingMain disease patternsa population of more than 500,000, with link networksTable 1 summarises main haematological disease between hospitals and that the treatment of acutepatterns and numbers of patients seen annually. leukaemia be limited to hospitals that treat at least fivepatients annually. 3 As a result, the number of units thatcan deliver the level 2b chemotherapy that is required for2 Organisation of the service and patterns patients with acute leukaemia has been reduced.of referralAll units that undertake stem cell transplantationA typical service(SCT), both autologous and allogeneic, are accreditedby JACIE, which is the Joint Accreditation Committee ofLaboratory service the International Society for Cellular Therapy (ISCT)The haematology laboratory provides a diagnosticand the European Group for Blood and Marrowand blood bank service to its host institution, whichTransplantation (EBMT).may include highly specialised investigations tosupport specialist clinical services. It also provides aHaemoglobinopathiesrange of tests for primary care, which may allowSickle cell disease and thalassaemia represent adiagnosis of a spectrum of haematological disease insignificant part of the haematologist’s workload in areasthe community. The source of specimen referralof the UK where the prevalence is high. In London,varies across hospitals, with the proportion ofsickle cell disease is now one of the most commonrequests from primary care ranging from 30% toreasons for admission to hospital and has the highest50%. 1 rate of multiple admissions for individual patients. 4,5C○ Royal College of Physicians 2013 127
Consultant physicians working with patientsTable 1 Incidence of haematological disease and numbers of patients seen annuallyPopulationDisease or treatment England and Wales Per 1,000,000 Per 500,000 Per 250,000Acute leukaemia 2,400 48 24 12CML 500 10 5 2–3CLL 4,000 80 40 20NHL – high grade 2,000 40 20 10NHL – low grade 5,000 100 50 25Hodgkin’s lymphoma 1,200 24 12 6Myeloma 3,000 60 30 15MDS, MPD and other 2,000 40 20 10Oral anticoagulant treatment 520,000 10,000 5,000 2,500Venous thrombosis 78,000 1,500 750 375Thrombophilia 2,600,000 50,000 25,000 12,500Symptomatic thrombophilia 30,000 600 300 150CLL = chronic lymphocytic leukaemia; CML = chronic myeloid leukaemia; MDS = myelodsyplastic syndrome;MPD = myeloproliferative disease; NHL = non-Hodgkin’s lymphoma.Patients require comprehensive care, which may includechronic transfusion programmes, iron chelation andfrequent hospital admissions for the treatment of sicklecrisis. National standards for the management ofpatients with haemoglobinopathies direct serviceswhich are delivered in the secondary and tertiary caresettings and in the community. Linked newborn andantenatal screening for haemoglobinopathy is aDepartment of Health (DH) initiative that requires adesignated lead clinician and careful links with obstetricclinics.Thrombosis and haemostasisThe care of patients with haemophilia and otherinherited bleeding disorders is organised throughhaemophilia comprehensive care centres usingmanagement guidelines produced by the UKHaemophilia Centre Doctors’ Organisation(UKHCDO) and the National Service Specification forBleeding Disorders. Patients require lifelong care, withinput from other disciplines including orthopaedics.A consultant haematologist in each hospital is oftenresponsible for supervising the control of oralanticoagulants (OACs). The consultant may also lead athrombosis service, directing a multidisciplinaryapproach to the management of the risk of thrombosisand the investigation and treatment of venousthromboembolism (VTE). This aspect of a consultanthaematologist’s work increased significantly during2010 following the development of national targets inEngland for VTE risk assessment that have been set inthe Commissioning for Quality and Innovation(CQUIN) payment framework and the publication ofthe NICE standards on the prevention of VTE.Transfusion medicineOne consultant haematologist is usually responsible forthe hospital blood bank and transfusion services. Theconsultant will be a member of the hospital transfusioncommittee, together with a specialist practitioner oftransfusion (SPOT) and the senior biomedical scientist(BMS) of the hospital blood bank. This team isresponsible for ensuring that appropriate policies andguidelines are in place to guarantee the safety of bloodtransfusion and the best use of blood to meet therequirements of British and European legislation.Hospital blood banks must ensure that all bloodcomponents can be traced accurately from donor torecipient.128 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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