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2 Specialties Immunology supervision of day-case clinics for infusion oftherapeutic antibodies (biologics) transition clinics for adolescents with primaryimmunodeficiency as they move from paediatric toadult services.The complexity of clinical referrals requires thatsufficient time is given to the assessment of patients atthe first consultation, which limits the number ofpatients who can be seen in a single outpatient session.A consultant immunologist working alone will typicallysee 5–10 (new and follow-up) patients in a singlesession, depending on the complexity of the patients’problems. An audit of primary antibody deficiency, andguidelines from UKPIN, suggest that a consultantshould be responsible for up to 100 patients withantibody deficiency in order to deliver optimum care. 11Specialist investigative proceduresConsultant immunologists are responsible for directingdiagnostic immunology services and perform a widerange of duties including clinical liaison, interpretationand validation of results, quality assurance, assaydevelopment, and supervision of biomedical andclinical scientists and StRs. Some consultants perform alimited amount of ‘hands-on’ laboratory work.In view of the work pressures on immunologists, CPAguidelines stipulate that a single consultantimmunologist should not support more than twolaboratories outside their base hospital at any one timeand the weekly off-site commitment to these should notbe more than two PAs (including travelling time).Driven by advances in laboratory technology and there-appraisal of the role of the physician in laboratorymedicine, 12 there is an increasing trend for integrationof significant parts of the conventional immunology testrepertoire in to multidisciplinary blood science or coreautomated laboratories. This initiative coupled withreconfiguration of pathology laboratories in line withthe Carter review 13 is likely to impact on the futurework patterns of immunologists by changing thebalance between laboratory and clinical activities.Specialist on callThe nature of on-call duties in immunology only rarelywarrants the out-of-hours attendance of consultantimmunologists. However, it is important that an on-callspecialist immunology service is available for thediscussion of clinical problems and emergencylaboratory investigations. The frequency of on-callduties for consultant immunologists will be determinedby the number of colleagues in a centre. Where possible,an on-call rota with a frequency of one in two or one inthree is recommended, although it is recognised thatconsultants who work single-handedly will havedifficulty with this arrangement. In such cases, thepossibility of forming a consortium with colleagues inadjacent regions to provide an acceptable level of covershould be explored.7 Opportunities for integrated careThe frequent requirement for multidisciplinary care forimmunodeficient patients who develop organ-specificcomplications has prompted immunologists to embraceenthusiastically the principles of integrated care acrossspecialties. The adoption of UKPIN accreditationstandards by many immunology centres has driven thedevelopment of protocols ensuring clear documentationof the clinical process and evidence-based managementguidelines underpinning the provision of integratedcare to patients with immunodeficiency.Participation in multidisciplinary clinics and/or teammeetings for patients with systemic autoimmunediseases and vasculitis are further examples ofintegrated care. Similarly, the principles of integratedcare have been applied to the investigation andfollow-up of patients with anaphylaxis followingattendance at accident and emergency departments.8 Workforce requirements for the specialtyCurrently, 60 consultant immunologists serve the entirepopulation of England and Wales.Limited data are available on the workload ofimmunologists, who are based mainly in teachinghospitals. Increasing awareness of immunologicaldiseases, coupled with the need to provide specialistadvice and direction to immunology laboratories,including those in larger DGHs, has placed atraditionally understaffed specialty with manyconsultants who work single-handedly under greatstrain.An estimate of the number of consultant immunologistsrequired in England and Wales is based upon the lastworkload survey undertaken by the RCPath, the RCPcensus and extensive consultation within theC○ Royal College of Physicians 2013 141
Consultant physicians working with patientsTable 1 Consultant work programme/specimen job planActivity Workload Programmed activities (PAs)Direct clinical careOutpatient clinics 5–10 patients per clinic 3–4New patientsFollow-up patientsIVIg infusion2–4 patients per clinic3–6 patients per clinic6–10 patients per clinicWard consultation and telephone advice 0.5Allergy, including desensitisation immunotherapy 1Laboratory workClinical liaison, interpretation of resultsQuality assuranceAssay developmentHands-on laboratory workSupervision of DGH immunology laboratoriesTotal laboratory work 3–4Total number of direct clinical care PAs7.5 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 tutoreg work for deaneries, royal colleges,specialist societies, DH or othergovernment bodies2.5 on averageLocal agreement with trustLocal agreement with trustspecialty. 14,15 The latest RCP census showed thatimmunologists worked an average of 12.5 PAs per week.This represents an excess of 10.8 hours worked abovecontractual obligations.Workforce requirements have been calculated on thebasis that most immunologists are based in teachinghospitals and the population served by existingconsultant immunologists is approximately40 million.Because there are insufficient data on immunologyworkload at DGH level, it is not possible to calculateworkforce requirements for a 250,000 population.Instead, the projected estimates are based on theassumption that each consultant will not be expected toexceed their contractual obligation of 10 PAs and noconsultant will have to practise on his or her own(currently 13% of consultant immunologists work ontheir own).On this basis, it is estimated that 105 whole-timeequivalent (WTE) consultants in immunology arerequired to serve the population of England and Wales(54 million). This translates into one consultantimmunologist per 514,285 population compared withthe existing provision of one per 0.9 million population.This is 0.31 WTE for 250,000 population, which is an142 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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