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1 Physicians in the NHS todayNationally they may include roles in the followingorganisations: medical royal colleges GMC Care Quality Commission Departments of Health National Institute for Health and Care Excellence(NICE) British Medical Association (BMA) National Clinical Assessment Service (NCAS).Supporting staff and facilitiesAll consultants require an office base with secretarialsupport and a pager or mobile phone. Some also needcomputer and internet access at home for results thatmay include radiology.The details will vary according to the specialty.‘Hot-desking’ and computer-sharing can function wellin some situations; the real question is whether thearrangements enable high-quality work.Some specialties work closely with scientists, specialistnurses and therapists, all of whom contribute to theextended clinical team and high-quality patient care.These staff often have additional skills contributing tomanagement, research teaching and audit.Doctors work very closely with nursing colleagues onthe hospital wards. It is essential that there is strongclinical leadership for the overall care of patients, andthat accountabilities are clear. A nurse should be presenton the ward rounds conducted by consultants, toensure that all issues are addressed. 22 Futuremanagement plans for patients need to be discussedbetween doctors and nurses, as well as other membersof the healthcare team and the patient, with excellentcommunication, so that everyone is working towardsthe same goal.Physicians have a duty to keep good records and tocollect clinical information so that it can be used formonitoring their own performance and that of theteam, thus leading to improvements in care. Accurateinformation also enables better planning andmonitoring of services. This information must beaccurately coded and the aggregate results fed back toclinicians so that they can work to improve care topatients. The accurate collection and coding of clinicalinformation needs a partnership between physicians,coding and information staff, with adequateadministrative support.The changing medical workforceOver the past few years the medical specialty workforcehas undergone quite dramatic changes and the comingyears are likely to be as tumultuous, albeit in a differentway. The consultant body has continuously increasedand 11,810 doctors are employed as consultantphysicians across the UK according to the RCP’s 2011census. 23 This expansion has been as a result of hugefinancial investment into the health structure of theUK which has given hospitals the freedom to developtheir services. Acute medicine has grown considerablyin this period of time (82.1%) with a total of 295consultants, which reflects the importance of thespecialty and the increased need for acute physicians bymost UK hospitals. Stroke medicine has grown the most(160 current consultants), although this was notdifficult as there were only seven self-declared strokespecialists in 2007.The consultant workforce remains predominantly malealthough this predominance is steadily changing witheach year, as the large female trainee workforce attainsconsultant posts. There is a wide variation in theproportion of female consultants between specialties,from 9.6% in clinical pharmacology and therapeutics to71.3% in palliative medicine. The proportion ofconsultants working less than full time is 16.6%, anincrease from the previously recorded 13.2%, whichmay well reflect the increasing female consultant bodyand therefore may well continue to rise.There remains a considerable difference between largeand small medical specialties and between differentregions in England, and the different nations of the UKin terms of successful appointments of consultant posts.Most specialties have no problem appointingconsultants in the south-east of England but thisbecomes harder in other parts of England, Wales andNorthern Ireland. Many smaller specialties are currentlystruggling to fill both consultant posts and trainingposts and these specialties need to be carefullymonitored and planned nationally.The number of specialty registrars has remained steadyat 6,726 with 48.1% being female (with a wide variationbetween specialties).The large number of specialtyC○ Royal College of Physicians 2013 9
Consultant physicians working with patientsregistrars has significant implications for the future ofthese doctors. If all attain their CCT, taking on average 7years to do so, consultant expansion would have to be6–8% to accommodate them. However, it seems veryunlikely in the current financial climate that consultantexpansion will continue at the same pace as it has donefor the past few years and already there are considerableconcerns about the creation of a new grade of specialist,instead of traditional consultant posts. Diabetes andendocrinology have already seen a problem with theirtrainees getting posts and in some parts of the UK overa third of trainees have left the country once they haveobtained their CCT.The national framework for specialist workforceplanning has also changed considerably in England overthe past few years with the creation of the Centre forWorkforce Intelligence (CfWI) to replace the WorkforceReview Team. This organisation is an informationsource to allow workforce planning locally, but despitegood intention there remains considerable anxietyabout the quality of the data on the current workforce,let alone the models used to plan the future workforce(which do not take into account financial constraint).The medical specialties, the RCP and the CfWI need towork together over the next few years to ensure thatuniform data are used and that sensible predictions aremade to plan training numbers.Since the last edition of Consultant physicians workingwith patients, the European Working Time Directive(EWTD) has come into full force for junior doctors,reducing the number of hours that can be worked perweek to a maximum of 48. This has had a major impacton the provision of healthcare by doctors in hospitalsacross the UK and has cancelled out any benefit thatcould have been gained by the increased size of theworkforce. Furthermore, the restrictions that theEWTD has applied have resulted in the loss of on-callworking for most junior doctors and the creation of fullshift rotas for nearly all bar consultants. It is interestingto note the impact this has had on consultants such that,in the 2011 census, 23 42.5% reported that they often hadto do jobs that would have previously been done byjunior doctors.New arrangements are coming into force in Englandfor specialist commissioning and for local educationand training boards. Together with the huge savingsthat are needed over the next few years, the medicalspecialty workforce will also face considerabledifficulties.Within the next few years the UK will, for the first time,become self-sufficient for medical graduates. With thiscomes the ability to fulfil the aspirations of achieving aworld-class NHS with a highly trained and motivatedmedical workforce.The future medical service will be consultant deliveredrather than consultant led. In some of the very acutespecialties this raises the possibility of full-shift workingand round-the-clock presence of a consultant. This isbecause consultant-delivered care is better for patientsand the hours worked by junior doctors are reducingsubstantially as a result of the EWTD and new trainingrequirements for doctors in training. The EWTDreduced the working week of the junior doctor from56 hours to 48 hours in 2009. There is a requirementnow for more structured teaching programmes fordoctors in training, with 4 hours of protected teachingtime each week and additional time for formalassessment and feedback, which takes a further hour ofboth the junior doctor and the consultant. The NewDealwasnegotiatedbytheBMAtogiveadequateresttime for junior doctors and to structure rotas aroundthe 56-hour working week. The rotas are now 48 hoursaweek.The consequence of these reductions of junior doctors’hours of work has been that they are less in evidenceduring the day and at night. The result of these changeshas been a gradual erosion of the consultant-led team ofjunior medical staff. This has had effects on access totraining and to continuity of care for patients. Oneparticular concern is that the wards during the day maynot have adequate junior doctor cover, if the juniormedical staff are on night rotas at that time. There aremoves to renegotiate the New Deal, to increaseflexibility. There are also discussions in Europe aboutchanging the application of the EWTD to juniordoctors. No one wants to see a return to fatigued juniordoctors working very long hours, but delivering trainingand good-quality patient care is proving to be verydifficult with the current inflexible arrangements abouthours of work.The workload of the medical registrar has become veryheavy and changes need to be made to have moredoctors on the wards and dealing with the emergencyintake (www.rcplondon.ac.uk/sites/default/files/future-medical-registrar 1.pdf).Moves to community care and the development ofTeams without walls, 24 which encompasses new10 C○ Royal College of Physicians 2013
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