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2 Specialties Palliative medicine– explicit standards for interval between referraland first assessment consultants in palliative medicine providing:– early medical review with sufficient time forthorough review and dedicated administrativesupport– rapid links to other relevant disciplines– 24-hour medical advice for colleagues incommunity and hospital MDTs with core specialists in palliative medicine,nursing, physiotherapy, occupational therapy andsocial work evidence-based clinical management with efficientinformation technology (IT) systems, and access tomedical notes and results of investigations efficient and effective communication andcollaborative working relationships within core andwider teams clinical audit and research programmes to evaluatetreatments and outcomes education and training programmes for continuingprofessional development (CPD) of own staff andothers patient and family involvement in managementplans and discussions about preferred place of careand death support for carers and families through illness intobereavement.In addition, specialist inpatient palliative care unitsshould have: adequate number of dedicated beds adequate medical staffing at all grades, includingout-of-hours cover trained specialist palliative care nurses with highnurse:patient ratio (UK average: 1:1.5) appropriate equipment for care of weak, cachecticand debilitated patients – eg pressure-relievingmattresses, electrically operated beds and chairs,easily operated nurse-call systems and assistedbaths/showers space for private interviews/counselling sessions,prayer, reflection and faith rituals comfortable sitting area for patients and visitors,with self-catering/overnight facilities dedicated space for viewing the deceased person.Clinical facilities should be integrated whereverpossible. The physical proximity of inpatient, outpatientand community teams and day-care facilities promotesgood communication and efficient use of consultantexpertiseandtime.Whereaservicecoversawidegeographical area, outlying beds or day-care units maybe provided in community hospitals with support fromspecialist palliative care.In acute hospitals, there needs to be private space forconversations, comfortable seating for patients andfamilies, self-catering/overnight facilities and near-wardteaching facilities. Drugs should be administered anddispensed promptly to avoid long waits for weakpatients. Adequate arrangements should be in place forrapid communication with the GP and communitynurses when a patient is discharged or dies.A national specialist palliative care peer-reviewedprocess is being tested at present. 9 A quality standardfor end-of-life care was published by the NationalInstitute for Health and Care Excellence (NICE) inNovember 2011, consisting of 16 quality statementswhich collectively describe a high-quality end-of-lifecare service. 10Maintaining and improving the quality of careService developments to deliver improved careHigh-quality services need to be responsive to patients’needs, efficient in use of resources, collaborative inrelationships with other services and continuouslyvigilant in maintaining standards of care through audit,teaching and research. Service developments include: joint clinics/MDTs in oncology and heart failure,respiratory, renal and neurological medicine access to 24-hour health and social care for palliativecare crises leadership and strategic innovation within localtrusts, including education, evaluation and research implementing end-of-life care and advance careplanning tools: integrated care pathways for thedying, Gold Standards Framework and PreferredPriorities for Care, or equivalent workforce planning.Education and trainingWork in this area includes: development of consensus syllabus forundergraduate palliative medicine 11 development of specialty curriculum, certificateexamination and assessment framework with theRoyal College of Physicians (RCP) development of a report on professionaldevelopment in end-of-life care for physicians 12C○ Royal College of Physicians 2013 191
Consultant physicians working with patients regular educational events, sometimes incollaborationwiththeRCPortheRoyalSocietyofMedicine (RSM) leadership of e-learning programme for end-of-lifecare (e-ELCA: www.e-elca.org.uk) 13 guidance on clinical governance, outcome measuresand audit mentoring scheme for new consultants training programmes for specialty trainees andspecialty doctorsResearchThere are relatively few academic departments inpalliative medicine. Research in this group of vulnerablepatients with a high attrition rate is difficult, yet anevidence base in this clinical area is crucial. Research isrequired in the efficacy and cost-effectiveness ofpalliative care interventions, models of care andtranslational research.The APM science committee runs a trainingprogramme in critical appraisal and research methodsfor the specialty. Increasing numbers of specialtyregistrars (StRs) and consultants in palliative medicineare achieving higher research degrees. A network ofAPM research champions support new researchersacross UK and Ireland.Specialty tools and national guidelinesNational guidance involving palliative care has appearedin a number of influential publications. 14–21 Reportsof relevance to the specialty include the NationalConfidential Enquiry into Patient Outcome and Death(NCEPOD), 22 the National Audit Office report 23 andGold Standards Framework After Death Analysis. 24 TheNational End of Life Care Intelligence Network, launchedin 2010, provides a focus for data relating to end-of-lifecare (www.endoflifecare-intelligence. org.uk).6 Clinical work of consultantsConsultants in palliative medicine provide clinicalleadership to specialist palliative care inpatient units,community and hospital palliative care teams, and daycentres. Their role includes: direct clinical care providing advice to primary and secondary carecolleagues attending site-specific cancer MDTs and forlong-term conditions, eg chronic obstructivepulmonary disease (COPD)Table 2 Programmed activities (PAs) contracted andworked (full-time consultants): Royal College ofPhysicians’ census 2011 25ActivityMean PAscontracted perweekAll activities 10.6 12.1Clinical PAs 7.1 7.6Supporting PAs 2.5 3.4Academic PAs 0.5 0.6Other PAs 0.5 0.5Mean PAs workedper weekPAs contracted and worked (less than full-timeconsultants): Royal College of Physicians’ census2011 25ActivityMean PAscontracted perweekAll activities 7.6 8.6Clinical PAs 5.4 6.0Supporting PAs 1.8 2.1Academic PAs 0.1 0.2Other PAs 0.3 0.3Mean PAs workedper weekNote: most consultants in palliative medicine play a greater role in thestrategic development of palliative care services locally than is commonin other specialties. A high percentage of (31%) 26 consultants inpalliative medicine work single-handedly, so they carry moreresponsibility for education, audit and research. running joint/parallel clinics with other specialists service development.Many are single-handed (31%). 26 Although traineenumbers have increased, palliative medicine remainsconsultant delivered and consultant led. Neither StRsnor consultants usually participate in the on-call rotafor acute general medicine.As outlined in Table 2, full-time consultants work anaverage of 48.4 hours (12.1 programmed activities(PAs)) and part-time consultants 34.4 hours (8.6 PAs). 25Consultant posts are often split between local districtgeneral hospitals (DGHs), tertiary hospitals,community services and specialist palliative care units(voluntary/NHS), with implications for cross-siteworking and travel. Considerable time is spent liaisingwith GPs and colleagues in primary and secondary care.192 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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