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2 Specialties Palliative medicineA more detailed document on the role of the palliativemedicine consultant has been produced by the APM. 27InpatientsThere are 223 adult inpatient specialist palliative careservices in the UK (52 beds per million population: 26%funded by the NHS, the rest funded by the voluntarysector). 28 Patients with complex needs for symptomcontrol, major emotional distress and family problemsare admitted. The ratio of deaths to discharges is 1.22(mean stay 13.7 days). 1 Patients are admitted forterminal care if adequate support/complex needs fordyingathomecannotbemet.Inpatient units may sit in separate buildings in thegrounds of acute and community hospitals or asstandalone units. Most have 24-hour, non-resident,specialist medical cover. Some only admit duringworking hours because of lack of on-site out-of-hoursmedical cover. Most units provide 24-hour telephoneadvice for colleagues in the community and hospital.Hospital palliative care teams (346 in the UK 8 )offeranadvisory and supportive service without taking overcare from the patients’ primary physicians and hospitalteams. The service usually runs during daytime workinghours, with some running 7 days a week. Out-of-hourstelephone advice is usually accessed from specialistinpatient units.OutpatientsThree hundred specialist outpatient palliative careservices are provided in hospices, community hospitalsor hospitals. 29 Eighty-four per cent of new referrals havea primary diagnosis of cancer. Some 275 services offerday care, ranging from medical/nursing focused modelsto social or rehabilitative models. 28 Other servicesinclude bereavement support, lymphoedema clinics,creative therapies, counselling and complementarytherapies. See section 7 for community-based care.7 Opportunities for integrated careThe nature of palliative care requires integrated teamworking across primary and secondary health and socialcare. Palliative care for patients at home is provided byGPs and community nurses, with advice, whererequired, from community specialist palliative careteams. There are 291 specialist community teams in theUK. 28 On average, each team sees over 550 new patientsper year (mean length of care: 123 days). 1Consultants in palliative medicine typically offer sharedcare with GPs in the community. Support and advicefrom clinical nurse specialists may be supplemented byhands-on care from carers provided by social services orMarie Curie (or equivalent) nurses. In some areas,hospice-at-home services are offered, ranging fromrapid-response services to sustained hands-on care athome, eg the Delivering Choice Programme 30 and otherhybrid versions of hospice-at-home and specialistcommunity services. There are now 120hospice-at-home teams. 28 More data and evidenceabout the impact of these services will emerge over thenext few years. The Gold Standards Framework (GSF)provides a framework for palliative care provisionin the community by facilitating identification ofpatients on a GSF register, which triggers discussionabout these patients’ end-of-life care at regular practicemeetings. 31Education and training is regularly provided byconsultants in palliative medicine as a routine part oftheir work. This helps non-specialist health and socialcare colleagues to remain skilled and up to date inpalliative care. The e-learning programme forend-of-life care 13 provides opportunity for blendedlearning across the sectors.8 Workforce requirementsThe RCP’s 2011 census UK 25 identified a head count of474 consultants in palliative medicine: England 387,Wales 29, Scotland 42 and Northern Ireland 16. Ofthese, 71% were women, and overall 44.4% workedpart-time. In 2011, there was an 8.4% (10% in 2010)unfilled vacancy rate.Key factors in workforce planning include: ageing population: cancer, predominantly a diseaseof older people, is the commonest diagnosis inpalliative care referrals increasing referrals for non-malignant conditions(20–50% of referrals): comparable need in terms ofsymptoms and social and psychological issues asthose with cancer high proportion of female doctors: 71% ofconsultants and 84% of StRs significant proportion of less than full-timeworking: 44% of consultants and 38% of StRs a detailed survey (1997) demonstrated thatworkloads were too high to allow adequate time forC○ Royal College of Physicians 2013 193
Consultant physicians working with patientsTable 3 Consultant workforce requirementMinimum consultant requirement ∗WTEPer 62.2 million population (2011)UK 505England 424Wales 24.8Scotland 42Northern Ireland 14.4† Consultants required per 160,000residentsConsultants required per 120,000residents, assuming 30% ofconsultants work less than full time∗ Basedonthefollowingestimates:• 660 cancer deaths per year for population of 250,000• 462 referrals per year if 70% access to specialist palliative care• 554 referrals per year if 20% non-cancer referrals are included• 1.54 WTE required if one WTE sees 360 new patients per year(APM calculation).† Assuming consultants work full time, one consultant can support apopulation of 160,000. However, 30% of consultants work less than fulltime, in which case one consultant can support a population of 120,000.11Table 4 Work of palliative medicine consultantsgenerated by a population of 250,000 as PAs(4 hours)Activity Workload PAsDirect clinical careWard rounds 339 admissions/year 4–5Outpatients4 new patients/weekplus 1–6 follow-upsHospital referrals 2–6 patients/week 3–5Community referrals4–6 domiciliaryvisits/week22–3Day care Assessments 0.5MDT meetings∗ On-call and weekendward roundsTotal direct patientcareWard: 1/weekCommunity team:1/week2115–19CPD, audit, research and clinical governance, allnecessary for delivering high-quality services. 32Supporting professional activities (SPAs)Work to maintain andimprove quality6–8On the basis of calculations that include all thesefactors, there should be a minimum of one whole-timeequivalent (WTE) consultant in palliative medicine forevery 160,000 residents (1.56 WTE consultants per250,000 population) (see Table 3). Given the excessivehours that consultants currently work, the newconsultant contract (10 PAs/week) and restrictions ofthe European Working Time Directive (EWTD), a moreappropriate pragmatic final estimate would be 2 WTEsper 250,000 population. This would require 505 FTEconsultants across the UK (based on 2011 population of62.2 million) comprising for England (424 FTE), Wales(24.8 FTE), Northern Ireland (14.4 FTE) and Scotland(42 FTE). The Centre for Workforce Intelligence reportfor England (2011) based on the RCP 2010 consultantcensus estimated the supply of consultants for 2020 willneed to increase to nearly 600 FTE (681 headcount).9 Consultant work programme/specimenjob planService models vary. Consultant job plans usuallyincorporate more than one of the followingTotal 21–27∗ Generally the on-call commitment is onerous. 35 Many consultants arefirst on call for specialist inpatient beds (on-call ratio at least 1:4). Thosewho are single-handed may have second on-call rotas of 1:1. Sleep isinfrequently disturbed but workload for first on call during a weekend issignificant. Time off in lieu is rarely included in job plans.components: inpatient hospice, community, acutehospital and day care (see Tables 4 and 5).This job plan does not represent the workload carriedby the majority of consultants currently in post andemphasises that the most common current pattern, inwhich a single consultant carries responsibility for workacross all settings, is not sustainable.10 Key points for commissionersThe APM has produced commissioning guidance forspecialist palliative care, in partnership with a numberof other organisations. 33 This can help commissionersto achieve a number of wider commissioning goals,especially in relation to domains 2 and 4 of the NHSoutcomes framework and the national QIPP indicatorsfor end-of-life care. The data and evidence on which194 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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