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

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2 Specialties Rehabilitation medicine Special clinics: examples of these include:– young adults clinic– prosthetic amputee rehabilitation clinic– specialised wheelchair and/or seating clinic– environmental control assessment clinic– spasticity clinic– incontinence clinic– diagnosis-specific clinics, eg MS clinics. Specialist investigative and therapeutic procedureclinics: these include clinics for botulinum toxin,phenol blockade and gait analysis.Specialist on callA consultant may be on call for inpatients one in two orone in three nights, but is unlikely to need to come intothe hospital more than once a month.Other specialist activity including activitiesbeyond the local serviceConsultants in RM often link with appropriatespecialties,aslistedinsection4.Clinically related administrationIn RM, assessments are complex; clinics often involveletters to numerous services and agencies, whichrequires at least half the duration of the clinic inaddition to the clinic itself. At least 1 PA per weekshould be allocated for administration.Consultants in RM participate in negotiating fundingfor complex care packages and liaising with primarycare trusts, social services and others. Reports onphysical and mental capacities, employment, benefits,insurance, etc, are also frequently required.Community workConsultants in RM increasingly undertake outreach ornetwork-based activity to support specialist teams inthe community. Activities include: MDT meetings (including interagency liaison) outreach clinics home visits (1 PA for 3 or 4 visits) scheduled visits to specialist nursing homes.wide-ranging needs, the practice of RM exemplifiesinteragency communication and cooperation.Vocational rehabilitation entails close relationships withother agencies, including employers.8 Workforce requirements: clinical andsupport staffCurrent consultant and trainee numbersThere are 177 whole-time equivalent (WTE) RMconsultants. 1 More than 90% of RM consultants areemployed full time. Development of new consultantposts is proving difficult due to current pressures tomeet government spending targets.There are about 65 specialty trainee (ST) posts in UK.National training numbers (NTNs) have remainedstatic although in common with other medicalspecialties RM is facing under-recruitment to STposts. This has implications for future consultantposts.Estimated requirement for consultantsThe BSRM recommends a minimum of 1.5 WTEconsultants per 250,000 of the population, including0.9 WTE consultants for inpatient and outpatientservices and 0.6 WTE consultants for communityprovision. This requires 195 WTE consultants forEngland (233 for the UK), which is an increase ofapproximately 32% on current numbers. Additionalconsultants are required for patients with highlycomplex needs. Current numbers are thus little over halfof what is required. Over a 10-year period, RM hasshown the second highest expansion rate at about 150%(Census 1993 to Census 2003), 31 but the currentshortfall remains urgent. Developing new consultantposts is in line with the National service framework forlong-term conditions (Quality Requirements 4, 5 and6). 5 The NSF also stipulates the need for networks ofservices that are close to patients’ homes for patientswith highly complex disabilities. In some parts of theUK (especially metropolitan areas) such networks havedeveloped to reflect a mix of ‘complex specialised’,district specialist and local general services.7 Opportunities for integrated careConsultants in RM have exceptionally well-developedlinks with community health and social services.Because people with complex disabilities haveNon-medical workforceThere is a parallel requirement for non-medical staff, asan RM consultant cannot practise effectively withoutaccess to appropriate numbers of specialist nurses,therapists and clinical psychologists.C○ Royal College of Physicians 2013 209
Consultant physicians working with patientsTable 1 Example of a job plan (England)Activity Workload Programmed activities (PAs)Direct clinical careInpatient ward rounds 20 inpatients 1 per ward roundReferrals 10–12 patients per week 1–2 (more if offsite travel is required)MDT meeting/case conference, etc Variable 2–4Outpatient clinics, including specialisedclinics45–60 mins per new patient and30–45 mins for follow-up patients1 per clinicOutreach work from base hospital Variable 1–2 (more if this is a key focus ofthe role)Work in another specialty Not often required –Work in general medicine/acute take Not often required –Work in academic medicine Few academic appointments 0–4 (more for formal academicappointments)Clinical administrationTotal number of direct clinical care PAsSupporting professional activities(SPAs)Work to maintain and improve thequality of healthcareOther NHS responsibilities ∗External duties ∗Clinic-related and outreachadministrationEducation and training, appraisal,departmental management and servicedevelopment, audit and clinicalgovernance, CPD and revalidation,researchFor example, medical director/clinicaldirector/lead consultant inspecialty/clinical tutorFor example, work for deaneries/royalcolleges/specialist societies/Departmentof Health or other government bodies, etc1–27.5–8.5 in most contracts2.5 in most contractsLocal agreement with trustLocal agreement with trust∗ Note: rehabilitation medicine is a small specialty with fewer consultants to service the same number of roles for colleges, deaneries and Departmentof Health, etc. These will take more time per consultant than in larger specialties.9 Consultant work programme/specimenjob planTable 1 broadly indicates activities, a specimen job planand the relevant number of PAs.10 Key points for commissioners1 Rehabilitation medicine is an underused resourcethat prevents hospital admissions and reducesunneeded expenditure and length of stay duringadmissions. It is key in delivering major traumanetworks and the NICE guidelines on criticalillness.2 Commissioning discussions will be hampered untilrehabilitation elements of healthcare are unbundled.Payment for specialist rehabilitation must reflect thecomplexity of patient needs.3 The BSRM recommends a minimum of sixconsultants per million population to provideboth inpatient and community services, whichrequires a 50% increase in current consultantnumbers.210 C○ Royal College of Physicians 2013
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