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2 Specialties Respiratory medicinemembers to take on leadership roles to develop systemsof respiratory care for local communities.Research – clinical studies and basic scienceThe specialty has an excellent track record forundertaking multicentre clinical research and continuesto encourage respiratory specialty trainees to take timeout of their training programmes to undertake researchprojects. With the changing research governance and tocorrect the long-term underfunding of both basic andclinical lung research, the UK Respiratory ResearchCollaborative (UKRRC) has been formed by the BTS,lung charities, research funding bodies and otherrespiratory professional societies, to prioritise andfacilitate translational lung research and build researchcapacity. Research training fellowships have alreadybeen appointed. An active respiratory specialty group ofthe UK Clinical Research Network has been establishedto encourage and facilitate research.Specialty and national guidelinesThe BTS has been at the forefront of guidelineproduction for more than 25 years. Guidelines arewritten in accordance with the BTS’s manual forguideline production, and the BTS guidelineproduction process was awarded NICE accreditation in2011. The BTS guidelines are based on availableevidence and adhere to the AGREE criteria(www.agreetrust.org). They are regularly updated andare available to download free from the BTS website(www.brit-thoracic.org.uk). As part of the BTScommitment to drive service improvement andpromote excellent patient care, BTS quality standardswill be produced for each BTS guideline, to provide aconcise set of markers of good practice. The first BTSquality standards document for bronchiectasis waspublished in 2012. 5Quality tools and frameworks, including nationalclinical strategyThe BTS provides an excellent web-based audit toolsystem, which has recently been revised and updated.National audits by the BTS are included on the list forinclusion in Quality Accounts in England, approvedaudits and regular newsletters, and National AdvisoryGroup for Clinical Audit and Enquiries (NAGCAE), andan annual audit report can be downloaded from thewebsite. Different areas of practice are audited in acyclical fashion; areas covered in 2012 included adultand paediatric asthma, adult and paediatriccommunity-acquired pneumonia, adult NIV,emergency oxygen, COPD discharge and bronchiectasis(www.brit-thoracic.org.uk/audit.aspx). The BTS is amajor partner in the next national COPD audit whichwill run from 2013. This new national audit, which willbe coordinated by the RCP, builds on previousinfluential national audits of COPD and COPD peerreview (www.rcplondon.ac.uk/resources/nationalcopd-audit-programme-starting-2013).In addition,the BTS, jointly with the RCP, has undertakeninfluential national audits of COPD and COPDpeer-review learning exercises in collaboration with theHealth Foundation (National COPD Resources andOutcomes Project (NCROP)).An outcomes strategy for COPD and asthma in Englandwas published on 18 July 2011. This long-awaitedstrategy identified six objectives that will drive work totransform respiratory care: better prevention of COPD,reducing premature death from respiratory disease,improving quality of life, improving safe and effectivecare, reducing the impact of asthma, and reducinginequalities in access to and quality of services. 6 ANICEtechnology appraisal on CPAP for the treatment ofobstructive sleep apnoea and hypopnea syndrome waspublished in 2008, 7 and the specialty was involved inupdating NICE’s COPD guidelines in 2010. 86 Clinical work of consultantsThis section includes an overview of clinicalprogrammed activities (PAs) required in respiratorymedicine for a nominal catchment population of aDGH of 250,000.Respiratory physicians have responsibilities for therespiratory health of the local population, as well as theindividual patient. Clinical PAs therefore need to use theknowledge and skills of hospital clinicians to servepopulations, as well as the patients referred to them.Models by which clinical leadership is included in jobplans and funded by commissioners already exist, andthere is an increasing need for respiratory leadershiproles to be formally recognised as clinical activities(sometimes referred to as knowledge and networkmanagement according to Right Care definitions). Thiswork may account for 1–2 PAs of a lead consultant’sworkload.Inpatient workConsultants usually undertake at least twospecialty-based ward rounds per week (2 PAs). Eachward round generates its own share of additionalC○ Royal College of Physicians 2013 229
Consultant physicians working with patientsadministrative duties, including discharge-planningmeetings, meetings with relatives and dischargesummaries (0.5–1 PA).Daily specialist visits are becoming increasinglynecessary because of the need for urgent specialistadvice to be available consistently to MAUs to enablerapid turnover and triage and to support medicalhigh-dependency units (HDUs). This is likely to involveeach consultant in an additional 0.5 PA per week.In addition, most respiratory physicians have a majorcommitment to acute general medicine. Duties includeward rounds to review patients on the day of admission(at least twice daily) and usually a ward round the nextmorning to review patients who have been admittedovernight. This may require one further PA in additionto on-call PAs.Each consultant team should have no more than 20–25inpatients under their care at any one time, includingwhen cross-cover is needed for leave. Respiratory wardsoften manage patients with a high need for expertmonitoring, management and consultant input,including those stepped down from the intensivetreatment unit (ITU). The maximum inpatient load forconsultants should be halved when such patients areincluded. A DGH of this size typically generates10 ward referrals per week to respiratory medicine fromother specialties, and 0.5–1 PA needs to be set aside forthis.Respiratory physicians who attend weekly meetings ofthe MDT require 0.5 PAs, and those with specific servicelinks (such as with critical care and thoracic surgeonson a transplantation service) will need pro-ratarecognition of PAs in their job plan.Outpatient workA DGH serving a population of 250,000 people typicallygenerates 900 new non-cancer respiratory referrals peryear. On the basis of consultants seeing 2–4 follow-uppatients for every new patient (the trend recently istowards the lower figure), the number of consultantclinic sessions available per year and the time for patientadministration to support the clinic, a total of 11–12PAs per respiratory department is required forrespiratory clinics.In addition, consultants may need to follow up about10–16 general medicine patients per week as theircontribution to the acute take and the general medicalservice. Most consultants only have time in their jobplan to offer two (to three) outpatient clinics a week(1 PA each) for specialty referrals, general medicalreferrals and follow-up appointments.New patients should be allocated 30 minutes forconsultant appointments and follow-up patients15 minutes (longer if trainees, medical students ornurse-led clinics are working alongside the consultantand for patients with complex respiratory problems).Based on a 4-hour clinic, a maximum of four new andeight follow-up patients can be seen per consultant.Experienced trainees (such as specialist registrars(StRs)), associate specialists and experienced staff-gradedoctors should see fewer patients. More junior traineesat foundation year 2 (F2) or core medical training(CMT) grade should attend the clinic for training andshould not be allocated extra patients.Specialist investigative and therapeuticprocedure servicesBronchoscopyMost respiratory physicians undertake onebronchoscopy session each week (1 PA), which shouldaccommodate no more than six bronchoscopies andfewer if complex procedures such as transbronchialbiopsy, pleural biopsy or drainage are added or if juniordoctors are being trained.Medical thoracoscopyThis service is growing in usefulness as it can increasediagnostic yield and reduce thoracic surgical workload,but it is demanding and requires an additional 0.5–1 PAper week, with 2 patients per session.Sleep-related breathing disordersThis is a rapidly developing area that has beenhighlighted by the publication of the National Institutefor Health and Care Excellence’s (NICE’s) technologyappraisal of CPAP. 7 Growth is likely to continue for theforeseeable future, as best estimates suggest that nomore than one in four patients with symptomaticobstructive sleep apnoea/hypopnoea syndrome(OSAHS) in the UK has so far been identified. A sleepservice will require anything from 1 PA to 7 PAs perweek, depending on the complexity of the service andthe number of patients. As a guideline, an averagedepartment in a DGH that serves a population of about500,000 and that has about 500 new referrals perannum, 200 new patients on CPAP per annum and a230 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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