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2 Specialties Respiratory medicinecumulative follow-up population of 1,500 on long-termCPAP is likely to need: consultant medical staff (5–8 PAs) nursing, scientific and technical staff (3–4whole-time equivalents (WTEs)) secretarial and clerical staff (1 WTE).Ward NIV for acute respiratory failure (due toexacerbations of COPD)This service must be available in all hospitals andshould be led by a respiratory consultant. In mosthospitals, one lead consultant supervises the serviceand, depending on the number of patients who requireNIV, would require 1–2 PAs.Domiciliary assisted-ventilation serviceWith the introduction of domiciliary NIV for patientswith COPD, in addition to patients with neuromusculardisorders and morbid obesity, it is likely that thesessional commitment required for this respiratoryservice will increase significantly. As a starting guide,1 PA should be allocated to run the domiciliary servicefor every 50 patients, including 10 new patients per year.Pulmonary rehabilitation servicePulmonary rehabilitation is a highly effective service.It is provided largely by an MDT, including RNSs andphysiotherapists, with dietitians, occupationaltherapists, social services, pharmacists and otherhealthcare professionals having sessional inputs. Thelead supervising clinician may need to allocate 0.5 PAper week for this – or more if the consultant also takessome of the educational sessions or pre-assessmentclinics.Specialist on callUnfortunately, very few DGHs are able to providecontinuous specialist advice from on-call consultantphysicians in respiratory medicine, although specialistadvice is usually available.Other specialist activities, including activitiesbeyond the local servicesExamples of specialist services provided at a local levelinclude the following: Lung cancer: most respiratory physicians managepatients with lung cancer as part of their normal jobplan, but those who attend meetings of the MDTrequire 0.5 PA per week for this and at least another0.5 PA is needed for the local lead lung-cancerphysician who coordinates services. Delivery of therelevant quality standards for the respiratorymedicine department of a DGH with averagestandardised mortality ratio for lung cancer requires10 PAs. Critical care involvement: respiratory physicians areincreasingly involved in the very time-demandingsupervision of HDUs and the provision of NIVrespiratory support outside ITUs. TB services: in most trusts, patients with bothpulmonary and non-pulmonary TB are managed byone or two named respiratory consultants. Oneconsultant takes the lead for the service, includingtracing contacts, managing difficult andmultidrug-resistant cases, and coordinating the localTB service network. The lead clinician requiresdedicated PAs for this based on the number of localcases: 0.5 PA per week for 25 TB cases annually, 1 PAfor 50 cases annually and pro rata for increasingnumbers, as long as they are adequately supportedby TB RNSs (1 WTE per 50 cases) andadministrative support. Specialist clinics: many consultants offer dedicatedclinics for patients with, for example, difficultasthma, DPLD and bronchiectasis. If such clinics arein addition to their usual two to three clinics perweek, an extra PA is needed per clinic.Examples of specialist service provision for specifiedconditions at a regional or supra-regional level areshown below: Cystic fibrosis: the care of patients with cystic fibrosisis normally managed by large regional centres. TheCystic Fibrosis Trust recommends0.75 WTE of specialist consultant grade time per50 patients under full care, supported by a full rangeof supporting staff, including non-consultant careergrade (NCCG) doctors. 9 A respiratory physicianwith appropriate expertise may provide local care topatients with cystic fibrosis as the spoke of ahub-and-spoke model, with a large regional centreas the hub; that physician will require half of the PAallocation stated above, based pro rata on thenumber of cases. Lung transplantation: the five lung transplantationcentres are based in Birmingham, Harefield,Manchester, Newcastle and Papworth. Each centrerequires consultant physicians who specialise in theassessment and management of patients aftertransplantation. At least 5 PAs per week arenecessary.C○ Royal College of Physicians 2013 231
Consultant physicians working with patients Pulmonary vascular disease: thisisorganisedonasupra-regional basis, and all seven centres (six inEngland and one in Scotland) have been approvedby the National Specialist Commissioning AdvisoryGroup (NSCAG) or National Services Division(NSD) in Scotland. All centres have at least twoconsultants trained in pulmonary vascular diseasewhowillbeabletocommitupto50%oftheirtimeto the specialty. Occupational lung diseases: consultants who work insuch units will receive many tertiary referrals andwill require at least 3–5 PAs per week for thiscomplex work.7 Opportunities for integratedrespiratory careAlthough respiratory medicine provides a mainlyhospital-based service, job patterns involvingcommunity work are increasingly being developed, andconsultants in integrated respiratory care, who havesessions both within a hospital and in the widercommunity, have been appointed in some areas.Examples of community work include: development of care pathways to facilitate care closerto home clinical leadership for integrated respiratory careservices to ensure excellent multidisciplinary clinicalcare across the whole pathway leading local respiratory networks education of primary and intermediate carehealthcare professionals medical input into pulmonary rehabilitation,respiratory nursing services and hospital-at-homeand outreach services clinics in a non-hospital-based setting clinical responsibility for high-quality lung functionand oxygen assessment services assessing and managing patients with complexbreathlessness in the community promotion of better end-of-life care for those withsevere lung disease.8 Workforce requirements forthe specialtyTo provide a high-quality, patient-centred, specialistrespiratory service, as described above, a DGH thatserves a population of 250,000 people requires 7 WTEadult respiratory physicians, equating to 1,428 WTEs inEngland. This assumes that they also undertake on-callwork, are adequately supported by a team of otherrespiratory professionals, have adequate facilities andresources, and work under a direct clinical contract of7.5PAs.Manyunitsfallwellshortofthisnumber.Withdemands for a consultant-led and -delivered service,pressures from the European Working Time Directive,an ageing population and the changing workingpatterns of consultants (with more opting to work lessthan full time), it is estimated that 1.4 consultants willbe required to replace every one current WTE in futureyears.In November 2012, 976 consultants were working inrespiratory medicine in England and, despite financialpressures, the numbers of respiratory consultants hascontinued to increase. In the last quarter of 2012 therewere 641 respiratory trainees in England, roughly half ofwhom are female; 104 of these trainees were out ofprogramme (OOP) at that time. Training programmedirectors and others continue to actively support OOPactivity, but it is increasingly difficult to fill gaps thatthen remain in training programmes with LAT (locumappointment – training) doctors (only 12% ofrespiratory LAT posts were filled in 2012). In contrast tosome other specialties, with the feminisation of theworkforce, there has been little increase in thenumbers of trainees or consultants working less thanfull time.Respiratory physicians who responded to the RCP’scensus in September 2011 were contracted for anaverage of 10.8 PAs, but worked an average of 12 PAs perweek, the vast majority of which were clinical. 10 Withchanges in working patterns and the move toconsultant-delivered service, it seems that consultantexpansion needs to continue for several years to come,albeit at a slower rate than we have seen in recentyears.9 Consultant work programme/specimenjob planThe 10-PA job plan shown in Table 2 assumes that thecorrect number of WTE consultants is employed in thedepartment. As respiratory services are delivered byteams, individualised job plans – in terms of bothcontent and number of PAs worked – can easily beadapted from the 10-PA job plan on a proportionalbasis to accommodate flexible working.232 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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