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

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2 Specialties DermatologyTable 1 Example of job plan (England)Activity Workload Programmed activities (PAs)Direct clinical careWard rounds, day-care supervision, nurseclinic supervision, ward referrals inhospitals with contractual agreementsGeneral outpatient clinicsReferrals from hospital colleagues;inpatient bed numbers vary12 for new clinic (20 min/consultation) or16 follow-ups (15 min) or combination0.5–1.53–4Skin surgery 7 cases of average complexity 0–1Skin cancer multidisciplinary team Weekly or alternate weeks 0.5–1Dermatopathology Variable 0–0.5On-call duties Variable 0–1Administration and managementSpecialist clinics‘Choose and book’, direct patient care,review of results, communication withother, healthcare professionals (0.4 perclinic or surgical list)eg paediatric, patch testing,phototherapy, psoriasis, skin cancer2–2.50–2Travel Variable 0–1Total number of direct clinical care PAs7.5 on averageSupporting professional activities(SPAs)Work to maintain and improve thequality of healthcareOther NHS hospital responsibilitiesExternal dutiesRevalidation, undergraduate education,nurse, GP and hospital doctor trainingand supervision, appraisal educationalsupervisor or programme director forspecialty registrars; departmentalmanagement and service developmentaudit and clinical governance CPD andrevalidation, research, etcMedical director/clinical director/leadconsultant in specialty/clinical tutorWork for deaneries/royalcolleges/specialist societies/DH or othergovernment bodies2.5 on average (1.5 minimum forrevalidation if no teaching/research/trainee supervision/departmentmanagement)Local agreement with trustTime for this has been agreed by NHSleadersof 989 (WTE) dermatologists, indicating a shortfall ofover 250 WTE dermatology consultants.Reductions in clinic numbers are required forconsultants supervising and training other doctors andmedical students. The impact varies (typically onepatient slot/individual) but may mean up to a 30%reduction in patient numbers.9 Consultant work programme/specimenjob planThe work programme/specimen job plan discussed hereis for a consultant dermatologist working in a districtgeneral hospital. The standard contract for a full-timeNHS consultant is 10 PAs per week, typically dividedinto 7.5 PAs for direct patient care including ward workC○ Royal College of Physicians 2013 87
Consultant physicians working with patientsand 2.5 PAs for supporting activities (SPAs) (7:3 ratio inWales).The balance of formal clinics, surgery, specialist clinics,ward work and supervisory activity will vary. Directpatient contact time must be accompanied byappropriate clinical administration time (1 clinical PArequires 0.4 PA administration time).Numbers in clinics should be adjusted to ensurecompletion within 4 hours (3.75 in Wales), includingclinic teaching and immediate clinical administration.The BMA and the RCP give 2.5 SPAs (3 in Wales) as the‘typical’ requirement, with 1.5 typically needed for thepurposes of revalidation. Additional time is required fortraining, the lead dean stating that StR supervisionrequires 0.5 SPA and FY1/FY2 supervision 0.25 SPAweekly. New jobs should detail the proposed SPAs andexisting consultants may need to justify SPAs at the jobplan review.Work for national bodies should be acknowledged andprogrammed and may require a negotiated reduction inthe clinical elements of the job plan. On-callcommitments will vary with local policies and staffinglevels. Those working part-time or in academic postsmust revalidate. Adequate SPA time must, therefore, beavailable while maintaining a sensible balance in apart-time contract. Hospital consultants involved inteaching and research need additional time for theseactivities, which will reduce the clinical elements of thejob plan.10 Key points for commissioners ofdermatology services1 Dermatology care should always be delivered byindividuals with the right skills, in the right setting,the first time.2 Patients offered choice should receive fullinformation about the qualifications, accreditationand range of services offered by providers.3 Dermatologists manage diseases of the skin,hair and nails in adults and children. As over2,000 conditions are recognised, accuratediagnosis is fundamental to successfulmanagement.4 Each year 54% of the population are affected byskin disease, and 23–33% at any one time havedisease that would benefit from medical care. 1,2 5678910References123Skin cancer is the most common cancer and thesecond most common cause of death in youngadults. Basal cell carcinoma numbers equal allother malignancies combined and increased by81% between 1999 and 2010. 3 Reportedmelanoma incidence increased by 50% over13 years. 4Consultant dermatologists see over 1,000 newpatients per year and provide expert management,leading and training an MDT of dermatologynurses and GPs working across traditionalhealthcare boundaries. Efficiency of consultants ismaximised by support and teamwork withspecialist nurses and secretaries, optimisingcommunication with the public and otherpractitioners.Thereisnoevidencethatintermediatecareindermatology saves money or reduces referrals tosecondary care, although such services may bepopular with patients. 7,8 There are DH documentson GPwSI training and governance that should befollowed for patient safety. 1 DH training andgovernance guidance (2010–11) for GPwSI surgeryfor low-risk skin cancers should be followed.Teledermatology may be a useful triage tool forgeographically remote areas but only as part of anintegrated consultant-led team subject to fullclinical governance; there is no evidence that it cansafely reduce referrals outside this setting. 16Dermatology consultants should not work inisolation but with consultant colleagues with arange of subspecialist skills.The British Association of Dermatologists clinicalservices unit (www.bad.org.uk)providesclear,evidence-based guidance 19 andisabletoadvisecommissioners about dermatology services andhelp resolve issues.Schofield JK, Grindlay D, William HC. Skin conditions inthe UK: a health needs assessment. 2009.www.nottingham.ac.uk/scs/divisions/evidencebaseddermatology/news/dermatologyhealthcareneedsassessmentreport.aspx [Last accessed 26 January 2013].Proprietary Association of Great Britain and ReadersDigest. A picture of health: a survey of the nation’sapproach to everyday health and wellbeing.London:Proprietary Association of Great Britain, 2005.Levell NJ, Igali L, Wright KA, Greenberg DC. Basal cellcarcinoma epidemiology in the UK: the elephant in theroom. Clin Exp Dermatol 2013; Mar 18.doi:10.1111/ced.12016.88 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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