Consultant physicians working with patients 5th edition - FSEM

Consultant physicians working with patients
for nearly all bar consultants. It is interesting to note the
impact this has had on consultants such that in the last
census, 21 59% reported that they were having to do jobs
that would have previously been done by junior doctors.
At the time of writing there are also plans to radically
change the structure of the NHS in England with
respect to commissioning of specialist services, locally
plan workforce requirements and thus local training
requirements. Together with the huge savings that are
needed over the next three years, the medical specialty
workforce will also face considerable difficulties in the
next few years.
Within the next few years the UK will, for the first time,
become self-sufficient for medical graduates. With this
comes the ability to fulfil the aspirations of achieving a
world-class NHS with a highly trained and motivated
medical workforce.
The future medical service will be consultant delivered
rather than consultant led. In some of the very acute
specialties this raises the possibility of full shift working
and round-the-clock presence of a consultant. This is
because consultant-delivered care is better for patients
and the hours worked by junior doctors are reducing
substantially as a result of the EWTD and new training
requirements for doctors in training. The EWTD
reduced the working week of the junior doctor from
56 hours to 48 hours in 2009. There is a requirement
now for more structured teaching programmes for
doctors in training, with four hours protected teaching
time each week and additional time for formal
assessment and feedback, which takes a further hour of
both the junior doctor and the consultant. The New
DealwasnegotiatedbytheBMAtogiveadequaterest
time for junior doctors and to structure rotas around
the 56-hour working week. The rotas are now 48 hours
aweek.
The consequence of these reductions of junior doctors’
hours of work has been that they are less in evidence
during the day and at night. The result of these changes
has been a gradual erosion of the consultant-led team of
junior medical staff. This has had effects on access to
training and to continuity of care for patients. One
particular concern is that the wards during the day may
not have adequate junior doctor cover, if the junior
medical staff are on nights rotas at that time. There are
moves to renegotiate the New Deal, to increase
flexibility. There are also discussions in Europe about
changing the application of the EWTD to junior
10
doctors. No one wants to see a return to fatigued junior
doctors working very long hours, but delivering training
and good-quality patient care is proving to be very
difficult with the current inflexible arrangements about
hours of work.
Moves to community care and the development of
‘Teams without walls’, 22 which encompasses new
relationships between specialists and GPs, will probably
require more and not less specialists coupled with new
contractual arrangements.
There is also an increased need to be aware of the health
of a local population and the incidence and prevalence
of particular diseases to best plan patient pathways
involving primary care and specialist care, as well as
public health medicine.
Changing delivery of medical care
The delivery of acute medical care has gradually
changed. The new specialty of acute medicine is
providing more of this service. The traditional role of
the consultant general physician in acute medicine has
reduced in recent years. However, the rising number of
medical admissions and the increasing number of frail
older people with a number of different conditions
means we have to think seriously about the best way to
care for the acutely ill medical patient and the best
balance between specialists and general physicians with
an interest in a specialty.
There is also a need for more specialist centres to give
highly specialised care to a population, eg thrombolysis
in stroke, because every hospital dealing with acute
medical admissions may not give this treatment. As
technology advances, there are merits in grouping
expertise together in specialised centres which cover a
bigger population than a local hospital. These
developments may drive the need for reconfiguration of
hospitals.
Working with patients
Patients, relatives and carers are knowledgeable. They
ask questions, and expect and require answers. They
want to be more involved in making decisions about the
pattern of their care. Many now communicate with
their doctors by text and email, asking questions derived
from internet searches. The doctor–patient relationship
C○ Royal College of Physicians 2011