Consultants prelims

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Consultants prelims

  1. 1. Dermatology 1 Description of the specialty and clinical needs of patients Dermatologists manage diseases of the skin, hair and nails in people of all ages. As over 1,000 conditions are recognised, accurate diagnosis is fundamental to successful management. High disease prevalence and low morbidity results in a large burden of skin disease, with estimates that about a quarter of the population are affected by skin disease that would benefit from medical care. Main disease patterns Inflammatory skin diseases are disabling, disfiguring, distressing and highly symptomatic. Chronic inflammatory skin diseases significantly reduce quality of life and impose a considerable burden within the community, impacting substantially on work, social interaction and healthy living. Skin disease is one of the most common reasons for injury, disablement benefit and periods of certified incapacity to work in the UK. Most dermatologists are skin surgeons as well as physicians, and lead the organisation and delivery of skin cancer services. Skin cancer is the most common cancer and an important cause of mortality in young adults. The numbers of basal cell carcinomas (BCCs) are equivalent to the total of all other malignancies and increased by 235% between 1980 and 1990. Melanoma is doubling in frequency every 10 years and resulted in 1,800 deaths in 2007, being more common than deaths from cervical cancer. 2 Organisation of the service and patterns of referral A typical service Approximately 15% of the population consults their GP each year because of a skin complaint. This high level reflects recent increases in the prevalence of conditions such as atopic eczema, venous leg ulcers and skin cancer. It also reflects the availability of effective treatments and patient demand for a specialist opinion. Recent government initiatives have promoted the delivery of care closer to home, with as much care as possible provided in intermediate and primary care settings. However, care should always be delivered by individuals with the right skills, in the right setting, the first time. The way in which services are provided will depend upon factors including local needs, geography, facilities and the availability of qualified staff. Patients requiring dermatological care are referred by their GP to secondary care or to a general practitioner with a specialist interest (GPSI) either directly or through a local Referral Management Centre (RMC) or Clinical Assessment, Treatment and Support Centres (CATS). Patients requiring further specialised care may be referred from secondary care to regional or national experts for treatment or specialised investigation. Hospital dermatologists also see and treat patients who are referred from within the hospital either as inpatients or outpatients. 116
  2. 2. 117 2 Specialties Dermatology Sources of referral from primary, secondary and tertiary levels Primary care services Most skin disease is managed within primary care, but the quality of care varies due to limited undergraduate and vocational training in dermatology. In primary care: q All patients should have rapid access to a healthcare professional with the skills to diagnose their skin disease and with referral protocols agreed between primary and secondary care. q GPs should be able to diagnose and manage the common skin disorders in their characteristic forms. q Patients with the common inflammatory skin disorders should receive education and care from a trained professional in a community setting. q After diagnosis, all patients with an ongoing skin disease should be cared for within local protocols for chronic disease management. Community specialist nurses can provide support for education and self-management of chronic inflammatory skin diseases such as psoriasis, eczema and acne in a community clinic. A practice of 5,000 patients will need at least 0.5 whole-time equivalent (WTE) practice nurses, who should work under the supervision of a named doctor and have links with dermatology nurses in secondary care. The community specialist nurse might provide: q disease information including access to patient support group(s) q treatment according to protocols and education in their use q easy access to further appointments or telephone advice q rapid access to a GP or consultant dermatologist in the event of treatment failure or acute deterioration. Community pharmacists can reinforce care and self-help messages at the point of dispensing. The skills of practice pharmacists, working under the supervision of a named doctor, should be utilised in the development of care plans, both generic and patient-specific. Secondary care services Hospital-based dermatology services receive approximately 700,000 referrals each year with referral rates between 10 and 21.8 per 1,000 population. Up to 50% of referrals relate to skin cancer and around 20% are for three major inflammatory diseases: eczema (dermatitis), psoriasis and acne. Unless there is substantial spending on facilities in the community, hospital-based services will continue as the most cost-effective and safe means of providing all elements of the dermatology service. These include: q facilities for dermatological surgery, meetings of multidisciplinary teams (MDTs) to review dermatopathology and management, data collection and analysis ensuring compliance of skin cancer management with the National Institute for Health and Clinical Effectiveness (NICE) guidance (2006) q care of medical dermatology outpatients with complex problems, sometimes in MDT clinics
  3. 3. q inpatient care of sick patients with severe skin diseases or skin failure, sometimes requiring access to intensive care facilities q phototherapy, iontophoresis, wound care and other day treatments q day-case units for infusion of disease-modifying drugs q paediatric dermatology services including laser surgery q investigation of cutaneous allergy q advice on the management of skin problems in patients admitted with other illnesses q skin cancer screening for organ transplant recipients q teaching, training and assessment of medical students, doctors and other healthcare professionals q collection and analysis of clinical data, clinical audit and compliance with clinical governance requirements q clinical research including therapeutic trials. Further, there is requirement for rapid-access skin cancer screening/treatment clinics. Dermatologists screen around 90% of those suspected of having cancers of the skin and treat approximately three-quarters of all skin cancers. The NICE Improving Outcomes Guidance (NICE IOG) for skin cancers recommends that high risk BCCs (the majority of cases) are treated in the secondary sector (www.nice.org.uk). Hospital-based services require approximately one consultant dermatologist and two dedicated dermatology beds per 100,000 population. Associate specialist and staff grade doctors form an integral part of the team in many hospital units. Departments require the support of pharmacists and trained specialist nurses who may: q treat patients in day-care units and on the wards, provide and supervise phototherapy (Psoralen and UVA treatment (PUVA) and ultraviolet (UVB)) light treatment, carry out contact allergy testing (patch testing) and care for wounds and chronic ulcers q provide information to patients, demonstrate and apply treatments, dress wounds, remove sutures or review follow-ups q assist in operating theatres and provide advice to patients undergoing surgery; some appropriately trained nurses perform skin biopsies or other surgical procedures such as cryosurgery q advise professional colleagues caring for patients with skin problems in the hospital and the community q provide outreach services for children with chronic skin disease q assist in training practice nurses q lead in the establishment and supervision of nurse-led clinics in primary care. Intermediate services Intermediate care clinics may be staffed by consultant dermatologists, non-consultant career grade (NCCG) doctors (who often work closely with consultant doctors in secondary care), GPSIs or specialist dermatology nurses. Such services should be developed in partnership with secondary care, be sustainable and be within a managed clinical network. New services should improve patient care and may reduce the need for hospital visits, but they should not reduce quality or safety. The cost effectiveness of such services should be evaluated as clinics provided by GPSIs can be more expensive than secondary care services.1 118 Consultant physicians working with patients
  4. 4. 119 2 Specialties Dermatology The service, the facilities and those delivering the service must meet national guidance for accreditation.2 GPSIs are expected to maintain their professional development by attending regular sessions in a local hospital dermatology department and by holding a joint clinic with the consultant at least once a month for the discussion of difficult cases. A trained specialist nurse might support the self-management of mild chronic inflammatory skin diseases such as eczema and psoriasis in intermediate care. The nurse should receive support at least once a month from a medical specialist (accredited GPSI or consultant dermatologist). An intermediate care service may include: q diagnosis and immediate or longer-term management q skin surgery (in line with local priorities and NICE IOG for skin cancer) q telephone advice for local GPs q support for dermatology specialist nurses working in the community. Locality-based and/or regional services CATS, which may be run by private companies or the NHS, are being introduced with the aim of triaging GP referrals and reducing workload in secondary care. Referral protocols should be agreed between primary and secondary care, but guidelines or protocols cannot replace clinical acumen and ‘reading between the lines’. Those triaging dermatology referrals must have the skills to recognise the urgency of the problem and the management required or patient safety will be compromised. The British Association of Dermatologists (BAD) recommends that GP referrals are always triaged by consultant dermatologists.3 CATS should only be established after consultation with all stakeholders, including those in secondary care and the public. Without engagement at all levels, CATS may merely introduce an additional tier of care, reduce patient choice and quality of care and destabilise local NHS hospitals. 3 Working with patients: patient-centred care Involving patients in decisions about their treatment Involving patients in decision-making about their care can be improved by adequate time for consultations with specialist doctors and nurses and the provision of high-quality written or web-based information. Some interactive programmes have been developed which could be made available to patients in hospital departments or GP surgeries. Education and self care: q Short videos about skin disease, treatments and phototherapy are readily available. Access to, and time with, a health professional to discuss the information received are required. q Patients should be involved in service planning through local forums involving both hospital trusts and primary care trusts (PCTs). q Day treatment units and nurse-led clinics are important areas of access to practical advice and training on effective self-therapy.
  5. 5. q Self re-referral for treatment or advice during the relapse of chronic inflammatory skin diseases such as psoriasis and eczema would facilitate self-management. q Dedicated telephone consultation times with specialist nurses can be valuable. Patient support groups Information about relevant patient support groups should be readily available in all dermatology departments. 4 Interspecialty and interdisciplinary liaison Multidisciplinary team working Many skin disease patients require the services of a number of different specialties and disciplines in addition to dermatologists. MDT clinics may include: q histopathology (includes all of the below) q rheumatology, immunology (connective tissue diseases, psoriasis) q gynaecology, urology, genitourinary medicine (genital diseases) q paediatrics (atopic eczema, genodermatoses) q plastic surgery, oncology (skin cancers) q oral medicine (muco-cutaneous disorders) q vascular surgery (leg ulcers) q psychology, psychiatry q infectious diseases (HIV) q medical genetics (inherited diseases). Working with GPs and GPs with a special interest Dermatologists work on a regular basis with GPs as clinical assistants or hospital practitioners in the hospital setting and as GPSIs in the intermediate setting. 5 Delivering a high-quality service What is a high-quality service? A high-quality service should provide the best-quality medical and social care to the maximum number of people within the minimum amount of time for the minimum cost and should be sustainable for the future.4 Components of this service include the following: Staffing: q Consultant dermatologists should have completed an accredited training programme, possess a Certificate of Completion of Training (CCT) or Certificate of Completion of Specialist Training (CCST) in dermatology and be on the specialist register of the General Medical Council (GMC). Applicants from outside the UK and Ireland will be expected to demonstrate comparable quality of training as assessed by the Joint Royal College of Physicians Training Board (JRCPTB). 120 Consultant physicians working with patients
  6. 6. 121 2 Specialties Dermatology q Dermatologists should not work in isolation, they must have appropriate support staff including specialist dermatology nurses. q There should be sufficient consultant staff to provide 24-hour (on call) access to dermatological advice for inpatients and the admissions unit. q Secretarial staff should be adequately trained in dermatological terms and policies and provided with appropriate word-processing and data collection facilities to allow proper clinical audit. Resources Specialised facilities are needed, ideally with physical proximity of inpatient, outpatient and day-care facilities to aid efficient working.5 These facilities are summarised below. Outpatient units should provide: q dedicated outpatient area q natural lighting q private area for undressing q wound dressing area q treatment rooms q facilities for contact allergy testing q rooms for patient education q medical photography services q access to a comprehensive pharmacy service q accommodation within the paediatric department for paediatric dermatology clinics and outpatient treatment for children. Surgical facilities should include: q well-lit and ventilated operating rooms q surgical packs of appropriate instruments q equipment for electrocautery, diathermy and hyfrecation q equipment for cryosurgery and storage for liquid nitrogen q facilities for freezing biopsies and storing frozen samples q laser-safe areas where required q facilities for Mohs surgery, eg specialist micrographic surgery, cryostat and histopathology equipment in some specialist units. Day-care centres should: q be staffed by dermatological nurses q complement inpatient care q ideally provide an out-of-hours service; a personal treatment plan should be made with each patient. Phototherapy units should: q be staffed by dermatological nurses who can provide skin care, rather than physiotherapists q deliver narrowband UVB (TL 01) and PUVA (psoralen plus UVA) light treatment q be supervised by a named consultant thus ensuring accuracy of dosimetry, record keeping and the training and monitoring of the staff who administer treatment q include the services of a medical physicist to monitor ultraviolet (UV) output of units.
  7. 7. In the near future, the issues for phototherapy units (above) are likely to be simplified and standardised by computerised national managed clinical networks (as in Scotland). Inpatient unit: q All dermatologists should have admitting rights to a dedicated inpatient dermatology unit staffed by trained specialist nurses. Consultants and/or medical staff in training should provide medical cover for these units. Patients with widespread chronic inflammatory skin diseases benefit from admission and are aided by the mutual patient support provided on a dermatological unit. Dedicated inpatient beds, some with facilities for reverse barrier nursing, are also required for patients with severe and life-threatening skin conditions. Regional centres need dedicated inpatient dermatology units for managing tertiary referrals of patients with complex diseases, and also for the training needs of undergraduates, junior doctors and other health professionals. q Two dedicated dermatological beds per 100,000 population are recommended, but a minimum of eight beds is necessary to support appropriate staffing for a self-contained unit. A recent BAD survey indicates that the bed provision has fallen to 1/100,000 due to cost pressures rather than any needs assessment. Ideally, the inpatient unit should be geographically close to the outpatient unit, and staff should be able to operate flexibly between the two. q Dermatological beds in general medical wards are satisfactory only if there are appropriate facilities for bathing and treatment and if patients receive care from specialist dermatology nurses. Care of patients with multisystem disorders – who require both specialist dermatological care as well as care of their medical and surgical problems – should be admitted to the area defined by their most serious problem. Outreach by dermatology trained nursing staff is essential for patients with significant skin disease on general wards. Support services Laboratory support services: q Dermatology requires the same support services as other general medical specialties, eg chemical pathology, haematology, radiology and microbiology including mycology; with particular requirement for histopathology and immunopathology. Support of other hospital specialties: q Dermatology patients require access to other hospital specialties, including plastic surgery, oncology, immunology and psychiatry. Maintaining and improving the quality of care Individual dermatologists may be involved in leading the clinical service and driving service developments designed to deliver improved patient care. These roles include the elements described below: Education and training Teaching and postgraduate education are essential parts of the work of dermatologists, who teach and train medical students, postgraduates, GPs and nurses. Although about 15% of GP 122 Consultant physicians working with patients
  8. 8. 123 2 Specialties Dermatology consultations relate to problems with the skin, only 20% of GP vocational training schemes contain a dermatological component; undergraduate curricula contain on average only six days of dermatology. Newly appointed GPs therefore have little experience of dermatological problems. If formal teaching occurs within ‘working’ clinics (as opposed to designated clinical teaching sessions), the number of patients that can be seen by the consultant will be reduced by approximately 30%. In units that have StRs there is an additional workload for the consultant. Mentoring and appraisal of medical staff and other professional staff These procedures are carried out at a local level, sometimes with the involvement of the regional representatives of BAD. Consultants spend a significant amount of time conducting assessments (such as mini clinical evaluation exercise (mini-CEX) and directly observed procedural skills (DOPs)) for medical students, foundation year 1 and 2 (F1/F2) doctors and StRs during clinical sessions. With the introduction of Care Closer to Home dermatologists will also assess those working in intermediate settings including specialist nurses and GPSIs. Continuing professional development Dermatologists are involved in the Royal College of Physicians continuing professional development (CPD) programme, which requires a consultant to spend a minimum of 50 hours each year on CPD, ie at least one half programmed activity (PA) each week. Clinical governance All consultants should be aware of the governance issues relating to their specialty and have time to document these as part of their preparation for annual appraisal. Formal meetings to discuss outcomes and review departmental data should be included in the work programme as part of the audit process. They may be taken in conjunction with teaching and training. Protected time should be allowed for local, regional and national audit. Research – clinical studies and basic science Dermatology has a strong research base. Basic science research is carried out in both teaching and district general hospitals (DGHs). The NHS work of academic dermatologists depends on their academic responsibilities and individual job descriptions, but most make a considerable contribution to the routine work of the NHS department in addition to setting up tertiary services. Major advances in clinical research have come from the close collaboration of dermatologists, laboratory scientists and patients. The role of all dermatologists in teaching continues to expand, particularly with the development of the new medical schools. Some academic dermatologists in large centres make a significant contribution to the broad academic community within their institution. Management duties Management duties include work done regionally and nationally, eg royal colleges, Department of Health (DH), specialist societies and deaneries.
  9. 9. Dermatologists may become involved in senior hospital management structures, which might include clinical directorship and service planning. It is essential that there is medical representation on local, regional and national committees, and appropriate time should be allocated in the work programme. For some consultants between half to one PA might be spent on such work. Individuals holding significant posts with national professional or governmental organisations may need to negotiate additional protected time. BAD has elected officers, as well as committees that require considerable input from individual dermatologists. These contribute significantly to national policy. Other roles include committee membership at the College and the British Medical Association (BMA), as well as involvement with NICE appraisals and guidelines. Specialty and national guidelines Service developments should take into account: q clinical and service guidelines produced and updated regularly by BAD (www.bad.org.uk/) q guidelines relevant to dermatology produced by NICE (www.nice.org.uk). Quality tools and frameworks: q Explicit standards should be set for the time from referral to first appointment for urgent and non-urgent patients. q In any outpatient clinic, time should be available for the doctor to read referral letters, to review and act on results and to dictate letters as well as to spend sufficient time with patients and their families as part of the consultation. The need for the flexibility to spend an extended time with the family of a child with atopic eczema should have a greater priority than the need to keep strictly to outpatient waiting-time guidelines. q There should be an agreed definition of a day case and recognition of the time required to perform the various surgical procedures. q When a patient is discharged from either inpatient or outpatient care the GP should be informed, with advice on further management, including follow-up. q Contracts should incorporate protocols for referral and for shared care, treatment guidelines, and standards for audit and quality control. Other outcome assessments that might be used are quality of life and patient satisfaction. Clinical work of consultants Inpatient work Ward rounds with specialist nurses and other members of the healthcare team, for whom teaching and training are an important component, usually occur on dermatology inpatients twice weekly. Requests for a dermatological opinion on acute medical or surgical admissions are common in referral work. 124 Consultant physicians working with patients
  10. 10. 125 2 Specialties Dermatology Outpatient work The greater part of the work of consultant dermatologists takes place in outpatient clinics. The nature, roles and services of these clinics varies considerably and they are outlined below. General dermatology clinics: 1 Without trainees or teaching commitments The ratio of new to follow-up patients will vary depending on the complexity of the cases seen. Depending on the time allocated to each patient, and the balance of new, follow-up, complex and simple cases, between 10 and 20 patients may be seen in a clinic. Some patients, new or follow up, with complex disease may require longer appointments. Some skin cancer screening clinics may allocate shorter appointments to each new patient, but if the consultant carries out one-stop skin surgery within the clinic, appointment times must be adjusted accordingly. Thirty minutes may be required for a surgical procedure. Flexibility is essential. 2 With trainees, non-training grades or teaching commitments For teaching to be effective, the patient numbers outlined above should be reduced by 20–30% for each doctor. Special clinics within dermatology: q tumour clinics – ideally with facilities for immediate skin surgery (one-stop clinic) q vulval clinics – with facilities for colposcopy q paediatric dermatology clinics – in suitable paediatric facilities with paediatric-trained nurses q other multidisciplinary clinics – particularly for psoriasis and atopic dermatitis, depending on the expertise of the consultant dermatologist, other specialist colleagues and hospital resources. Specialised investigative and therapeutic procedure clinics: q dermatological surgery – including Mohs micrographic surgery q laser surgery – requiring a laser-safe area and general anaesthetic facilities for treatment of children with vascular naevi q contact dermatitis and occupational skin disease (involving workplace visits) – as well as allergy testing in the hospital department q photobiology – with facilities for phototesting q wound care – eg leg ulcer. Specialist on call Consultants with a highly specialised practice would expect to provide a reasonable on-call service for these patients. Dermatology trainees are expected to have experience of acute on-call dermatology and Acute Medical Units (AMUs) expect dermatology expertise to be readily available. Other specialist activities beyond local services These include involvement in cancer networks and community services.
  11. 11. Clinically related administration This includes tasks such as screening and prioritising referral letters, reviewing and acting upon laboratory results, communicating with and about patients with colleagues in writing or by telephone or email. A reasonable balance between direct patient contact and clinical administration for dermatologists appears to be 1:0.5 based on clinicians’ diaries. This reflects the large numbers of outpatients seen in the specialty. 7 Workforce requirements for the specialty In 2007, there were 560 (490 WTE) consultant dermatologists (substantive and locum posts) in the UK and approximately 210 StRs. For the population of 61,000,000, the workforce requirements for a high-quality, consultant-led service are 610 (WTE) dermatologists. Dermatology is predominantly an outpatient specialty and the following calculations are based on the workload in the outpatient department. A 250,000 population generates 3,750 new patient referrals. Each new patient on average generates two follow-up appointments making a total of 11,250 patients each year. In areas where referral patterns have changed in the light of recent government initiatives, up to 40% of referrals may be retained in primary care. As such, a 250,000 population would continue to generate 2,250 new and 4,500 follow-up patients per year in secondary care. Consultant working alone Assuming a consultant has no travel to other centres, no inpatients, no ward round, no on call, no specialist clinics and no MDTs, he or she would be able to undertake two new, two follow- up and one skin surgery clinic per week. If working without an assistant and with no trainees or students to teach, he or she can see an average of 10 new patients (mix of neoplastic lesions and inflammatory rashes) per new clinic, 20 cases per follow-up clinic and up to seven cases in a skin surgery clinic (depending on the complexity). Therefore, in such a week, a consultant without assistance could see 20 new, 40 follow-up patients and undertake up to seven surgical procedures. This allows an appropriate amount of time for some ‘in clinic administration’. Clinics mixing old and new cases would adjust numbers in a pro rata manner. Activities related to direct clinical care such as reviewing and prioritising referral letters, checking and acting upon laboratory results and communicating with colleagues, generate approximately 0.5 PA for each clinic. Therefore, a consultant would work 5 PAs in the outpatient clinic with 2.5 PAs of supportive administration and management. Additional PAs are required for ward work, travel, teaching, MDTs, on call, or special interest clinics – or the number of outpatient clinics should be reduced appropriately. See Table 1. Assuming a consultant works 42 weeks per year, he or she could see 840 new and 1,680 follow-up patients and perform up to 280 procedures. On this basis, for a consultant-only service, a 250,000 population would require 4.5 consultants (ie 1 consultant per 55,500) or 2.7 consultants per 250,000 (1 per 90,000) if 40% of referrals are retained in primary care. This, however, does not allow for a special expertise clinic, teaching medical students, supervision of any grade of staff, ward work, on call, travel or MDTs. Therefore, the working recommendation is that there should be at least one dermatologist per 100,000 population. 126 Consultant physicians working with patients
  12. 12. 127 2 Specialties Dermatology Consultant working with an assistant or trainee Non-consultant medical staff who support the dermatology service require variable supervision, necessitating a reduction of approximately 20% in the number of patients per clinic. Therefore, a consultant working with a trained non-consultant doctor could together see an average of 16 new patients or 32 follow-up patients per clinic (or eight new and 16-follow up for a mixed clinic). The calculation made above indicates a requirement for three consultants plus three WTE assistants per 250,000 population. Trainees are regarded as supernumerary to the service, but will require time from the consultant for training within the clinic. Consultant teaching medical students If undergraduate teaching occurs within a working clinic, a reduction of at least 30% will be required. Notes on clinic size calculations: q Traditionally, a ratio of one new patient to two follow-up patients was seen in a mixed clinic, eg six new patients plus 12 follow-up patients. As follow-up numbers decline with changes in community service delivery, many follow-ups are sufficiently complex to require longer appointments. Casemix is therefore important in deciding clinic numbers. q Current PCT contracts often stipulate target follow-up ratios. However, it may be difficult to discharge more patients if GP referrals are appropriate and the needs of trainees are considered. Knowledgeable GPs only refer patients with complex problems needing specialist management, whose care requires more than one or two visits. Follow-up ratios may approach 1:2.5 if phototherapy and patch testing are included. q Each consultant should work with a maximum of two staff requiring supervision (trainee and/or non-training grades). q No consultant should work in isolation from colleagues. q The pattern of work will depend on the specialist services provided by individual consultants and departments, eg skin surgery, contact allergy (patch) testing, wound healing, paediatric dermatology, phototherapy and dermatopathology. Consultant work programme/specimen job plan The job plan outlined in Table 1 is for a consultant dermatologist working in a DGH. The standard contract for full-time NHS consultant is for 10 PAs, typically divided into 7.5 PAs related to direct patient care, and 2.5 related to supporting activities (SPAs).
  13. 13. The balance between formal clinics, ward work and supervisory activity will vary. Direct patient contact time must be accompanied by the appropriate clinical administration time. Numbers in clinics should be adjusted to ensure completion within four hours including teaching and immediate clinical administration. Additional administrative responsibilities will require further time to be drawn from the 7.5 PAs allocated to patient care. The 2.5 SPAs are described by the BMA and College as the typical requirement. For existing consultants these will need to be justified at appraisal and will include CPD, teaching, training and the supervision of others; the lead dean has suggested that StR supervision will require 0.5 SPAs per week and that F1/F2 supervision will require 0.25 SPAs per week. In the light of Care Closer to Home initiatives, GPSIs and specialist nurses will also require increasing supervision. For new jobs the prospective job plan should outline the proposed needs for SPAs. 128 Consultant physicians working with patients Programmed Activity Workload activities (PAs) Direct clinical care Ward rounds, day care Number of beds varies 0.5–1 Outpatient clinics 10 new for new clinic, or 3–4 20 follow-ups (for a follow-up clinic) Skin surgery 7 cases of average complexity 0–1 Skin cancer MDTs Variable 0.5–1 Dermatopathology Variable 0–0.5 On call Depends on number of colleagues 0.5 Administration and management Direct patient care, review of results, 1–2.5 communication with other healthcare professionals Special interest clinic eg paediatric, patch testing, 0–2 phototherapy, psoriasis and skin cancer Travel Variable 0–1 Total number of direct clinical care Pas 7.5 on average Supporting professional activities (SPAs) Work to maintain and improve the quality Education and training, appraisal, 2.5 on average of healthcare departmental management and service development, audit and clinical governance, CPD and revalidation, research Other NHS responsibilities Medical director, clinical director, lead Local agreement consultant in specialty, clinical tutor with trust External duties Work for deaneries, royal colleges, Local agreement specialist societies, DH or other with trust government bodies Table 1 Example of job plan
  14. 14. 129 2 Specialties Dermatology Work for national bodies should be acknowledged and programmed. This may require a negotiated reduction in the clinical elements of the annual job plan. The on-call commitment will vary with local policies and staffing levels. Those working part time or in academic posts will still be required to complete the full complement of SPAs, so no significant reduction in the 2.5 PAs allocated for this should be made. Job planning in teaching hospitals Teaching hospital consultants will need additional time for teaching and research. This will reduce the clinical elements of the job plan. References 1. Sibbald B, McDonald R, Roland M. Shifting care from hospitals to the community: a review of the evidence on quality and efficiency. J Health Serv Res Policy 2007;12(2):110–117. 2. Department of Health Guidance and competencies for the provision of services using GPs with special interests (GPSI) in community settings: dermatology and skin surgery. London: DH, 2007. 3. BAD (2007) Guidance for commissioning dermatology services (www.bad.org.uk). 4. Quality in the dermatological contract. A report from the workshop on quality issues in dermatological contracting of the British Association of Dermatologists. J R Coll Physicians Lond 1995 Jan–Feb; 29(1):25–30. 5. BAD (2006) Staffing and facilities for dermatological units (www.bad.org.uk).

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