Diabetes and Endocrinology


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Diabetes and Endocrinology

  1. 1. Diabetes and endocrinology i Description of the specialty and clinical needs of patients The specialty of diabetes and endocrinology deals with the diagnosis and management of a diverse range of hormonal and metabolic disorders. It encompasses a wide variety of conditions ranging from the most common (eg Type 2 diabetes), which are responsible for a large component of the chronic disease burden of healthcare, to those that are rare but eminently treatable (eg pituitary tumours). Most conditions are chronic, requiring long-term and often lifelong management. There is a strong evidence base for the management of disorders encountered within the specialty. Delayed, inadequate or inappropriate treatment leads to poor health, reduced lifespan and increased burden on the health service. Type 2 diabetes is a common multifaceted disorder that is rapidly increasing in incidence. The demands of glucose control management are progressive and, almost invariably, concurrent management of hypertension and dyslipidaemia is also required. Type 1 diabetes often starts in childhood and the intrinsically unstable nature of the condition is often compounded by emotional and behavioural problems common to adolescent and young adult medicine. In either kind of diabetes, potential complications are protean. Untreated they lead to disability and early death. Endocrine disorders range from the relatively common (eg polycystic ovarian syndrome (PCOS), hyperthyroidism and hypothyroidism) to rare and very rare conditions, which are nonetheless extremely important to identify because they are usually both eminently treatable (eg pituitary tumours, multiple endocrine neoplasia (MEN), Addison’s disease) and devastating if neglected. ii Organisation of the service and patterns of referral Primary, secondary and tertiary care Diabetes services These are largely outpatient based. A complex local network of services is required to encompass the needs of all people with diabetes throughout their lifelong pathway of care. Much of the routine work can be provided in primary care by nurses, dietitians, podiatrists and GPs. A core requirement for all patients is support for self-efficacy, which necessitates effective, ongoing patient education programmes. At various stages, however, specialist physician management is required: at the time of transitions (eg new diagnosis of Type 1 diabetes or the progression to more complex therapy for someone with Type 2 diabetes); for particular clinical scenarios (eg young people with diabetes, diabetic pregnancy, metabolic emergencies, serious intercurrent non-diabetic illness, psychosocial interactions); and for the identification and collaborative management of complications (eg severe diabetic foot disease, diabetic nephropathy, erectile dysfunction, painful and autonomic neuropathy, macrovascular disease). Because diabetes is so common, and because there are both ongoing and intermittent unpredictable components of management, the local organisation of an integrated diabetes care service is a complex exercise. Rapid changes in the structure and delivery of services are occurring as a result of: ❚ treatment developments such as continuous subcutaneous insulin infusion ❚ technological developments such as remotely accessed blood glucose results, call-centre support, and electronic care records 123
  2. 2. CONSULTANT PHYSICIANS WORKING WITH PATIENTS ❚ workforce changes such as consultant nurses and podiatrists ❚ the 2003 GP contract ❚ general practitioners with a special interest (GPSI) in diabetes ❚ changing primary/secondary care organisational relationships. Endocrine services For common conditions such as PCOS and thyroid disorders services are often organised on a multidisciplinary/multisector basis, which is much less complex but in other respects similar in structure to that for diabetes. Unusual endocrine disorders require sophisticated laboratory and clinical imaging support for diagnosis, and close liaison with highly specialised surgical services for treatment. Nonetheless, following diagnosis, management and initial stabilisation, the ongoing care of endocrine disorders is also beginning to change under the enabling influence of technologies that permit remote monitoring and electronic communication. iii Working with patients: patient-centred care Patient choice and involving patients in decisions about their management Treatment choices in diabetes and endocrinology are often complex and entail difficult risk assessments. Lengthy, well-informed negotiation between specialists and patients is necessary in order to achieve optimum outcome. Young people with diabetes and endocrine disorders require support and negotiated management appropriate to their stages of physical and emotional development. Long-term clinical records are indispensable; ideally, they should integrate information and results from all the healthcare providers and be accessible to both professionals and patients. Access to information, opportunities for education and promoting self-care Because diabetes is always chronic, and many endocrine disorders are also lifelong conditions, supported self-efficacy is a core part of delivering appropriate services. Patient education programmes are an essential component of management for Type 1 and Type 2 diabetes and feature increasingly in the management of endocrine conditions such as PCOS, pituitary disease and hypogonadism. National and local patient organisations are prominent and supportive in these areas as well. iv Interspecialty and interdisciplinary liaison Multidisciplinary team (MDT) working and collaboration with other specialists is a characteristic of almost all aspects of diabetes and endocrine specialist care. The diagnosis and ongoing care of children, young people and adults with Type 1 diabetes demands close collaboration between paediatricians, paediatric diabetes specialist nurses, physicians with a special interest in diabetes, adult diabetes specialist nurses, dietitians and, often, contributions from podiatrists, optometrists and psychologists. For Type 2 diabetes, primary care teams make the majority of the diagnoses and provide the ongoing care. Specialist services provide consultative advice at intervals and, at times, temporary ongoing care for particularly difficult metabolic or complicated management problems. Diabetic foot care requires an extensive MDT including community podiatrists and district nurses, hospital podiatrists, orthotists, microbiologists, vascular surgeons and orthopaedic surgeons, in addition to diabetes specialist nurses and physician specialists. Diabetes pregnancy care requires integrated team working with obstetric and midwifery colleagues. Other 124
  3. 3. PART 2 ■ Diabetes and endocrinology aspects of diabetes care involve collaborative management with ophthalmologists, nephrologists, stroke physicians, cardiologists, rheumatologists, emergency care teams, elderly care teams and every kind of inpatient hospital care for which people with diabetes are admitted. The need to involve such specialties is often concurrent with the need to reconfigure the metabolic care plan. Both diabetes and endocrinology are heavily dependent on close collaboration with laboratories but this is particularly the case for endocrinology where access to specialist laboratory techniques may determine the ability to deliver service. Endocrinology is also dependent on a variety of sophisticated imaging techniques requiring close collaboration with specialist radiologists. For the management of pituitary disease endocrinologists work in teams with neurosurgeons and radiotherapists; for thyroid and adrenal disorders partnership with an endocrine surgical team is essential; while for reproductive endocrinology it is necessary to work closely with specialist gynaecologists. Several complex endocrine disorders have their origins in childhood (eg growth disorders, Turner’s syndrome, congenital adrenal hyperplasia (CAH)) so liaison between adult and paediatric services during the vulnerable transition period is essential to effective continuing care. The management of genetically based endocrine disorders such as CAH and MEN will usually involve geneticists. The majority of specialist endocrine practice requires specialist nurse support. v Delivering a high quality service Characteristics of a high quality service High quality diabetes services are managed on a cross organisational basis in ‘natural health economies’. They deploy primary, intermediate, secondary and tertiary care facilities in an integrated programme that aspires to achieve all of the standards set out in the National Service Framework (NSF) for Diabetes. Services continually self-assess their structures and processes using systems such as DiabetesE, and monitor outcomes of care through national clinical audit. In endocrinology, as for diabetes, common conditions need to be managed collaboratively between primary and secondary care according to local guidelines and with ongoing audit of satisfaction and outcome. Regional centres deal with the rarer endocrine conditions and should be co-located with the laboratory and imaging and surgical teams in order to provide a seamless, comprehensive, safe, high quality service. vi Quality standards and measures of the quality of specialist services Diabetes ❚ The National Service Framework for Diabetes: www.nelh.nhs.uk/nsf/diabetes/default.htm ❚ NICE health technology appraisals: www.nice.org.uk/catrows.asp?c=153 ❚ Numerous NICE guidelines: www.nice.org.uk/catcg2.asp?c=20034 ❚ A service assessment mechanism: www.diabetesE.net ❚ National audit and regional audits for specific aspects of care such as pregnancy. ❚ International guidelines: International Society for Paediatric and Adolescent Diabetes (www.ispad.org); American Diabetes Association (www.diabetes.org/for-health- professionals-and-scientists/cpr.jsp) 125
  4. 4. CONSULTANT PHYSICIANS WORKING WITH PATIENTS Endocrinology ❚ NICE health technology appraisals for the use of growth hormone: www.nice.org.uk/ catrows.asp?c=153 ❚ Society for Endocrinology national guidelines that contain standards against which practice can be audited: www.endocrinology.org/SFE/handbk.htm ❚ International guidelines: American Association of Clinical Endocrinologists www.aace.com/clin/guidelines CLINICAL WORK AND/OR LABORATORY WORK OF CONSULTANTS IN DIABETES AND ENDOCRINOLOGY Contributions made to acute medicine Most consultants with a specialist interest in diabetes and endocrinology work in acute hospitals. They contribute substantially to the provision of the acute general medical service. Usually they participate in a one in 10 to one in 14 acute take rota that includes post-take ward rounds on the emergency medical admissions unit. Additionally, they will lead a ward-based team responsible for about 16–20 unselected general medicine inpatients. Direct clinical care Work in the specialties Specialty service provision varies between a strong or exclusive bias to diabetes or endocrinology or, most commonly in a district general hospital (DGH), a mix of diabetes and endocrinology. Some physicians in diabetes now work solely in the provision and management of diabetes services in the community (community diabetes physicians) and may be employed by primary care trusts. A few endocrinologists work exclusively to provide an endocrine specialist service from within a tertiary referral centre concentrating on pituitary disease, rare endocrine tumours and inherited endocrine disorders. A substantial number of hospital-based physicians with a special interest predominantly in diabetes provide a lead role for diabetes services throughout their local community. Inpatient work Very few patients will be in hospital because of their diabetes or endocrine disorder. Most endocrine investigations are conducted on an outpatient or day case basis. Diabetic foot disease is the most commonly admitted diabetes-related disorder and is increasingly managed on an outpatient basis with the support of community-based high-risk foot care teams and home intravenous therapy services. Inpatient consultation work varies considerably depending on the co-specialty profile of the hospital. Because of the high prevalence of diabetes as a co-morbidity among hospital inpatients (10–15%) there is a substantial workload in supporting colleagues in other specialties when their patients develop metabolic problems; this is increased substantially if there are tertiary referral maternity, renal, vascular or cardiac services. For endocrinology, the workload is greater where a hospital has neurosurgery, a cancer centre or a specialist endocrine surgical service. 126
  5. 5. PART 2 ■ Diabetes and endocrinology Outpatient work General internal medicine (GIM) The GIM load varies considerably. Thirty minutes should be allowed for new patients and fifteen minutes for follow-up patients. Diabetes services New patient consultations for people with diabetes are generally complex and require about thirty minutes of consultation time. Review diabetes patients require about twenty minutes but may require more time (30 minutes for diabetes renal service) or slightly less time (15 minutes for diabetic foot disease or antenatal care). Many of these consultations will need to be organised jointly or coordinated with other specialists, for example renal services with nephrologists, foot services with podiatrists, vascular surgeons with microbiologists, antenatal services with obstetricians. Endocrine services New endocrine patients require about 30 minutes of consultation time and review patients about 15 minutes. Complex reviews for pituitary patients or endocrine tumours, paediatric transition or genetic consultations may take longer and require joint or co-consultation arrangements with colleagues from other specialties. Work to maintain and improve the quality of care This work encompasses continuing professional development (CPD), clinical governance, professional self-regulation, education and training. For many consultants at various times in their careers it may also include research, management and providing professional advice. Management is a common component of diabetes service provision. The role typically involves providing ‘whole systems’ clinical and organisational leadership across a care community usually comprising about 250,000 people and includes responsibility for the education, development and quality assurance of primary care and community staff and those working from a hospital base. ACADEMIC MEDICINE Physicians in the specialty who have university contracts generally divide their time equally between research and a work programme similar in configuration but reduced by 50% of the volume to their NHS colleagues. Quite frequently, the clinical contribution will be restricted to the specialty (for example, no GIM or only endocrinology). The academic component of such posts is normally orientated primarily towards research productivity but there is likely to be a substantial teaching load and other academic, administrative and managerial responsibilities attached. WORKFORCE REQUIREMENTS FOR DIABETES AND ENDOCRINOLOGY Current workforce numbers The 2003 annual Royal College of Physicians/Diabetes UK Survey identified 501 whole time equivalent (WTE) consultants in diabetes and endocrinology in England and Wales (522 individuals) on 30 September 2003. This is a provision of one consultant per 81,000 population in England and one per 96,000 in Wales. Long-term (over six months) vacancies had increased substantially from the previous year’s survey, from three to 17. 127
  6. 6. CONSULTANT PHYSICIANS WORKING WITH PATIENTS Sixty-five hospitals in England and seven in Wales had single-handed consultants in diabetes and endocrinology. Of the appointments to consultant posts in the preceding year, 42% came from previous holders of consultant posts, as opposed to 27% in 2002 and 10% in 2001. Of advertised posts, 40% had failed to result in an appointment. Estimate of number of consultant physicians necessary to provide a specialist service to a population of 250,000 This is a difficult exercise. There has been a considerable increase in the numbers of patients with Type 2 diabetes and the prospect of formal screening for diabetes is likely to result in a very steep increase in demand for diabetes care; epidemiological studies suggest that screening may double the number of those identified as having diabetes. However, the National Service Framework for Diabetes and other initiatives such as the College advocacy of the Chronic Disease Model are encouraging the development of ongoing primary and intermediate care diabetes services. The combination of these factors makes accurate prediction of the need for specialist and secondary care diabetes care a complex calculation. The best current estimate is that the increased prevalence and longevity of people with diabetes, the increased complexity of care, and the provision of new care models will mean no net change in the diabetes specialist workload. However, the nature of that work is likely to change quite radically with more time devoted to problem solving and support of primary and specialist colleagues. Similarly, for endocrinology it is expected that the devolution of more routine care will be balanced by the increased complexity of treatment options for rare conditions. Table 1 is a calculation based on currently available information from central sources and clinical centres. This is a detailed analysis of the present position based on current work patterns but it is recognised that these are likely to change substantially during the period up to the projection for 2009. Nonetheless, as explained above, it is anticipated that overall workload can be reasonably calculated using the current position. Table 1. Calculation of the need for consultant physicians with specialist training in diabetes and endocrinology in a district of 250,000 2004 2009 District populationa 250,000 253,773 Diabetes Prevalence at 0.3% increase/yearb 3.5% 5% Number of people with diabetes: 8,750 12,689 Number with Type 1 diabetes 875 1,000 Number with Type 2 diabetesc 7,875 11,989 Diabetes outpatient work for district Assume all Type 1 diabetes seen in hospital 875 1,000 Assumed % of Type 2 diabetes seen in hospitald 30 25 Estimated patients with Type 2 diabetes seen in hospital 2,363 2,997 Estimated total diabetic clinic population 3,268 4,022 Number of patients seen as new in diabetes clinice 300 300 Hours/year at 30 minutes/patient 150 150 Mean hours/week 2.9 2.9 128
  7. 7. PART 2 ■ Diabetes and endocrinology 2004 2009 Number of annual reviews in diabetes clinic 3,268 4,022 Hours/year if allow 20 minutes/review 1,089 1,341 Mean hours/week 20.9 25.8 Assume 33% of patients are seen >1/yearf 1,078 1,327 Hours/year if allow 20 minutes/appointment 359 442 Mean hours/week 6.9 8.5 1 x 2.5 hour diabetes antenatal clinic/week 4 4 1 x 4 hour foot clinic/week 4 4 1 x 2 hour adolescent clinic/week 2 2 1 x 4 hour renal clinic/week 4 4 Total diabetes outpatient activity with supporting admin time 67.1 76.8 at + 50% (hours/week) Endocrine outpatient activity Endocrine new referrals (assume 0.12% of population/year)f 300 305 Hours/year if allow 30 minutes/new patient 150 152 Mean hours/week 2.9 2.9 Endocrine follow up appointments(n)g 1,250 1,268.9 Hours/year if allow 15 minutes/follow up 312.5 317.2 Mean hours/week 6.0 6.1 Total endocrine outpatient activity with supporting admin time 13.3 13.5 at + 50% (hours/week) General medical outpatient activity General medical new patient referrals hours (2 patients/week at 30 mins)h 1 1 General medical/ward follow-ups hours assume 10 patients/week at 15mins 2.5 2.5 Total general medical outpatient activity with supporting admin time 5.3 5.3 at + 50% (hours/week) Diabetes + endocrine + general medical outpatient activity (hours/week) 85.7 95.7 Diabetes community work hours/week to include NSF implementation/ 4 8 retinal work/LDSAG/training GPSI etc Inpatient work (assumes sharing one firm on 1 in 10 rota) Allow 8 hours/week for care of existing inpatients 8 8.1 Allow 4 hours/week for emergency work 4 4 Allow 6 hours/week for referrals/surgical support 6 6 Inpatient hours/week 18 18.1 Allow admin time to support inpatient work at 20% of total 3.6 3.6 Inpatient total hours/week 21.6 21.7 Total clinical hours 111 125 Total clinical programmed activities (PAs) 27.8 31.4 Total PAs corrected to 7.5/2.5 CPA/SPA ratio (at 10 PA contract) 37.1 41.8 Total PA needs for 250,000 population corrected for 8 weeks absence/consultant/yearj to give 43.8 49.4 Worked out as 1 consultant per x population 57,018 51,368 129
  8. 8. CONSULTANT PHYSICIANS WORKING WITH PATIENTS Notes a Increases by 0.3% pa: Government figures. b International Diabetes Federation (IDF) estimates and data from centres. IDF suggest prevalence of 6% by 2010. This does not take account of any NSF screening programs. c Rate of rise much faster in Type 2 than in Type 1 diabetes. d Assumed to decrease over time with increased primary care involvement. e May well increase with time as prevalence increases; will depend on local care pathways. f Mean estimate from current practice; may well increase as complexity of hospital patients is likely to increase. g Data from centres: new patient referrals at 0.12% of population per year. h Data from centres. j Annual leave and study/professional leave. LDSAG = local diabetes service advisory group SPA = supporting professional activities This analysis would suggest a current need for approximately 4.5 WTE consultants for a district of 250,000, rising to 5 WTE consultants by 2009. This analysis is for a consultant-provided service and does not take outpatient activity by other grades into account. The demands of acute medicine on specialist registrars and the need to supervise junior doctors when in the clinic mean that most consultants feel it is not possible to quantify their input. Some centres run parallel nurse-led clinics, which are not included in the calculations; these need medical supervision and could be seen as balancing the input from non- consultant medical staff. National consultant workforce requirements Based on the above estimate of one consultant physician per 57,000 population, and one per 51,500 in 2009, this would give a current WTE requirement for England and Wales of 931, rising to 1,030 in 2009. This should be contrasted to the estimate of 426 from last year’s specialty survey. 130
  9. 9. PART 2 ■ Diabetes and endocrinology CONSULTANT WORK PROGRAMME/SPECIMEN JOB PLAN The programme below assumes the above estimated number of physicians sharing a general medical commitment and working a 10 PA contract. This would fit a typical DGH in diabetes and endocrinology and would be different for more specialised or academic posts. Programmed activities Activity Workload (PAs) Direct clinical care Inpatients Ward rounds, referrals and other associated activities 20–25 patients 1.5–2 Outpatient clinics Diabetes 4 new and 6 follow up or 12 follow up* 2–4.5 Endocrinology 4 new and 8 follow up or 16 follow up* 0.5–2 General medical 4 new and 8 follow up or 16 follow up* 0.5 Patient related and supporting clinical administration 1.5–2.5 Total number of direct clinical care PAs 7.5 on average Supporting professional activities (SPA) Work to maintain and improve Education and training, appraisal, departmental 2.5 on average the quality of healthcare management and service development, audit and clinical governance, CPD and revalidation, research Other NHS responsibilities eg medical director/clinical director/lead Local agreement consultant in specialty/clinical tutor with trust External duties eg work for deaneries/Royal Colleges/specialty Local agreement societies/Department of Health or other with trust government bodies etc *for a four-hour clinic session 131