Consultants prelims

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Consultants prelims

  1. 1. Gastroenterology 1 Description of the specialty and clinical needs of patients The specialty of gastroenterology and hepatology cares for patients with both benign and malignant disorders of the gastrointestinal (GI) tract and liver. The specialty encompasses a wide range of conditions – from common disorders to highly complex problems – and specialised procedures such as endoscopic resection of cancers and transplantation. Common problems include change in bowel habit, indigestion, irritable bowel syndrome, inflammatory bowel disease, cancers of the GI tract, gastro-oesophageal reflux disease, chronic viral hepatitis and, in recent years, hepatic steatohepatitis and the rising burden of alcoholic liver disease. Gastroenterologists also see patients with a variety of general medical problems, particularly anaemia and weight loss. Much of the work, particularly to exclude organic disease in symptomatic patients and to provide rapid diagnosis and treatment for patients with suspected GI cancer, is based in outpatients. The investigations required often include endoscopy and imaging. An acute and emergency inpatient service is needed for common problems such as gastrointestinal haemorrhage, acute inflammatory bowel disease, decompensated liver disease (particularly due to alcohol), other forms of liver failure and abdominal pain. Gastroenterology departments have an essential role in the implementation of the two-week referral strategy for improving the diagnosis and treatment of GI cancers. Several departments have combined to form multidisciplinary teams (MDTs) in order to provide the critical mass of specialists needed to meet the guidelines of the Department of Health’s (DH) Clinical Outcomes Group (COG) for the provision of specialist services.1 Tertiary referral units may receive patients with complex hepatobiliary disease and complex nutritional problems that require total parenteral nutrition, as well as those who need complex non-malignant GI surgery and complex therapeutic endoscopy. Patients who require transplantation of the liver and small intestine are referred to the small number of units that undertake organ transplantation. 2 Organisation of the service and patterns of referral Rapid changes in referral patterns due to the implementation of primary care-based commissioning have led to multiple sources of referral to gastrointestinal services, which may be shared between providers based in primary care and secondary care. Closer working between hospital specialists and GPs with a special interest should improve ’patient flows’. Most symptomatic patients are looked after by their GP, and most problems are resolved by discussion, primary care-initiated investigation, advice and medical treatment. Nonetheless, there has been a continuing steady increase in outpatient and inpatient work for gastro- enterologists, particularly in relation to alcoholic liver disease and the increasing numbers of cancers of the GI tract that occur in an aging population.140
  2. 2. 2 Specialty Gastroenterology The increasing ‘acuteness’ of medical admissions has meant that gastroenterologists have had to reorganise their work in order to be able to take part in a daily triage of patients with emergency gastroenterology problems and to provide more time for ward referrals and emergency and unplanned endoscopy. These changes are an inevitable consequence of a reduced inpatient bed pool. The inpatient casemix usually comprises patients with cancer, severe alcoholic liver disease and inflammatory bowel disease. Close liaison with colleagues in surgery, radiology, pathology and oncology facilitates the treatment of different forms of GI disease. Combined outpatient clinics undoubtedly improve management, and the weekly cancer MDT meetings are a useful forum for discussing all complex cases. Meetings with radiologists and pathologists should take place at least once a week and can be combined with formal training sessions for trainees. Many units have established posts for specialist nurses working in inflammatory bowel disease, liver disease, disorders of bowel function and nutritional support and for those working as endoscopists. Larger departments will often employ consultant GI nurses, and GPs with special interests (GPSIs) will often carry out sessions in the hospital unit.3 Working with patients: patient-centred care Patient choice and involving patients in decisions about their treatment Much of the outpatient work in gastroenterology relates to the management of chronic conditions such as chronic liver disease and inflammatory bowel disease. Success depends on a good working relationship with the patient, whereby the patient has a full understanding of and participates in the management of his or her condition and it is clear where responsibility lies in patient care among the specialist, patient and GP. Inflammatory bowel disease is one example in which patients will often initiate a change in their treatment in the face of a relapse of their disease, usually in close liaison with the specialist team or GP, or both. Patients are represented on the joint gastroenterology/hepatology committee of the Royal College of Physicians (RCP) and, through the National Association for Colitis and Crohn’s Disease (NACC), are involved in the generation of standards of care for patients with inflammatory bowel disease. Similarly, patients have been involved in setting standards for nutritional support through Patients on Intravenous and Nasogastric Nutrition Therapy (PINNT) – a core group of the British Association for Parenteral & Enteral Nutrition (BAPEN). The British Society for Gastroenterology (BSG) Endoscopy Section has devised comprehensive information leaflets for all patients undergoing endoscopy. The British Liver Trust and CORE – the main GI charity – also produce many helpful documents for patients. All of the charitable bodies have excellent interactive websites, as does the BSG, whose website has a dedicated patient information area. Opportunities for education and promoting self care Specialist GI nurses can expand the opportunities for patient education through discussion, leaflets and CD-ROMs and by directing patients to interactive websites. Many opportunities for improved patient care are available, including clear guidelines for the primary-care management of patients with peptic ulcer and non-ulcer dyspepsia. Locally 141
  3. 3. Consultant physicians working with patients agreed referral protocols enhance care pathways for patients with suspected cancer, iron- deficiency anaemia and suspected liver disease. New guidelines on all of these conditions have been commissioned and produced by the BSG in the last five years. Targeted outpatient clinics and joint medical and surgical assessment and management are increasingly being developed in all areas of the specialty. Other major advances have been made in diagnostic and therapeutic endoscopy, particularly by the implementation of the global rating scale for endoscopy units and the introduction of new techniques such as narrow-band and confocal endoscopy, endoscopic ultrasound, capsule endoscopy and radiology, and computer tomographic colography. Some invasive diagnostic procedures such as endoscopic retrograde cannulation of the pancreas are being replaced by magnetic resonance imaging techniques. All of these developments need to be underpinned by first-class teaching and training. The introduction of new biological treatments for inflammatory bowel disease and better antiviral treatments for chronic viral hepatitis, the identification of patterns of inheritance of genes that predispose to inflammatory bowel disease and the introduction of endoscopic mucosal resection are all remarkable examples of progress. 4 Interspecialty and interdisciplinary liaison Multidisciplinary teams and working with other specialists The practice of gastroenterology involves many specialties and perhaps a greater overlap between medical and surgical practice than for any other specialty. For this reason, well-organised MDT working is essential. This is coordinated through MDT meetings, and facilitating close liaison with tertiary referral centres is an integral part of the management of complex GI problems – eg complex liver disease, pancreatic cancer, liver or small bowel transplantation and complex nutritional problems that often require home parenteral nutrition. Specialist nurses in nutrition, stoma care, GI oncology, general gastroenterology and management of the treatment of viral hepatitis play an increasingly valuable role in improving the quality of service, communication and liaison between disciplines within the team. Hospital and community dieticians are vital members of the GI team. Working with GP specialists The development of GPSIs and other primary care practitioners with an interest in gastroenterology has been a major advance during the last five years. Nationally, primary care specialists have been closely involved in the production of guidelines by the National Institute for Health and Clinical Excellence (NICE). Locally, GPSIs have helped to develop guidelines for the shared care of patients with chronic gastrointestinal conditions and have also worked closely with hospital-based gastroenterologists to develop networks, to supervise Clinical Assessment, Treatment and Support Centres (CATS), to determine the relevance of protocols for Choose and Book referrals, and to ensure the more efficient use of direct-access endoscopy services. These developments have significantly shortened waiting times for the diagnosis of patients with alarm symptoms.142
  4. 4. 2 Specialty Gastroenterology5 Delivering a high-quality service Characteristics of a high-quality service Care for patients with GI symptoms should be timely, patient focused and consultant based. Although most patient care takes place in the outpatient department, this should be supported, in ideal circumstances, by a combined medical and surgical inpatient unit that provides senior- level expertise for the management of inpatients with GI emergencies 24 hours a day, seven days of the week. A high-quality service will: q have properly timetabled audit and clinical governance meetings q fulfil the Joint Advisory Group on GI Endoscopy’s requirements for Endoscopy q have sufficient time for staff development and appraisal q provide consultant input at a high level into clinical management q facilitate research and academic interests where appropriate q implement national and local guidelines on patient management. Consultants will also work closely with colleagues in other trusts to provide clinical networks to ensure that patients receive the highest quality of care. The BSG has produced a document on care standards for patients with GI disorders2 and recommendations on out-of-hours care.3 Resources required for a high-quality service Specialised facilities Specialised facilities are described clearly in the BSG’s working party report of 2001 (Provision of endoscopy-related services in district general hospitals4) and the 2006 report.5 Specialised facilities include a diagnostic and therapeutic endoscopy unit; facilities for parenteral nutrition; and operative, anaesthetic and intensive therapy unit (ITU) support and interventional radiology in tertiary referral units such as regional liver centres, which may or may not offer transplantation. There must be arrangements to support close collaboration with colleagues in oncology. Workforce requirements: clinical and support staff Workforce requirements are considered in detail later in this chapter. Those that relate to endoscopy services are detailed in the BSG working party report.4 Adequate secretarial support for every consultant is essential. The complex working pattern of specialists and consultants necessitates that each has their own office. Communication is central to the safe management of patients, and good information technology (IT) is necessary for auditing standards of practice within the department. Computer terminals should be present at all workstations and in endoscopy rooms and offices. In most gastroenterology departments, specialist nurses in endoscopy, cancer and palliative care are fully integrated into the management structure. Quality standards and measures of the quality of specialist services Specialist society guidelines In 2006, the BSG produced a quality standards document backed up by data gathered over a one-year period.2 This provides information on all aspects of gastroenterological practice and 143
  5. 5. Consultant physicians working with patients how this can be improved. The BSG provides guidelines for the highest standards of care in all areas of clinical practice in gastroenterology. These have been published by Gut and are available on the BSG’s website (www.bsg.org.uk). 6 Clinical work of consultants Contribution made to acute medicine Most gastroenterologists are general physicians with a specialist interest in gastroenterology (85%). They therefore commit a major part of their time to the management of patients with general medical problems as part of their unselected acute medical take, ward work and outpatient work. The range of clinical commitments includes inpatient and outpatient services in general medicine, gastroenterology and hepatology; a specialist diagnostic and therapeutic endoscopy service; and facilities for nutritional support. Gastroenterology is characterised by high-volume and frequent inpatient and outpatient consultations, several sessions per week in diagnostic and therapeutic endoscopy and the inpatient care of patients within acute medicine and the specialty. Regular collaborative meetings are held to discuss clinical problems. Other tasks include contributions to the teaching and appraisal of medical staff and the teaching of medical students, continuing professional development (CPD), clinical audit, clinical research, administration, commissioning and service management. Since the last edition of this document, significant demands have been added to the work expected to be delivered by consultant gastroenterologists. Acute medicine has become more onerous, with many hospitals running a daily triage service to specialist departments. The supervision and training of junior doctors is more prescriptive and occupies more time. Specialist cancer services may have been localised to fewer units, but the extra time required for MDTs and to dealing with two-week cancer referrals in general hospitals is a considerable workload. Since the last edition, the DH has introduced fixed maximum waiting times for outpatients, diagnosis and treatment, and endoscopy. These policy changes have had a considerable impact on the day-to-day work of gastroenterologists, who now have to devote a significant amount of time to service redesign and commissioning. In addition, consultant job plans and limitations on hours are having a detrimental effect on the provision of out-of-hours GI emergency care. Direct clinical care This section describes the work of a consultant physician providing a service in acute general medicine and gastroenterology and recommends a workload consistent with high standards of patient care. It sets out the work generated in gastroenterology by a 250,000 population and gives the consultant workload as programmed activity (PA) for each element of such a service. The gastroenterology committee of the RCP and the BSG have published several studies concerned with the provision of a combined general medical and gastroenterology service. The most recent summarised the nature and standards of gastrointestinal and liver services in the UK.2144
  6. 6. 2 Specialty GastroenterologyWorking for patientsA consultant-led team should look after no more than 20–25 inpatients at any time. Mostpatients are admitted on emergency ‘take’ days with various general medical problems or aregastroenterological emergencies triaged to the ward. A minority are admitted, urgently orelectively, for evaluation of GI problems. PAs need to be allocated for at least three specialistward rounds per week and one post-take ward round per week per consultant, bearing in mindthe RCP’s recommendations on the amount of time that should be devoted to each patient.5Outpatient workNew patient clinicA consultant physician in gastroenterology working alone in a new patient clinic may see6–8 new patients in a session usually equivalent to one PA. The exact number of patients isdependent on experience and the complexity of the problem. Each new patient should be given20–30 minutes.Follow-up clinicsA consultant physician working alone in a clinic for selected patients after acute medical orgastroenterological admission may see 12–15 patients in a session usually equivalent to one PA.A physician working alone in a specialist follow-up clinic for chronic GI and liver disease sees12–16 patients in one session. In practice, most gastroenterologists will run clinics that involvea mixture of new and old patients.Support from junior medical staffOutpatient clinics are often run with doctors in training – either foundation programmedoctors or specialist trainees. The consultant must allocate time to review the patients seen bythe trainees. The number of patients seen by junior members of staff depends on theirexperience. For each junior doctor, the outpatient workload is increased by about 50% of thatundertaken by the consultant. It should be noted that this creates a potential saving only inoutpatient and endoscopy consultant sessions and not in the other components of theconsultant’s work. Moreover, this saving (which amounts to perhaps one session) iscounterbalanced by the need for the consultant to devote time to training (including trainingin endoscopy). A specialist trainee should be able to see four new patients or 10 follow-uppatients or some combination of the two. Time must be allowed for training and shouldamount to about half an hour during a clinic 3.5 hours in duration.Diagnostic and therapeutic endoscopy serviceThe workload of a consultant physician undertaking endoscopy depends on the procedure:q Diagnostic upper gastrointestinal endoscopy: allowing 15–20 minutes per procedure, a maximum of 10–12 procedures should be carried out in a session equivalent to one PA. For a teaching session, eight patients should be allocated.q Diagnostic flexible sigmoidoscopy: a maximum of 8–10 procedures should be carried out in a session equivalent to one PA. 145
  7. 7. Consultant physicians working with patients q Therapeutic upper gastrointestinal endoscopy: this includes injection sclerotherapy, banding of oesophageal varices, injection of bleeding ulcers, palliative treatment of oesophageal cancer and placement of feeding tubes (percutaneous endoscopic gastrostomy, PEG). Such procedures take twice or three times as long as routine upper GI endoscopy and, allowing 30–40 minutes per procedure, 5–6 might be undertaken in a session (4–5 for a teaching session). q Therapeutic flexible sigmoidoscopy: this usually involves polypectomy and takes twice as long as routine flexible sigmoidoscopy; 5–8 procedures might be undertaken in a session. q Diagnostic and therapeutic colonoscopy: there should be a maximum of six colonoscopies per session (three if a teaching session) allowing 30–40 minutes per procedure. q Training endoscopy lists: it is essential that adequate time for training is allowed and that special endoscopy training lists are scheduled into the programme. Training sessions inevitably reduce the service throughput. Hands-on training cannot be carried out during a busy service endoscopy list. q Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP): a maximum of four procedures should be carried out in one session. q Endoscopic ultrasound: three to four procedures should be carried out in one session. On call for gastroenterological emergencies The BSG have published a new document on out-of-hours care3 calling for a reorganisation of services to provide for safe care of all gastroenterological emergencies. Sessional time must be allocated for emergency out-of-hours endoscopy work – predominantly the management of gastrointestinal haemorrhage. In larger units with more trained endoscopists, emergency cover that is available 24 hours a day, seven days of the week should be the aim. This can be achieved in smaller units only by the continuing dedication of staff working long hours or by units merging in order to provide such 24-hour care. As far as possible, the aim should be to schedule sessions during the week and at weekends to manage patients admitted with acute GI haemorrhage. Such rotas should include all of those with appropriate skills, particularly members of the medical and surgical GI teams. Nutrition service Consultant physicians with an interest in gastroenterology are usually responsible for leading the enteral and parenteral feeding service. This should be within the context of a MDT with core members: dieticians, nurses, pharmacist and clinician (usually a gastroenterologist). Supervision of home-based parenteral nutrition for patients with type 2 or 3 intestinal failure is usually provided from specialist centres. Nutritional rounds need to be regular and would be expected to account for two hours per week for the gastroenterologists who take responsibility for the nutritional service. Such rounds will often include critical care and surgical wards. All acute hospitals should have at least one nutrition nurse.6 The presence of a functioning MDT for nutrition will dictate recognition of specialty registrar (StR) training in clinical nutrition. This will not be the case in all acute hospitals, only 50% of which have such teams at present. Gastroenterologists are responsible for the placement of PEG tubes and are now required to be intimately involved in the assessment of the procedure and in obtaining consent.146
  8. 8. 2 Specialty GastroenterologyAcademic medicine The clinical contribution of academic gastroenterologists varies widely depending on their other responsibilities. Many clinical academics provide a substantial contribution to the clinical service, however, and often provide specialist tertiary advice. Most academic gastroenterologists have an honorary consultant contract with their local NHS trust, and the usual ratio of academic work to service work is about 50:50. Wide variations and great flexibility exist in practice, but the advent of job planning has achieved greater clarity. With such an honorary consultant contract, the academic gastroenterologist would expect to provide proportional input into the gastroenterology service. It should be stressed that this will be proportionate for all activities in a gastroenterologist’s job description, including support, training, governance, teaching and administrative roles, as well as direct patient-related activities. As local circumstances permit the negotiation of a different proportional contract, the activities may vary from centre to centre. For example, an academic leading a very active research group would require 70–80% of their time to be devoted to this activity. The university (or other academic employer) would agree the proportions (including funding) with the local trust. The academic employer is responsible for the academic time of the clinical academic. Clinical academics inevitably develop national and international roles, and, consequently, these activities should be allocated between academic and clinical time by local negotiation. As academic gastroenterologists are often research leaders or leaders in the organisation and development of clinical education, they are an important resource for their clinical colleagues. Good relationships within a gastroenterology unit therefore are vital, so that academic input can support the development of the clinical service and the clinicians can be involved in up-to- date academic developments.7 Workforce requirements for the specialty Current workforce numbers From 1 March 2008, there were 788 consultant gastroenterologists in England. There has been a recent reduction in the expansion of consultant posts from around 7% per year from 2000–2005 to just fewer than 3% in the last two years. A whole-time equivalent (WTE) consultant currently serves a population of around 70,000; however, there is considerable regional variation. Presently, 13% of consultants are women and only 6% work part time. A greater than 50% expansion in the number of trainees in gastroenterology has been seen over the past five years. There are currently between 550 and 600 trainees at StR level in gastroenterology in England. Consultant programmed activities (PAs) required to provide a service in gastroenterology to a 250,000 population The numbers of PAs required depends on the volume of inpatient, outpatient and endoscopic work and can be calculated for any given workload. Although it is not yet universal practice, it is assumed that consultant physicians with an interest in gastroenterology work together to run 147
  9. 9. Consultant physicians working with patients a single inpatient service. Increasingly, one or more consultants will specialise in providing hepatology services, maintaining liaison with a regional liver centre for the appropriate management of acute liver failure, and some of the complications of cirrhosis. Inpatient service Three consultant PAs per week should be allocated for inpatient rounds, discharge letters and other related administration, with an additional consultant PA per week for a post-take ward round. Each consultant requires one PA per week to see inpatient referrals, patients and relatives on an ad-hoc basis and to review the results of investigations. Each consultant is likely to commit half a PA to formal MDT meetings. Outpatient service Outpatient services are often provided by the consultant staff and team in training. The reduction of junior doctors’ hours and the commitment to run the emergency medical service often means that the junior medical staff cannot attend outpatient clinics regularly. In this example, it is assumed that the consultant physician is working alone in the outpatient department. New outpatient referrals A district general hospital (DGH) serving a 250,000 population should see at least 4,100 new patients with GI conditions each year: this will be made up of about 3,600 urgent cancer referrals, as estimated in the two-week cancer referral guidelines, and about 500 additional GI and hepatology cases. A variable proportion of this workload – around 1,500 cases – will be seen by gastrointestinal surgeons. The remaining 2,600 require 8–10 consultant PAs per week for consultants working alone in the outpatient clinic. The incidence of liver disease is increasing rapidly, particularly as a result of alcohol-associated liver damage and obesity-related liver disease. In addition, up to 0.7% or more of the population may be carriers of hepatitis C or B, and the workload associated with this is likely to increase. General medical outpatient follow-up post-discharge Up to three consultant PAs are required per week to provide this service. Outpatient specialist follow-up clinic per week Ten consultant PAs per week are required for this service. This assumes that the ratio of new:return patients is about 1:3. Diagnostic and therapeutic endoscopy service: q Diagnostic upper GI endoscopy: the annual incidence for upper GI endoscopy in the general population is 1.5%. Compliance with NICE guidelines is likely to reduce this to around 1% or 2,500 procedures in a DGH serving a 250,000 population. It is assumed that half of the procedures will be performed by GI physicians and that, with training requirements, this will amount to three PAs per week.148
  10. 10. 2 Specialty Gastroenterologyq The annual incidences of flexible sigmoidoscopy and colonoscopy are currently 0.8% and 0.6%, respectively, but with screening for colon cancer and increasing referrals through the referral system for suspected lower GI cancer, this is presumed to increase to 1% each, which amounts to 2,500 of each procedures annually. Half of these are likely to be performed by GI physicians. Nine PAs per week are required for these procedures, allowing for training requirements.q Endoscopic ultrasound scanning (EUS) and ERCP: these are currently performed at an annual incidence of 0.2%, with little change anticipated. Four PAs are needed for ERCP and EUS, assuming that 80% of these are performed by GI physicians.q Cancer screening and surveillance programmes: the need for screening high-risk groups within the population and the move towards more screening of the general population to identify those with cancer is now being defined more clearly.Out-of-hours endoscopy serviceThis service requires up to one consultant PA per week.Nutrition serviceThis service requires up to two consultant PAs per week.Consultant programmed activities (PAs) required per week to provide aservice in gastroenterology and General Internal Medicine in a districtgeneral hospital with an average workloadDirect patient careWhere members of the junior medical staff provide support for the inpatient service andconsultants provide the outpatient and endoscopic service, about 54 PAs are required. Thenumber of PAs required to run the service is reduced if part of the work is undertaken byconsultant colleagues – eg those in radiology or surgery might share the endoscopic workloadover and above that assumed in the calculations above. It has been assumed that half of allupper and lower GI endoscopic procedures will be performed by non-GI physicians – eitherother consultants or nurse specialists. Regular help in outpatients from junior medical staff –each of whom might contribute to the work done by around 50% of that recommended for aconsultant PA – will also reduce that consultant sessional requirement. The demands foreducational supervision have increased and are not likely to decrease. It should be noted thatcommitments may change with the development of outreach clinics in primary care andendoscopic services outside NHS hospitals.Work to maintain and improve the quality of careAdditional PAs for each consultant are required for this work. This has been estimated at 2.5PAs per consultant as per the RCP’s guidelines and includes: CPD; teaching of junior medicalstaff, nursing staff and medical students; administration and management; clinical research;and clinical governance. 149
  11. 11. Consultant physicians working with patients On the basis of these conditions and recommendations, the number of PAs needed to provide a clinical service in gastroenterology and general medicine for a DGH serving a 250,000 population can be calculated. Allowing 2.5 PAs for each consultant for the supporting activities (SPAs) given above, the total is 69 PAs (this assumes six consultants all working 11.5 PAs per week). This is about the current paid workload of consultant gastroenterologists across the UK. Table 1 summarises the work programme of consultant gastroenterologists providing a service for a 250,000 population, giving the recommended workload and allocation of PAs. Table 1 The work of consultant gastroenterologists generated by a 250,000 population (PAs per week) Programmed Activity Workload activities (PAs) Direct patient care Ward rounds (except on-take and 3 post-take) Outpatient clinics New patients 6–8 patients per clinic 9 Follow-up patients 12–15 patients per clinic 13 Diagnostic and therapeutic endoscopy Diagnostic and therapeutic upper GI endoscopy (10–12 patients per PA) 3 Diagnostic flexible sigmoidoscopy (10–12 patients per clinic) 3 Diagnostic and therapeutic colonoscopy (6 patients per clinic) 6 EUS and ERCP (5 patients per clinic) 4 Nutrition service 2 On-take and mandatory post-take rounds Rota 1:10 for this example 1 MDT meetings 3 Additional direct clinical care 6 On-call for emergency endoscopy 1 (assuming some registrar input to the rota) Total direct patient care 54 Work to maintain and improve the 15 quality of care (6 consultants) Total 69 This number of PAs indicates that six consultants with 10–12 PAs per week would be required. Consultant workforce requirement nationally The calculation allows an estimate of the consultant requirement to be made. Assuming the population of England and Wales is 52,585,000 (DH’s figures for 2004), the total need in England and Wales is 1,262 WTE consultants in gastroenterology (with general medicine).150
  12. 12. 2 Specialty Gastroenterology Assuming that the ratio between WTE and the ‘head count’ of gastroenterologists increases from the current 1:1.2 to 1:1.3 (Workforce Review Team assumption), 1,640 posts will be needed across England and Wales to fully meet service demand. Currently, there are 788 in England and 45 in Wales. An approximate doubling of posts from the current position therefore will be needed. Over the next seven years, a Certificate of Completion of Training (CCT) in gastroenterology and general medicine is likely to be obtained by around 400 trainees over and above those needed to replace those retiring, which will enable an expansion of 400 posts. These calculations have taken account of an increasing demand for colonoscopy for colorectal cancer screening. This has been estimated to generate the need for an additional 50 consultants. The calculations do not include the extra staffing required in hospitals with a major regional referral practice (eg regional liver units) or national centres (eg intestinal failure units). Finally, working patterns seem to be changing gradually, so that there are more part-time workers and increasing numbers intending to work flexibly. Although the calculations above have taken these trends into account, they may not have done so sufficiently.Consultant work programme/specimen job plan Table 2 summarises an example of the work programme of consultant physicians undertaking gastroenterology and acute general medicine, giving the recommended workload and allocation of PAs. Table 2 Example work programme of consultant physician undertaking gastroenterology Programmed Activity Workload activities (PAs) Direct clinical care On-take and mandatory post-take rounds (According to numbers of admissions, 1–4 rota and non-consultant support.) It is recommended that all other activities are cancelled for a large proportion of the time when a consultant is on take for acute medicine, which will clearly have an impact on the routine clinical workload that can be undertaken by a consultant. On call for emergency endoscopy 0–1 Ward rounds and other inpatient work 2 (except post-take rounds – see above) Referrals and specialist services 1 (eg nutrition rounds, monitoring service) Diagnostic and therapeutic endoscopy* Diagnostic upper GI endoscopy: 10–12† 1–2 Therapeutic upper GI endoscopy: 5–6† Diagnostic flexible sigmoidoscopy: 10–12† Diagnostic and therapeutic colonoscopy: 6† Diagnostic and therapeutic ERCP: 5† continued 151
  13. 13. Consultant physicians working with patients Table 2 Example work programme of consultant physician undertaking gastroenterology – continued Programmed Activity Workload activities (PAs) Direct clinical care – continued Outpatients (general medical or specialist) New: 6–8 patients per clinic 1–2 Follow-up: 12–15 patients per clinic Clinically related administration 1.5–2.5 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 eg medical director, clinical director, Local agreement lead consultant in specialty, clinical tutor with trust External duties eg work for deaneries, royal colleges, Local agreement specialist societies, DH or other with trust government bodies *List sizes will be reduced proportionately if training is included. †Numbers = patients per four-hour list. The figures given are the best estimate of consultant requirements from available evidence. They will need to be reviewed to assess the impact of the European Working Time Directive (EWTD) and the implementation and interpretation of the new consultant contract, about which much uncertainty remains. References 1. Department of Health. Clinical outcomes guidelines. London: DH, 2000. 2. British Society of Gastroenterology. Care of patients with gastrointestinal disorders in the United Kingdom, a strategy for the future. London: BSG, 2006. 3. Barrison IG. Out of hours gastroenterology. A position paper. London: BSG, 2007. 4. Barrison IG, Bramble M, Wilkinson M et al. Provision of endoscopy related services in district general hospitals. London: BSG, 2001. 5. Royal College of Physicians. Consultant physicians working with patients. Third edition. London: RCP, 2005. 6. National Institute for Health and Clinical Excellence. Nutritional support in adults, oral nutrition support, enteral feeding and parenteral nutrition. London: NICE, 2006.152

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