Demographic changes in the UK population mean that there is an increasing proportion of older patients with complex multisystem needs. There is therefore a growing need for generalist medical skills. Physicians such as geriatricians already have these skills, but other specialty physicians are increasingly utilising them as patients present more frequently with co-existing problems rather than a single specialty issue.
A total of 42% of consultant physicians currently contribute to general internal medicine (GIM). The greatest contribution is from geriatricians (20%), respiratory physicians (16%), gastroenterologists (15%), endocrinology and diabetes mellitus consultants (14%) and acute physicians (12%). There has been a trend of greater participation over recent years. To create a flexible workforce that can meet the needs of the ageing population, in future trainees will increasingly undergo training in both specialty and general internal medicine. Currently 61% of trainees are dual accrediting in GIM and a specialty.
Fig 1: Commitment to acute/general internal medicine, 2016–17
There are four main drivers for 7-day services: reducing mortality, increasing hospital efficiency, providing easier access to NHS services, and ensuring patients receive the same standard of care regardless of the day of the week.
Acute physicians may be involved in either general medical services and specialty-specific services, or both. The 2016–17 census demonstrated that 76% of all consultant physicians undertake regular contracted work in the evenings and/or weekends. A survey in 2017 showed that 72% of those working regularly out of hours felt that a full 7-day service would be ideal for their specialty, given enough resource.
Fig 2: Consultants on-call commitments, by specialty
Not surprisingly, there has been least support for 7-day services from those who already work less than full time. Currently 22% of the consultant population works less than full time. This represents 41% of female consultants and 11% of male consultants. The proportion of female consultants is growing: currently over 35% are female, but for those under the age of 35 this rises to more than 50%, with a polarisation of specialties without an out-of-hours commitment. Thus there is potentially a conflict between the needs of the population for increasing generalist skills out of hours, provided by a workforce with an increasing proportion who may be unable or reluctant to commit to this.
Fig 3: Number and gender divide of consultants and HSTs, by specialty
There is increasing demand for healthcare, while the current budget leaves the number of physicians and trainees static. To help meet demand, other healthcare providers may become involved. Physician associates (PAs) are a new healthcare professional who, although they are not doctors, work to the medical model, with the attitudes, skills and knowledge base to deliver holistic care and treatment within the general medical and/or general practice team. PAs are dependent practitioners who work within agreed guidelines and predetermined levels of senior supervision (consultant, registrar or GP).
The NHS relies on teams to design, deliver and develop world-class patient care. Effective team-working reduces medical errors, increases patient safety and improves patient mortality rates. The RCP has produced a series of four Improving teams in healthcare resources which aim to promote high-functioning teams in the clinical setting. These resources are an amalgamation of evidence, case studies and practical guidance. They are designed to be of practical use to all members of the healthcare team whether a medical student, junior doctor, physician associate or medical director. An example of one possible healthcare team is shown in Fig 4 below.
Fig 4: One possible healthcare team
Physicians are increasingly looking after inpatients within the hospital, particularly out of hours, and therefore any gaps in trainee rotas are of significance. The last consultant census (2016) revealed that overall 55% of consultants are frequently or often aware of gaps in trainees’ rotas, such that patient care is compromised in 22% of these, while in 75% a solution can be made so that care is not compromised.
Fig 5: Number of consultants aware of gaps in trainee rotas, by specialty
The situation is worst in those specialties contributing to the acute take. In 2016, LATs (locum appointments for training) were abolished in England, so that any trainee post not filled by an NTN (national training number) holder will be more difficult to fill, which is likely to exacerbate the problem. 6% of consultants are regularly asked to act down, 23% on a one-off basis. Again, this occurs more frequently in the acute specialties.
As well as being a competent clinician, a physician also needs to be a leader, researcher, teacher and trainer, involved in the management of the medical service and in training other professionals. Over a lifetime career the proportion of time spent in each of these roles will vary. The amount of time spent carrying out management, audit, research or training responsibilities usually, but not always, increases compared with clinical commitments. Within a department, roles may be distributed among several people but it is likely that every individual will undertake some activity in each area.
In the future, there are likely to be increasingly diverse demands and opportunities for consultants, with diverse working patterns. Over the course of an individual consultant’s career whole-time, less-than-full-time, 7-day working and out-of-hours commitments may all be undertaken in varying proportions. Within a specialty department, members will have different preferences at different stages, contributing to the workforce as a whole and over a lifetime career. There cannot be many professions that offer this much flexibility and variety of opportunity.
(Figures 1,2,3 and 5 reproduced from: Focus on physicians: census of consultant physicians and higher specialty trainees 2016–17. London: RCP, 2017. Figure 4 reproduced from: Improving teams in healthcare: Resource 1 - Building effective teams. London:RCP, 2017)