Workforce and job planning

Physician workforce

The number of acute internal medicine physicians recorded in the 2018–19 census of consultants and higher specialty trainees in the UK is:

Role

Total

Proportion working less than full time (LTFT)

Consultant

853

17%

Higher specialty trainee

396

12%*

*HST LTFT percentages are calculated from JRCPTB data to give overall figures which may differ from those in the census

These figures relate to physicians who work substantively for the NHS.

Consultant workforce

Acute internal medicine (AIM) is the fastest growing medical specialty in the UK. However, many consultant posts remain unfilled. In 2015 there were 90 consultant appointments unfilled – 48% of those posts advertised – and in almost all cases this was due to no applicant.

The RCP’s Acute care toolkit 4: Delivering a 12-hour, 7-day consultant presence on the acute medical unit , provides guidance on developing the acute medical service. It is difficult to accurately say how many consultants are required in AIM, as acute medical care is multifaceted, and includes the acute medical unit, short-stay ward, ambulatory emergency care (AEC), emergency department in-reach and the acute medical take. Consequently, service models vary between hospitals (see The effectiveness and variation of acute medical units: a systematic review). This variation in service model is mirrored by the varying contributions of consultants in AIM and general internal medicine (GIM). The demand for acute medical services, coupled with the shortfall in AIM consultants, has prompted hybrid models of care, for example, geriatric medicine and acute frailty services or emergency physicians and AEC. In larger teaching hospitals, specialty takes will provide care for patients with specific conditions, such as respiratory or cardiology.

The Society for Acute Medicine monitors BMJ advertisements for consultants in AIM. Their data shows that from February to September 2016 there were 162 permanent AIM appointments and 27 permanent AIM-specialty joint appointments. There was wide variation in the allocation of programmed activities (PAs) to job plans, although the recommended ratio is 7.5 direct clinical care (DCC) PAs to 2.5 supporting clinical activity PAs (SPAs). Consultant job plans should be designed according to the BMA/NHS Employers guide to consultant job planning from 2011.

AIM attracts fewer consultants to working less than full time than most medical specialties. This is an interesting observation as the sessional nature of AIM is a theoretically attractive proposition for people who wish to work less than full time. Prospective employers should still consider posts where working less than full time is supported.

To attract the limited pool of potential AIM consultants is a challenge for hospitals in the UK. Many hospitals offer attractive packages, including financial lump sums when joining. Units which are successful in recruiting consultants usually have excellent leadership and job plans which achieve the right balance of direct clinical care and commitment to service and personal development.


Job planning

Job plans vary, based on service design and local resources. The following examples are illustrative and reflect the heterogeneity of job plans in AIM. A common feature is annualisation, where an agreed volume of work is distributed over a defined timeframe. Further details on annualisation can be found in the BMA/NHS Employers guide to consultant job planning from 2011. Advice can also be sought from the Society for Acute Medicine (email [email protected]).

Example 1

The unit:

  • 54 beds, nominally 24 AMU and 30 short stay, with provision for 8 Level 1 beds
  • Ambulatory emergency care (AEC) unit co-located with AMU
  • Average take is 35 patients per day with 30% receiving their care in the AEC unit
  • 3.75 whole-time equivalent AIM consultants
  • AIM consultants cover AMU from 08.00–20.00 on Monday–Thursday and 08.00–17.00 on Friday
  • Outside these times the AMU cover is from the on-call team
  • On-call is shared with GIM on a 1:12 rota
  • Weekday on-call is a single consultant available by telephone from home
  • Weekend on-call is a single consultant on call from 17.00 on Friday to 08.00 on Monday. The consultant is resident on the AMU from 08.00–17.00 on Saturday and Sunday
  • Consultants get the day off after the weekend
  • There are separate stroke and cardiology rotas
  • The unit is closed, where specialists can visit to offer advice but patients remain under the AIM team, providing continuity of care and control over beds and patient flow.

Job plan

This example job plan is bespoke for an AIM consultant. It reflects the requirement to cover the unit at all times, as sessions cannot be cancelled.

Day

Time

Work

DCC/SPA

PA

Monday

08.00–13.00

13.00–17.00

17.00–20.00

AMU

AMU

AMU/AEC

DCC

DCC

DCC

1.25

1.0

1.0

Tuesday

09.00–13.00

13.00–17.00

Clinic (specialty interest)

Clinic (GIM)

DCC

DCC

1.0

1.0

Wednesday

09.00–13.00

Clinical admin

DCC

1.0

Thursday

09.00–13.00

13.00–14.00

14.00–17.00

SPA

Grand round

SPA

SPA

SPA

SPA

1.0

0.25

0.75

Friday

08/09.00–13.00

13.00–17.00

AMU/SSU (alt weeks)

AMU/AEC

DCC

DCC

1.125

1

Saturday

Sunday

Additional agreed activity to be worked flexibly

0

Predictable emergency on-call work (after 19.00 and before 07.00)

1.0

Unpredictable emergency on-call work (after 19.00 and before 07.00)

Total PA

11.5

AMU = acute medical unit, AEC = ambulatory emergency care, SSU = short stay unit

Example 2

The unit:

  • 42 beds, including nine Level 1 beds with an additional ten trollies for assessment
  • Level 1 beds are for non-invasive ventilation but do not cover vasopressors or inotropes; the patient to nursing ratio is 2:1
  • Average take is 35 patients per day
  • 5 whole-time equivalent AIM consultants
  • Support from GIM consultants
  • During the week (excluding Level 1) two consultants cover the unit; an AIM and a GIM consultant
  • Level 1 beds are covered by a separate consultant
  • The AIM consultant works the take Tuesday and Thursday, staying until 21.00 followed by telephone overnight
  • The GIM consultant works the take Monday and Wednesday, staying until 21.00 followed by telephone overnight
  • Both consultants then hand over their patients to weekend consultant on Friday lunchtime
  • Weekday on-call Monday–Thursday is split between two consultants, an AIM and a GIM physician
  • Weekend on-call is Friday–Sunday. The AMU is covered by a single consultant who sees all patients on AMU and the medical take and is available on the phone overnight
  • There are 15 consultants on the weekend rota, 5 AIM and 10 GIM
  • The weekend consultant takes hand over on Friday lunchtime and hands back Monday lunchtime
  • Monday lunchtime handover – the AMU is split and the weekend consultant hands over one half of the patients to an AIM consultant and the other half to a GIM consultant. Patients stay under the care of these two consultants for the rest of their stay on AMU (up to 72 hours)
  • This model provides continuity of patient care under a single consultant with the exception of weekends, although this is mitigated by a robust handover process
  • The unit is closed, where specialists can visit to offer advice but patients remain under the AIM team, providing continuity of care and control over beds and patient flow.

Job plan

The following job plan example is for a 5-week rolling rota covering 11 PAs (8.5 DCC, 2.5 SPA).

Week 1: Take week

Either:

Monday/Wednesday

Tuesday/Thursday

Friday

Or:

Monday/Wednesday

Tuesday/Thursday

Friday

-

08.00–18.00

11.00–21.00, with overnight on the phone

08.00–12.00, followed by handover to weekend consultant

-

11.00–21.00, with overnight on the phone

08.00–18.00

08.00–12.00, followed by handover to weekend consultant

Week 2: AEC

Monday to Friday

09.00–17.00, including hot clinics, DVT, OPAT, admission avoidance, virtual ward

Week 3: Level 1

Monday to Friday

09.00–17.00

Week 4

DCC administration, SPA, special skill time, teaching, research etc

Week 5

Annual leave or prospective cover for absent colleagues

On-call

Three first on-call weekends per year. See all AMU patients twice daily and acute take patients

Friday

Saturday/Sunday

Monday

12.00–21.00 and overnight

08.00–20.00 and overnight

08.00–12.00, followed by handover to weekday consultant

Three second on-call weekends per year. Ward reviews and step downs to wards from AMU

Saturday/Sunday

09.00–14.00

AEC = ambulatory emergency care, DVT = deep vein thrombosis, OPAT = outpatient parenteral antimicrobial therapy

Trainee workforce

In 2015/6 there were 336 trainees in AIM and it was the eighth largest medical specialty for training. Job prospects for trainees are very good with a number of unfilled gaps in consultant AIM posts.

Recruiting sufficient numbers of AIM trainees is problematic. In the 2016 round 1 of ST3 (specialist trainee) recruitment, only 65% of the 75 available posts were filled. In round 2, 72 doctors applied, of whom 48 accepted interview, with 43 attending. Of these, 24 were appointable, while 19 were deemed unappointable.

For many reasons, nearly all acute medical specialties are facing problems recruiting high-quality applicants. In AIM this problem is greater than in other acute specialties. In 2015 the Society for Acute Medicine and Health Education England launched takeAIM, a project to attract people to AIM, from medical students to CMT/ACCS (core medical training/acute core common stem).

27/06/2018