Workforce and job planning
The number of endocrinology and diabetes physicians recorded in the 2018–19 census of UK consultants and higher specialty trainees is:
Proportion working less than full time (LTFT)
Higher specialty trainee
*HST LTFT percentages are calculated from JRCPTB data to give overall figures which may differ from those in the census
The job planning information below is included as guidance and not intended to be prescriptive. Activities will vary according to population served, demographics and location. For further information, see the BMA/NHS Employers guidance from 2011. This guidance stated that a 10 PA job plan should include 7.5 programmed activities (PAs) dedicated to direct clinical care (DCC) and 2.5 PAs to supporting professional activities, out of which 1.5 PAs should be core SPA for CME and personal development.
The range of activities for the specialty of diabetes and endocrinology should include:
- Outpatient clinics including list sizes
- Inpatient specialty and GIM ward
- Any specialist list sizes, such as insulin pump clinic or pituitary MDT clinics
- On-call commitment will vary depending upon the local arrangements
- Commitment to GIM depends on whether the service has a bed base of diabetes/endocrine/GIM patients under their care
- Additional activities could include research, management, external work such as deanery posts etc.
The census 2015–16 has shown that the average number of PAs worked by D&E consultants is about 11.5.
Diabetes inpatient care
Specialist ward-based care
Consultants have historically undertaken two or more specialty-based ward rounds per week (2 PAs). Each ward round generates additional administrative duties, including discharge-planning meetings, meetings with relatives and discharge summaries which is time consuming (0.5–1 PA). However, in the current models of delivering acute GIM and specialist services, daily ward visits have become necessary to ensure that patients are reviewed daily by consultants and to facilitate timely review and discharge from hospital in order to maintain patient flow. This involves each consultant in an additional 0.5–1.0 PA per week. Each consultant team (minimum of two) should have no more than 20–25 inpatients under their care at any one time, including when cross-cover is needed for annual and study leave. A reasonable estimate is that to cover a ward of 20–25 inpatient beds, at least 5–6 PAs of consultant time will be needed. This does not include cover of wards over the weekend, which will require additional resource to deliver 7-day services.
Acute Medical Unit
To provide a high-quality service to patients on the AMU it has become necessary to have a minimum 12–14 hour presence and a minimum of two to three daily consultant ward rounds to review new and at-risk patients, including covering twilight period. This is essential to meet the guidelines that every acute ill patient admitted to AMU should be reviewed by a consultant within 12 hours of admission.
Specialist early supported discharge
To provide a 7-day service a minimum of 6–8 consultants is needed to provide diabetes specialist input at the front end, and care to patients admitted to diabetes and endocrine wards. However, if diabetes and endocrine consultants take part in unselected take the numbers required are likely to be significantly higher, depending on local arrangements.
Referral work involves each consultant in an additional 0.5–1 PAs. Some of the referral work can be taken on by endocrinology and diabetes nurse specialists, eg diabetes reviews. Additional specialist nurse support is required for patient self-management and education. In addition, some less complicated inpatient reviews are performed initially by trainees in endocrinology and diabetes with support and advice from their consultant colleagues.
A district general hospital (DGH) serving a population of 250,000 people could typically generate up to 600–800 new diabetes referrals and a similar number of endocrine referrals per year. The number of patients seen in tertiary centres is likely to be variable and based on the population covered and, to a degree, the level of endocrine expertise in the secondary referral centres. On the basis of consultants seeing 2–4 follow-up patients for every new patient, the numbers of consultant clinic sessions available per year and the time for patient administration to support the clinic, 5–6 consultants are needed per endocrinology and diabetes department. In addition, consultants may need to follow up about 10–16 general medicine patients per week as their contribution to the acute take and the general medical service (these are not universal arrangements), which will need to be taken into account. In a typical 10 PA job plan, consultants will only have time in their job plan to offer a maximum of three or four outpatient clinics a week. Specialty referrals, general medical referrals generated from others, and their follow-up appointments require 0.5 to 1 PA a week.
The provision of outpatient services and the casemix and complexity have changed over the last decade in diabetes. Diabetes teams often now see patients in an MDT setting (insulin pump, foot clinics, young adolescent, transition and joint antenatal and renal clinics being obvious examples), where the MDT members make an equal contribution to the clinical consultation to come to an agreed plan with the service users. These sorts of clinics therefore require adequate time to provide a good clinic consultation.
New diabetes patients should be allocated at least 30 minutes for consultant appointments and follow-up patients at least 20 minutes (longer if trainees, medical students or nurse-led clinics are working alongside the consultant, and for adolescents and young adults and patients with complex problems or in an MDT clinic). Based on a 4-hour clinic, a maximum of two new and eight follow-up patients or 10 review patients can be seen per consultant.
Experienced trainees (such as specialist trainees (StRs), associate specialists and experienced staff-grade doctors) should see fewer patients with appropriate supervision, bearing in mind quality of care and training needs, and there should be time within the clinic template to allow for discussion of these patients with consultants. Junior trainees at foundation year 2 (F2) or core medical training (CMT) grade should attend the clinic for training and should not be allocated extra patients. Attendance at 48 outpatient clinics over their 2-year training period is about to made mandatory for CMT trainees.
For general endocrine clinic lists two new and 10 follow-up appointments (or three new and eight follow-up), are manageable at consultant level if not supervising other lists. The number of follow-up slots should be reduced by two if supervising specialist trainees (StR). Specialist trainees’ lists should be limited to two new and six follow-up appointments.
For specialist endocrine clinics, especially in tertiary centres, complex patients require integration and planning of data from clinical history, other documentation, endocrine results and radiology/nuclear imaging. For a joint MDT clinic therefore, a maximum of 10 patients in total with two new and eight follow-up slots would appear adequate. Local discussion with consultant colleagues is good practice when finalising clinic templates.
Clearly, in situations where a single consultant might be supervising two trainees and two lists, this needs to be taken into account, and the consultant lists adjusted accordingly. This allows sufficient time to manage workload and ensure trainee supervision in the clinic is not compromised and the patient’s experience of clinic consultation is of optimum quality.
Given the commitment to outpatient specialty and subspecialty clinics as outlined above, covering a general medicine ward base, diabetes inpatient support and contribution to acute medical on-call and the essential training of both junior doctors, undergraduates and patients, the safest staffing level for a 21st century diabetes/endocrine department is a minimum of six consultants to deliver 5-day working and eight consultants for 7-day working.
Support from clerical and secretarial staff to arrange follow-up appointments and day ward investigations as well as phlebotomy input (many endocrine patients require blood tests which need special handling, such as ACTH) is crucial to ensure efficiency within the clinic and minimise subsequent visits (eg for measurement of complex bloods) for the patient.
Insulin pump service
- A multidisciplinary team trained in carbohydrate counting and insulin pump therapy (this should include a consultant, and at least two educators)
- Access to diabetes specific psychology services
- Ideally all members of team to have some ‘psychology’ training such as motivational interviewing/counselling skills.
- These clinics are MDT clinics and attended by a consultant with a specialist interest in CSII, a specialist dietitian and diabetes nurse specialist. The optimum time allocated to patients in a follow-up slot is about 30 mins, allowing 8 patients to be seen in a 4-hour clinic. There is recognition that these patients will frequently need to be seen outside such a clinic for other support (pump download, CGM details etc). Therefore a specialist nurse-led clinic/service is a model which is proving to be successful, in addition to the MDT pump clinic described above.
Thyroid cancer service
Workforce implications: The MDT consists of thyroid/head and neck surgeon, endocrinologist, oncologist (or nuclear medicine physician) with support from pathologist, medical physicist, biochemist, radiologist, specialist nurse, all with expertise and interest in the management of thyroid cancer. The MDT needs to meet frequently (weekly or fortnightly) to meet the needs of patients.
Nearly all patients with a diagnosis of thyroid cancer require lifelong follow-up for surveillance against recurrence (which can happen even after decades from the original diagnosis) and for the consequences of treatment (eg small risk of second new cancers due to exposure to radioiodine, renal impairment due to treatment of hypoparathyroidism). There is a need to stratify risk of recurrence after completion of treatment and adjust the intensity and frequency of follow up accordingly. A parallel specialist nurse-led clinic to the consultant led clinics is a model which is proving to be successful.
Chronic non-specific symptoms which impact on quality of life are common and access to trained counsellors and clinical psychologists is required in some cases.
Pituitary MDT and centre quality
Workforce implications: The clinicians listed above all require time in their job plans to attend the MDT. The lead clinician (usually a D&E physician) requires time to prepare for the MDT and produce reports from the MDT (typically 1 PA). In addition, the MDT requires a full-time coordinator.
Adrenal MDT and centres
Workforce implications: The membership of the adrenal MDT includes an endocrinologist, experienced adrenal surgeon, expert adrenal pathologist, adrenal oncologist, chemical pathologist, endocrine nurse specialist, with access to specialist adrenal anaesthetics. Hub and spoke models of care need to be established on a regional basis to endure appropriate patient access to specialist care, with video linking as necessary.
The clinicians listed above all require time in their job plans to attend the MDT. The lead clinician (usually an endocrinology and diabetes physician) requires time to prepare for the MDT and produce reports from the MDT (typically 0.5 PA). In addition, the MDT requires a full-time coordinator.
Reproductive endocrinology disorders
Workforce implications: This service requires a multidisciplinary approach with close liaison between endocrinologists and gynaecologists and urologists. Hub and spoke models of care need to be established on a regional basis to endure appropriate patient access to specialist care, with video linking as necessary.
The clinicians listed above all require time in their job plans.
Adolescent and young adult including transition
Workforce implications: Adult physicians and paediatricians need to work closely together to share expertise and specialist nurses are key to support the young person. NICE guidance states that all young people undergoing transition should have a member of the team who is their named worker. Young people with disorders of sexual development require a more complex multidisciplinary team around them including the involvement of gynaecology and/or urology and psychology as detailed in UK guidance.
The clinicians listed above all require time in their job plans.
Late effects of cancer therapies
- Late effects specialist nurses embedded in the service as the patient’s key worker and care coordinator and to provide health promotion
- MDT coordinator
- Specialists outside of oncology experienced in managing specialty-specific late effects of cancer
- Access to clinical psychologists experienced with working with survivors.
- Adrenal surgery needs to be performed by appropriately experienced adrenal surgeons embedded within an adrenal MDT
- An adrenal MDT with core membership as defined in the Specialised Endocrine Services Specification, NHS England.
Leadership and coordination of the broad service is usually provided by an endocrinologist with a specific interest in adrenal disorders. An effective, networked model for adrenal disease allows the many effective treatments within this field to be most appropriately delivered to those most in need, thereby ensuring cost effectiveness and best outcomes.
- Endocrinologist/chemical pathologists with an interest in lipid disorders
- Lipid clinic set up according to local service needs
- Access to genetic testing to individuals felt to be at risk of familial hypercholesterolaemia (regional laboratory that hosts DNA testing)
- Access to CASCADE testing for high risk individuals and their families through FH nurses
- Access to new therapies (eg PCSK9 inhibitors)
- Lipid nurse to provide ongoing support to patients, initiating injectable treatments and ongoing reviews.
Bone and mineral disorders
- Fracture liaison nurses as part of an embedded fracture liaison service at all sites managing fractures (secondary or primary care-based)
- DXA scan technical staff
- Parathyroid surgery performed by appropriately experienced parathyroid surgeons.
Disorders of sex development (DSD)
- A multidisciplinary team trained in DSD
- Access to DSD specific psychology services
- Access to urology, obstetrics and gynaecology services with expertise in DSD
- Provision of weekday support from endocrine unit (via telephone).