Workforce and job planning

Physician workforce

The number of respiratory 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

1,456

16%

Higher specialty trainee

765

11%*

*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. 

Job planning

The job plan below is an example 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.

Respiratory medicine job plan

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 (0.5–1 PA). Daily ward visits have become necessary to ensure that patients are reviewed daily by consultants and to facilitate timely review and discharge from hospital. This involves each consultant in an additional 0.5–1.0 PA per week. Each consultant team should have no more than 20–25 inpatients under their care at any one time, including when cross-cover is needed for leave. Respiratory wards often manage patients with a high need for expert monitoring, management and consultant input, including those stepped down from the intensive treatment unit (ITU). The maximum inpatient load for consultants should be halved when such patients are included.

Medical Admissions Unit

To provide a high-quality service to patients on the MAU it has become necessary to have a minimum of twice daily consultant ward rounds to review new and at risk patients.

Specialist early supported discharge

To provide a 7-day service a team of at least six professionals is required. The team usually includes respiratory nurses, respiratory physiotherapists and occupational therapists under the clinical supervision of a respiratory consultant who requires time to meet the team and discuss patients on a daily basis.

Inpatient referrals

Referral work involves each consultant in an additional 0.5–1 PAs. Some of the referral work can be assumed by respiratory nurse specialists, eg COPD and asthma reviews. Additional specialist nurse support is required for patient self-management and inhaler technique education.

General respiratory outpatients

A DGH serving a population of 250,000 people typically generates 900 new non-cancer respiratory referrals per year. On the basis of consultants seeing 2–4 follow-up patients for every new patient, the number of consultant clinic sessions available per year and the time for patient administration to support the clinic, a total of 11–12 PAs per respiratory department is required for respiratory clinics. 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. Most consultants only have time in their job plan to offer 2–3 outpatient clinics a week (1 PA each) for specialty referrals, general medical referrals and follow-up appointments. New patients should be allocated 30 minutes for consultant appointments and follow-up patients 15 minutes (longer if trainees, medical students or nurse-led clinics are working alongside the consultant and for patients with complex respiratory problems). Based on a 4-hour clinic, a maximum of four new and eight follow-up patients can be seen per consultant. Experienced trainees (such as specialist trainees (StRs), associate specialists and experienced staff-grade doctors should see fewer patients. More 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.

Lung cancer services

The service requires 10 PAs spent in lung cancer per 200 new patients per year, one full-time lung cancer nurse specialist per 80 new diagnoses per year, access to medical and clinical oncologists with at least one third of their job plan devoted to lung cancer, and access to specialist thoracic surgeons. There must be local provision of first visits with respiratory physicians, with the above expertise and supportive infrastructure. This may mean commissioning these services from the centre where it may be easier to attract doctors with the necessary specialist interest. These clinicians will need travel time to provide services locally.

Lung cancer MDT

The clinicians listed above all require time in their job plans to attend the MDT. The lead clinician (usually a respiratory physician) requires time to prepare for the MDT and produce reports from the MDT (typically 2 PAs).  In addition, the MDT requires a full time coordinator for every 300 new patients per year.

Secondary care asthma service

To provide an inpatient review service a respiratory consultant requires the support of a full time asthma nurse and at least one PA for inpatient referrals. Additional sessions are required for a weekly asthma clinic (1PA), and bi-monthly transition clinic (0.25 PAs) an asthma MDT (0.5 PAs) and for time to support networks of asthma care (1PA).

Regional difficult asthma service

NHS England has set out the staffing requirements for a tertiary difficult asthma service.

COPD

A COPD service requires specialist respiratory nurse support to assist in patient review, education and self-management, stopping smoking support, administrative support, and access for patients to pulmonary rehabilitation.

Tuberculosis

The lead clinician in a DGH requires 1 PA per week for every 50 new cases per year.  A TB service requires one full-time equivalent TB clinical nurse specialist (CNS) for every 40 index cases, one TB CNS WTE for every 20 enhanced case management cases and one TB CNS WTE per 80 latent cases. Additional PAS are required for network activities. The TB service requires administration support. The TB MDT requires the presence of respiratory and infectious disease specialists, a radiologist, a microbiologist and a paediatrician. The British Thoracic Society (BTS) offers an MDRTB Clinical Advice Service with the aim of ensuring that all cases of MDRTB are discussed via a virtual multi-disciplinary team meeting.

Interstitial lung disease (ILD)

For a DGH, in addition to the time required to see patient in outpatients at least 2 PAs per month are required to prepare for and attend regional MDTs. For the regional ILD centre at least 0.5 WTE respiratory physicians working exclusively in ILD, but may be 1–2 WTE depending on population/workload. In addition, a regional service requires at least 0.25 WTE dedicated respiratory pharmacists and a 0.5 WTE service/MDT coordinator. NHSE has set out a service specification for adult ILD services.

Sleep disordered breathing

BTS estimates that up to 2 WTE consultants are required in each DGH to provide a comprehensive service for patients with obstructive sleep apnoea (OSA). In a regional service offering complex investigations another 2–3 WTE are required which may cross specialties including neurology or psychiatry depending on local expertise. Clinic support and training require junior doctors at ST3 and above to be involved in the service. Diagnostics are usually organised by appropriately trained technical staff. These staff and nursing specialists can supervise trials of treatment and follow-up services in consort with medical specialists. For 2,000 patients in a DGH setting 3 WTE staff might be required with technical or nursing backgrounds.

Bronchoscopy

BTS has produced guidance detailing the minimal staffing and competency levels required to perform both standard and complex bronchoscopy and guidance on the number of patients who can be investigated on each list.

Non-invasive ventilation (NIV)

While acute NIV is often delivered by specially trained physiotherapist or nurses, NIV services require a designated respiratory consultant lead who will require 1–3 PAs to perform this role. BTS has recently published Quality Standards for acute NIV following publication of the 2017 NCEPOD report, Inspiring Change.

Domiciliary assisted-ventilation service

1 PA should be allocated to run the domiciliary service for every 50 patients, including 10 new patients per year. It is likely that the sessional commitment required for this respiratory service will increase significantly.

Occupational lung disease (OLD)

Each OLD centre should be staffed by at least two consultants with expertise in occupational lung diseases; jointly they will accept and see a minimum of 50 new referrals per year, managed through an existing care pathway where one is available. Consultants who work in such units will receive many tertiary referrals and will require at least 3–5 PAs per week for this complex work. Specialist nurse input is regarded as vital, as is a dedicated pulmonary physiologist to carry out specific challenge work. Time will need to be specifically factored in for clinical assessment, challenge work, MDT work, and home and workplace visits.

Cystic fibrosis

The Cystic Fibrosis Trust recommends 0.75 WTE of specialist consultant grade time per 50 patients under full care, supported by a full range of supporting staff, including non-consultant career grade (NCCG) doctors. A respiratory physician providing local care will require half of the PA allocation stated above, based pro rata on the number of cases.


Pulmonary hypertension

NHS England has set out the staffing requirements for hub and spoke pulmonary hypertension services.

Lung transplantation

Each centre requires consultant physicians who specialise in the assessment and management of patients after transplantation. At least 5 PAs per week are necessary.

18/09/2018