Changes in working practices

The consultant physician perspective

RCP Workforce Unit

Role of the College

To improve the quality of patient care by continually raising medical standards

Key areas pertinent to today:• Monitoring physician numbers• Setting standards for acute care including

handover• Reviewing impact of EWTD

Consultant delivered service

Specific issues:

• EWTD• Consultant and registrar expansion• Patient/doctor ratios• Quality of training

EWTD on patient care and trainingMuch better

Better No change WorseMuch worse

Has EWTD changed the quality of your training? 0.9% 5.1% 44.8% 37.8% 11.4%

Has EWTD changed the amount of specialty training you undertake? 0.6% 4.5% 42.9% 41.0% 11.0%

Has EWTD changed the amount of GIM training you undertake? 0.7% 6.7% 52.8% 30.0% 9.8%

Has EWTD changed the quality of patient care? 0.7% 4.6% 36.5% 42.0% 16.2%

Has EWTD changed the quality of patient care relating to continuity of care?

0.6% 2.3% 25.5% 32.6% 39.0%

Has EWTD changed your quality of life at work? 0.9% 10.5% 39.7% 40.1% 8.8%

Has EWTD changed your quality of life at home? 4.2% 23.8% 47.5% 16.8% 7.7%

Have you had problems implementing EWTD? 68% said yes

• “Multiple. Junior presence on the wards is fewer, patient care has been compromised. Occasionally Consultant has cancelled elective activity to cover juniors’ jobs.”

• “Cannot find any external locums.”• “If there is even a single person off sick or on unexpected

leave there are insufficient junior staff hours to adequately cover all the requirements for the functioning of the firm as a whole.”

• “Major problems, need to beg/force internal locums to help at short notice causing unhappiness.”

• “Yes – shift pattern very disruptive to training.”

How often do you use locums?

Strongly agree

Agree Neutral DisagreeStrongly disagree

Internal locum cover is easy to organise 1.6% 6.3% 12.7% 46.0% 33.3%

External locum cover is easy to organise 1.6% 4.8% 6.5% 30.6% 56.5%

Internal locums are usually reliable 25.8% 71.0% 3.2% 0% 0%

External locums are usually reliable 1.6% 19.4% 45.2% 30.6% 3.2%

Internal locums are usually high quality 23.8% 57.1% 17.5% 1.6% 0%

External locums are usually high quality 0% 9.7% 41.9% 40.3% 8.1%

Patient care is usually worse when internal locums are employed

1.6% 3.2% 9.5% 66.7% 19.0%

Patient care is usually worse when external locums are employed

9.7% 33.9% 43.5% 12.9% 0%

Sickness rates

T otal epis odes of s ic k leave taken

0

5

10

15

20

25

30

35

40

HO S HO R E G

T ra ining g ra de

Epis

odes

8/2006 - 8/2007

8/2007 -8/2008

Tra ining

How to we solve EWTD and H@N?

Increasing the number of consultants• Benefits

– Shorter patient stay– Reduced mortality– Improved patient safety– More trainers– Less restrictions within EWTD– Low sickness rates

• Drawbacks– ?Increased readmission rate– Cost

Early discharge and consultants on AMU

McNeill et al, Clin Med 2009

3,500

4,000

4,500

5,000

5,500

6,000

6,500

7,000

7,500

8,000

8,500

9,000

9,500

10,000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Census year

To

tal

nu

mb

er o

f co

nsu

ltan

ts

0

1

2

3

4

5

6

7

8

9

Total number of consultants

Annual % consultant expansion

An

nu

al % co

nsu

ltant exp

ansio

n

Consultant numbers and expansionEngland, Wales and Northern Ireland 1994 - 2002United Kingdom 2003 - 2008

Cardiology trainee’s future

Since 2001:

Registrar numbers have increased by 66.3%

Consultant numbers have increased by 25.9%

My team – April-June 2009

0

5

10

15

20

25

30

35

40

45

50

Patients per doctor

Summary

• EWTD has stretched the profession• Night-time care is currently maintained but

under threat in the future• Consultant expansion is needed• There is a large emerging workforce which

could be used