Posts Tagged ‘Acute medicine’

New doctors doubt readiness for acute care

By Mike Broad - 13th December 2011 10:11 pm

Young doctors perceive themselves to be least well prepared in acute care and prescribing, a study reveals.

The study, which involved an extensive literature review, examined the preparedness in acute care and other Tomorrow’s Doctors outcomes of newly qualified doctors and the perceptions of their colleagues.

Senior colleagues also doubt newly qualified doctors’ ability to deal with acutely ill patients.

Last month, Dr Foster’s Hospital Guide suggests patients requiring emergency care were more at risk at weekends and would benefit from more consultant cover.

This research suggests that the education of juniors is also an issue.

The ability to recognise acutely unwell patients and to instigate generic resuscitation is essential for all newly qualified doctors. However, this research suggests that recent changes in UK undergraduate training, while improving preparedness in some areas, may have neglected acute care.

The authors, from the University of Edinburgh, said the results - published in the Postgraduate Medical Journal - “may be of little surprise” to those involved in either undergraduate or postgraduate medical training.

They added: “While not a good surrogate for actual preparedness, perceived preparedness is important in influencing the behaviour of new graduates and therefore warrants further consideration.”

Read the full paper.

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How can we meet the demand for medical generalism?

By Mike Broad - 23rd November 2011 10:34 am

The career aspiration of most young doctors is to become a specialist.

From the day they walk into medical school they are largely taught by consultants with impressive job titles who have spent most of their career becoming super-specialised in their particular field.

In addition to being culturally groomed for specialisation, rapid advances in medical science and health technology have driven the growth of sub-specialisation. Depth rather than breadth has become the medical paradigm. Specialism holds the key to professional acclaim, prominence and esteem.

Conversely, generalism has bordered on extinction in many of the larger hospitals.

Dr Laurence Buckman, chair of the BMA’s GP committee, comments that “generalism in hospital has largely disappeared - and I am not suggesting that this is a good thing - but I think that the era of the general physician with an interest in something has largely gone. That is not necessarily in the best interests of patients, but it is so”.

The Association of Surgeons goes further saying the term generalist is now “pejorative” and this will not improve unless the general surgeon, general physician and GP are rewarded for their holistic approach to medical care.

The irony of the decline of generalism’s standing is that in hospital medicine - not just primary care - it’s needed now more than ever.

The UK’s ageing population has profound implications for the NHS. Almost 45% of all hospital in-patient treatments in 2009-10 involved people aged 60 or over, and patients aged 60-74 stayed an average seven days in hospital in 2009-10 - 11 if they were aged 75 or over. This compares to an overall average of 5.6 days.

Six out of ten older people are now thought to be living with at least one long-term condition, many of whom have two or more.

Complex needs do not fit neatly into one specialty, and a clear need for doctors who can competently deal with the whole patient begins to emerge.

This mismatch between patient need and doctors’ career aspirations prompted the Royal College of GPs and the Health Foundation to set up high profile commission to review medical generalism with a view to its future development.

The review suggests that the new demographics - 18 million people living with a long-term condition within 20 years - demand a fundamental reappraisal of how medical students are taught to think about illness and disease.

In order to learn how to deal with far greater degrees of complexity and uncertainty than their predecessors would have faced, trainee doctors will need to dwell much less on narrow disease silos and to focus much more on the breadth of possible permutations of co-morbidity.

Professor Sir John Tooke, vice provost (Health) of University College, London, says: “Part of the way of dealing with this is to stop trying to think of medical education as a series of systems or disciplines; it is really thinking of it as a more holistic process and series of care pathways which will involve a range of conditions which happen to present in different ways.

“It is re-thinking how you package the experience.”

A pragmatic first step, however, would be to build more emphasis on generalist skills into the training regime. As the Royal College of Physicians commented, increasing generalist skills in hospitals will complement - not challenge - excellent specialist skills and help to improve patient care overall.

The other significant driver behind the resurgence of medial generalism in hospitals is the demand for increasingly consultant-led, round-the-clock, high quality care. To achieve this, a more equal balance between generalism and specialism will be required.

The commission’s review calls for closer integration between generalist and specialist working. Well-trained staff are most effective in well-designed models of care, it says. To capitalise on the skills and approach of the generalist in either community-based or hospital-based services, models of shared care are needed so that the additional expertise of specialists can be embedded in a predictable and robust way.

But the commission also calls on generalists in both primary and secondary settings to be able to demonstrate the value of what they do and take pride in their professional and public profile. Above all, there is insufficient robust and up-to-date research to be able to evaluate and inform adequately all aspects of generalist practice and its relationship to specialist services, the review concludes.

Other recommendations of note include appraisal systems including assessments of the relationship between generalist and specialist services; development of quality indicators to measure performance over a broader range of patient outcomes; and, a care payment system that recognises the whole person rather than promoting piecemeal treatment.

The Royal College of Physicians called the review “timely” and said it’s crucial to consider whether the medical workforce has the right mix of skills to deliver the highest standard of care to patients.

College president Sir Richard Thompson said: “Patients need doctors with the skills, knowledge and expertise to make rapid diagnoses, find new and innovative ways of treating diseases, and provide holistic, high quality care both in hospitals and the community.

“Patients are increasingly likely to have complex needs that do not fit within one speciality, for almost two-thirds of hospital beds are occupied by people over 65. More doctors must be better placed to respond to these patients’ needs. Whereas specialist care delivers the best outcomes for those with well-demarcated clinical syndromes, we believe that increasing generalist skills in hospitals will complement excellent specialist skills and help to improve the overall care of patients.

“Excellent generalist care must be valued as much as specialist treatment, with doctors encouraged to gain experience in a range of care settings in order to develop a broad base of skills.”

Hospital Dr has teamed up with exhibition company Closer Still to help acute and general physicians maintain and develop their ‘broad base of skills’. Attend Acute & General Medicine Conference 2012 for free – if you register now. Click here for more information.

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“Toolkit helps physicians meet acute pressures”

By Mike Broad - 21st October 2011 11:46 am

A new toolkit to support high quality care for acutely ill patients has been launched by the Royal College of Physicians.

The pressures on acute medical services in NHS trusts are immense, it says, with increasing numbers of patients with medical emergencies are being admitted to hospital, particularly elderly patients with multiple, complex medical conditions.

The RCP says this workload requires care to be organised on the basis of seven-day working and to ensure that sufficient staff with the right skills and expertise are available to not only meet demand, but also provide the best outcomes for patients.

The toolkit highlights the key principles of high quality care applicable to all patients and makes recommendations in relation to six recognised problem areas which include limited acute consultant physician hours in AMU; standardisation of early warning scores to track deteriorating patients and trigger intervention; standardisation of documentation and prescribing; and, poor quality handovers.

The toolkit recommendations include guidance on job plans, rotas, the mix of consultants involved, clinical leadership and teaching.

There’s also advice on implementing the forthcoming National Early Warning Score to identify patients whose condition is deteriorating and take early corrective action.

The toolkit makes particular reference to uniform medical record-keeping across the NHS using standards developed by the RCP’s Health Informatics Unit, and developing and using standardised observation, prescription and fluid balance charts. The importance of high quality handover is also emphasised.

Dr Mark Temple, RCP acute care fellow, said: “The relentless increase in emergency admissions is the number one concern of doctors in the NHS. This pressure is likely to intensify in the next few years and the challenge to all staff is to ensure patient care is consistently safe and of the highest quality.”

Acute care toolkit 2: High quality acute care is the second RCP acute care toolkit, providing practical solutions and recommendations with the aim of improving the care of acutely ill patients.

See the toolkit.

Register for free, CPD-accredited acute and general medicine training here.

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“Support extended consultant delivered services”

By Mike Broad - 21st September 2011 1:58 pm

A leaked NHS London report suggests that over 500 deaths a year in London could be prevented if consultant cover was increased at weekends.

Sir Richard Thompson, president of the Royal College of Physicians, commented on the report in a letter published in The Independent.

Here is that letter in full:

Dear Sir,

Your article ‘Hospital staff shortages cause 500 deaths a year’ shows too few junior doctors are caring for too many patients over night and at the weekend. Patients who are admitted to hospital in the evening and at the weekend risk receiving sub-standard care.

Despite the best efforts of consultants who work above their contracted hours, patients are not getting sufficient input to their care from senior doctors during these periods. The supervision and training of junior doctors is also adversely affected by a lack of senior input during these periods. More doctors are required to provide this high level service.

The Royal College of Physicians believes that there is an urgent need to review workforce patterns in hospitals to ensure that medical in-patients receive direct input from consultant physicians on a seven day a week basis.

We previously issued guidance for physicians caring for very sick patients. Hospitals admitting acutely ill medical patients should have a consultant physician on-site for at least 12 hours per day, seven days per week, at times related to peak admissions. Consultants should have no other duties during this period.

We can begin now by reconfiguring acute services. Concentrating specialist services in centres of excellence will improve standards and help to provide a consultant delivered service.

Furthermore, junior doctors’ contract, the New Deal, and the European Working Time Directive must be renegotiated to provide more local flexibility when designing staff rotas in hospitals.

The RCP calls on the government to take urgent action to ensure that extended consultant delivered services - providing safer care for patients and the opportunity for excellent training of the next generation of doctors - can be achieved.

Yours faithfully

Sir Richard Thompson

President

Royal College of Physicians

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More weekend consultant cover could prevent deaths

BMJ - 9:31 am

Increasing cover by consultants in acute medical and surgical units at weekends could prevent more than 500 deaths a year in London, early findings from a review of acute medicine and emergency general surgery services in the capital have shown.

The electronic survey of the 31 hospital emergency units in London, conducted in March by the strategic health authority NHS London and London Health Programmes, an NHS unit that aims to improve the delivery of healthcare in the capital, found that on-call consultant presence on site is significantly less overnight and at weekends than on weekdays.

Only half of patients admitted as medical emergencies at the weekend were “always” seen by a consultant within 12 hours, compared with three quarters on weekdays.

The draft report Acute Medicine and Emergency General Surgery: Case for Change also shows that in 2009-10 the hospital mortality rate in London was 0.32% higher for patients admitted at the weekend than among patients admitted during the week.

Read more at the BMJ.

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What does the future hold for acute medicine?

By Dr Chris Roseveare, consultant in acute medicine at Southampton University Hospitals NHS Trust and president of the Society for Acute Medicine - 24th July 2011 1:35 pm

I didn’t train in acute medicine. In 1994, when I started ‘specialist’ training, this was not an option. The idea, back then, that consultants be trained specifically to manage and run the medical ‘take’ was as alien as the sight of a consultant clerking a patient on the ward. Medical take was the responsibility of the on-call medical registrar. The consultant was available for moral support, and possibly for the admission of royalty or an A-list TV personality, but was certainly not a ‘hands on’ presence.

On my first day as a medical registrar I led the post-take ward round with two ‘juniors’. I was not fazed by this - after all I had been an SHO in a DGH for 2 years and had passed my MRCP two months earlier; medical take was easy….or so I thought. I traded my white coat for a pin-striped suit to ensure that nobody doubted my credentials and off I went. If I had known then half of what I have learned since, I suspect I would not have been quite so confident in my abilities.

It is hard to believe how much has changed in the intervening 17 years. Nobody wears a suit now - ‘bare below the elbows’ made sure of that - and every patient gets a consultant review within 24 hours. In some hospitals, the consultant will see patients within minutes of their arrival and there is increasing pressure to provide this level of care seven days per week.

This will require a considerable increase in the numbers of hours of consultant time devoted to acute medical care, but who will be providing this? Will it be the new breed of full-time, trained ‘acute physicians’ or an ongoing responsibility for doctors trained in other medical specialities, dually accredited in general medicine?

Let’s consider the numbers - a seven day, 12 hours per day, consultant-led service, as recently proposed by the Royal College of Physicians, would require at least seven full-time acute physicians; double this if an overnight presence were also required. Over a thousand new appointments at a time when the NHS is tightening its belt? I think not.

There will be many acute medicine consultant appointments over the next few years; most of these will go to trainees who have completed an acute medicine training programme. A full-time acute physician can lead and develop the service and should provide value for money in their daily role on the AMU. However, in reality most hospitals will have to rely on ‘general’ physicians participating in the acute take for the foreseeable future.

So, would I recommend junior doctors to train in acute medicine? Unequivocally ‘yes’. If you want to be an acute physician the training is designed to prepare you for the role. I have filled in many of the gaps from my general medicine training in the 12 years since I was appointed, but I am envious of the experience which our current trainees (and my recently appointed acute medicine-trained colleague) have been able to attain.

As yet there are no data to prove that a trained acute physician is more effective on the AMU than a dually accredited specialist/general physician, but I suspect this will come with time. In the meantime a balance needs to be maintained - general and acute physicians, working side-by-side, is a model which is likely to continue and should be supported.

To attend a high quality and  affordable acute and general medicine training in 2012 register your interest here.

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“Doctors and managers must not forget the lessons of Stafford”

By Dr Paul Woodmansey, consultant cardiologist at Mid Staffordshire NHS Foundation Trust - 23rd February 2011 4:14 pm

This article first appeared in a recent issue of the RCP’s Clinical Medicine.

Stafford Hospital, or as it is more usually referred to in the press, the ‘beleaguered’, ‘troubled’ or ‘scandal hit’ Stafford Hospital, is a medium-sized district general hospital sited near the centre of a small town surrounded by beautiful countryside and a handful of small market towns. It is generally considered to be a pleasant place to live and bring up a family, lying in a rural oasis between the urban sprawls of the Black Country to the south and the Potteries to the north.

When the Healthcare Commission published its report in March 2009, this modest hospital was catapulted onto the front pages of national newspapers and politicians queued up to express their disgust on television and the radio. There has been much discussion within the hospital and local papers as to whether some accounts of poor care were exaggerated, the use of hospital standardised mortality rate (HSMR) has been strongly questioned and many colleagues elsewhere have expressed relief that it was our hospital not theirs which had received such in-depth scrutiny.

It soon became clear that the real position of the hospital in the national league of awfulness did not matter. What did matter was that many patients had received poor care and, for some, their treatment was appalling.

The reason for this has been picked over at length but it essentially boiled down to poor managerial and clinical leadership in some areas, lack of clinical staff, particularly nurses, with inevitable low morale and, to some extent, lack of equipment.

What kind of hospital is Stafford at the time of writing in October 2010? Certainly not perfect, but by many measures vastly improved. There are more consultant posts in the emergency department and the number of consultants in acute medicine has increased. There has been a review of surgical specialties and a significant increase in nursing numbers.

For the staff, it remains a work in progress and much is still to be done to regain the confidence of the local population.

While many poor judgements were made and the need to blame is entirely understandable, it is important to recognise that nobody who worked at Mid Staffordshire Foundation Trust came to work with the intention to do harm. However, the entire senior management team has since been replaced, many by short-term appointments. This has been necessary and helpful, but also unsettling.

How did we let it happen?

No doubt all the consultants in Stafford have asked themselves this question. There were certainly times when consultants raised serious concerns and it seems that ‘the management’ did not listen or did not act. We understood the very difficult financial situation and most of the time we did as many in the health service do, and got on with our daily jobs working very hard to make the best of difficult circumstances.

It is important to understand that in most parts of Stafford Hospital patients were receiving good treatment, but it is sobering to realise how one can get used to such poor standards in other areas. In retrospect more of us should have made it clear that there were unacceptable staffing levels and practices in emergency care.

New way of working

If a hospital’s performance was measured by the number of visiting agencies visiting the place, Stafford would be by far the best hospital in the country. Of particular value to the consultant physicians was the help offered by Dr Ian Sturgess and Russell Emeny of the interim management and support team and Professor Sir George Alberti.

It seemed that this terrible situation could be turned into an opportunity to make genuine improvements. A small group led by myself and Dr Shaun Nakash in acute medicine realised that consultant input was the key to better and more efficient patient care.

We practised the old model of the acute medical take which was run by a specialist registrar with a morning consultant-led post-take ward round the following day. In the summer of 2009, a few of us informally trialled a ‘new way of working’ in which all patients referred to medicine would be seen by the on-call consultant as soon as possible, ideally within two hours of referral. The assessment was recorded by a junior doctor on a specially designed page in the emergency care pathway which prompted the consultant to make a clear problem/diagnostic list, management plan and to estimate the date and time of discharge, whether venous thromboembolism prophylaxis was required and the most appropriate ward for the patient, or if community care was possible.

After what seemed to be a successful trial, the entire consultant physician body accepted the new way of working and it was formalised from July 2009. The acute medical consultants manage the weekdays between 0800 and 1600 after which the on-call physician takes over and is present on the ‘shop floor’ from 1700 to 2030. A post-take ward round for all the night patients is carried out at 0800 the following morning.

This is consistent with the guidelines produced by the Royal College of Physicians for managing non-elective care.

In December 2007, we introduced a Saturday morning ‘trouble-shooting’ round in which the on-call consultant visited all the medical wards to see any sick patients and to aid weekend discharges. More recently a similar Sunday morning ward round has been introduced. The ‘new way of working’ at the weekends involves the attendance of the on-call physician in the afternoons and into the evening in addition to the Saturday and Sunday morning post-take rounds.

We do not claim that this approach is unique, but it has led to an increase in early discharges and appears to have coincided with a reduction in mortality including at the weekend. What has struck me particularly is the relative ease in which this major change to our working lives was introduced.

So, how did it come about? Consultants proposed the change and tried it and their colleagues quickly accepted that it was good for patient care.

Work in progress

Having made some progress with the first 48-hours of acute medicine, we are currently focusing on care on the specialty medical wards. Perhaps the greatest challenge to consultant physicians (and our managers) is the recognition that a consultant delivered - not led - service is required. I suspect that most people accept the principle, but the practice tends to be more difficult.

It is necessary for patient safety and because of the pace of life in a modern hospital, including the need to reduce length of stay and our inability to rely on junior doctors means that our patients need senior input every day.

It should involve seeing all new patients on the ward, all sick ones and some of those planned for home. Many timetables (including mine) are set up in such a way as to make this difficult. However, daily review is best practice. I believe that we need to remember that the reason we have hospitals is to care for the acutely ill and while outpatient activity is very important, the relative priorities, including financial ones, have become distorted.

A patient with stable angina can wait a while with little risk. When a patient with an acute cardiac condition, severe enough to be in hospital, is admitted to my ward on Monday afternoon after my ward round, it is simply wrong for them to have to wait to see me until my next planned round on Thursday. I and my colleagues therefore squeeze in ward reviews and in-patient referrals in between other activities, but we are now working in job planning to make this core activity.

A personal view

In my opinion a major underlying cause of the ‘Stafford scandal’ was that most of us, including politicians and healthcare professionals, had lost sight of the fundamental priority of a national health service. That is to provide excellent and immediate care to those who become suddenly very unwell. There have been tremendous improvements in many areas such as cardiac, cancer and orthopaedic care.

However, the importance of the care of sick elderly patients who make up the bulk of our medical ‘takes’ have only rarely grabbed the headlines. Care of these patients is expensive in staff time and resources, it is often difficult and tiring and can only be delivered in a high-quality way by departments which are equipped appropriately, are well staffed by motivated individuals and led by enthusiastic consultants.

What are the lessons to learn?

It might be comforting to imagine, but no one should fool themselves into thinking, that the problems which occurred in Stafford were unique. Our hospital did not have the worst HSMR in the country during the period under investigation. Delivery of good healthcare is difficult, particularly in the pressured environment of emergency care.

Much as I would love to return to the relative anonymity of old, politicians, healthcare mangers and clinical staff must not forget the lessons of Stafford. What does it say about this still rich country if we cannot fund sufficient nurses and doctors to look after our sick and elderly when they most need it? As consultants we are the ones who need to lead change and we are the most powerful advocates for our patients and sometimes have to muster the courage to state loudly and clearly when ‘care’ is simply not good enough.

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“More consultant cover needed out-of-hours”

By Mike Broad - 2nd December 2010 9:58 am

Senior doctors need to be more available to work in acute admissions units, a survey finds.

The research, by the Royal College of Physicians, on the way care for very ill patients is managed recommends that hospitals need to increase the out-of-hours availability of consultants for acute care.

Care for very ill patients has improved significantly over the past few years due both to the introduction of acute medical admissions units in most major hospitals, and a major increase in the number of consultant physicians specialising in acute medicine to assist other hospital specialists working in acute medical admission units.

Despite these changes, the RCP says, many patients are only seen once per day in a formal ward round instead of the recommended two daily ward rounds. In three quarters of the acute medical admissions units accepting patients directly from GPs, there are regular bed shortages, so the report recommends that there are sufficient beds in future to ensure that very ill patients gain appropriate access to acute admissions wards.

Sir Richard Thompson, the new president of the Royal College of Physicians, urged the government to address the standard of care in hospitals in the evenings and at weekends. He said new working patterns are needed.

Forty eight per cent of consultant physicians responsible for assessing and treating the acute take still have to do routine clinics or other parts of their job as well as at the same time seeing the urgent patients. These duties should be cancelled on those days to allow physicians to concentrate wholly on the very ill patients.

Only 3% of hospitals provided weekend cover from consultant physicians specialising in acute medicine for nine to 12 hours and none for over 12 hours. Nearly three-quarters of hospitals in the survey had no cover from consultant physicians specialising in acute medicine over the weekend.

An accompanying statement from the RCP council recommends that consultant physician cover is available in hospitals every day for 12 hours per day.

Dr Jonathan Potter, clinical director of the RCP’s clinical effectiveness and evaluation unit, said: “Despite improvements in facilities and staffing, hospitals still need to address working arrangements to ensure that senior doctors are readily available to provide a consultant led service in acute medical admissions units seven days a week.”

Previous studies show that a consultant-delivered service is best for patient treatment and recovery.

Representatives of 126 hospitals completed the survey - 114 from England, six from Northern Ireland and six from Wales.

Read the RCP president’s blog on the issue.

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Acute admissions unit in Watford shows way

By Francesca Robinson - 4th November 2009 8:41 am

A next generation acute admissions unit - one of the largest in the UK - has cut death rates and the time patients stay in hospital since it opened in March.

Early figures show that the average length of stay at the 120-bed unit at Watford General Hospital has fallen by 1.9 days to 5.4. Standardised mortality ratios and readmission rates have also fallen.

But the success of the unit in fast tracking patients is putting pressure on other hospital departments where the throughput of patients is slower.

The unit, created as part of a reconfiguration of acute services by West Hertfordshire Hospitals Trust, enables patients admitted as an emergency to be seen and assessed rapidly by a consultant. 

The consultant physician on duty can readily access specialists in respiratory medicine, cardiology, neurology, gastroenterology and rheumatology, who visit the unit regularly.

The unit houses state of the art diagnostic equipment, two new cardiac catheterisation laboratories and a modern pharmacy department with a robotic dispensary. A short stay ward enables patients to be monitored for 48 hours.

“This model is becoming increasingly used by NHS trusts for obvious reasons and it really is the way to deliver acute services and acute care,” said the trust’s medical director Dr Colin Johnston.

The unit is run by a team of three acute care physicians who do the early morning ward rounds then deal with new admissions that arrive in the morning. A specialty ‘physician of the day’ works a shift from 1-9 pm and is on call for the rest of the night. At weekends consultants will work 9am to 9pm, seeing patients as they come in.

The rapid turnover of patients has put pressure on staff. Johnston said: “People are having to work very hard in the unit. Patients are coming through all the time and there is a lot of pressure to see people and triage them quickly. It is tough on consultants, particularly the more senior ones who are not used to this intensity of work. It has been a big change.”

He predicts that over time younger physicians will do more of this intense acute work, using it to gain experience before moving into their specialty interest.

The unit does, however, put pressure on other departments. “The real problem at the moment is with the efficiency of the main part of the hospital,” he said. “We have put on so much intensity at the front end while at the same time there is a big demand on consultants at the back end for specialty work and to make sure we are achieving the 18-week and outpatient targets. We simply don’t have enough consultants.”

But Johnston said the PCT is not keen to see expansion in the consultant workforce in the acute sector when policy is to move more services out in to the community.

He said: “The long term success of the unit depends on joining up all the other issues and making sure we have got the community care, the adult care services and all the other agencies that need to be working with us in place. There is a still a lot to be done.”

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Acute care system hits targets but lacks training

By Mike Broad - 6th August 2009 11:19 am

New full-shift, acute care systems being trialled for assessing and reviewing patients are compromising juniors’ training, a study shows.

The system at the Royal Liverpool University Hospital, which is in widespread use around the country, enables it to hit NHS targets but has reduced the opportunities for trainees to learn.

The hospital’s acute medicine model is a full-shift system with no integration to maintain unit links between the trainee and consultant on-call rotas.

GPs and A&E SpRs refer patients to the hospital’s acute medical unit and heart emergency centre. SpRs perform reviews of patients overnight and between consultant ward rounds in the day. There are two formal consultant-led post-take ward rounds per day in the units, ensuring consultant review of all admissions within 24-hours.

Waiting times in A&E and time to assessment by a consultant in acute settings improved with the new system. However, restrictions in working hours prevented junior doctors from being present when the patients they admitted to the wards were reviewed by a consultant. At this stage, around half of all diagnoses are changed and the current system has no mechanism for feedback to the initial assessing team.

The authors of the research, published in Clinical Medicine this week, note that the patterns of work and systems employed at the Royal Liverpool are likely to be found in other hospitals struggling to balance government targets for waiting times with the new target for reducing junior doctors’ working hours. Since 1 August, trainees are restricted to working a 48-hour week.

Dr Solomon Almond, consultant physician at the Royal Liverpool, said: “The results of our audit highlight the benefits for patients of being seen by consultants soon after admission. However, the restriction of junior doctors’ hours meant there is less time for consultants to discuss their decisions with the doctors in training.

“Ideally all emergency admissions would be seen straight away by consultants accompanied by the junior doctors. This would re-establish the link between hands-on clinical medicine, training and experience that was for many years the foundation of post graduate medical education in this country.”

Commenting on the research, Dr Andrew Goddard, director of workforce planning at the Royal College of Physicians, said: “This study shows that increasing the input of consultants into the care of medical patients admitted to hospital changes the way doctors are trained. The short term benefits to the patient of seeing a consultant first may be offset by loss of training opportunities for the consultants of the future.”

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