Mark Newbold

What is the future role of hospital consultants?

For several years now there has been an assumption that care will move from hospitals out into the community. This means different things to different people, but it seems to be generally accepted that some sort of shift in emphasis will happen.

At the other end of the spectrum there is increasing specialisation, driven largely by medical advance and a need to staff specialist rotas on a 24/7 basis. Both have profound implications for consultants and, in turn, for the hospitals they work in.

At the specialist end of things, it has long been accepted that concentrating resources can improve outcomes. Vascular surgery, cancer care, and more recently major trauma are examples that come to mind. Next may be acute surgery, or stroke, based on the greater London work that shows improved outcomes from reducing the number of acute receiving units. This trend could lead over time to fewer, larger, acute centres, which have the activity and critical mass to provide all specialist services under one roof.

In smaller units there will come a point at which the ‘general take’, be it medical or surgical, is unattractive to clinicians who feel that much of the interest of an unselected take has bypassed their hospital in ambulances heading directly for the large unit up the road. And of those patients remaining, data shows that most are people with (often multiple) long term conditions, often combined with age-related frailty.

This evidence from integrated systems elsewhere suggests that this group can benefit from more proactive, home-based care. This isn’t General Practice or community healthcare as either currently work in the UK, but an escalating system of early support and intervention that is planned and overseen by a specialist, with an educated and enabled patient at the centre.

Maybe this is the future for certain hospital specialists? A trial in our hospital by a colleague in respiratory medicine showed there can be significant benefit for patients through this approach, in particular a reduced frequency of acute exacerbations, and thus admission to hospital.

This system would see hospital consultants leading teams that care for patients in a holistic way, whether they attend hospital or not, and with a funding stream based on a ‘year of care’ tariff that incentivises fewer admissions. A new role for most hospital specialists, certainly, but one that aligns the needs of this large and growing group of patients with a sustainable future for specialist hospital functions.

Much more preferable, I would have thought, to simply shrinking our services as care is provided elsewhere by other agencies. And preferable for the patient too? If I had chronic airways disease, or chronic heart failure, or age-related frailty, I would prefer to be under the care of a specialist-led team than a generic community service.

Is this a scenario that readers of this blog recognise? Is it an appropriate way forward for some of our specialties? Does it mitigate the threat of steadily reducing in-patient capacity and consequent viability problems in hospitals?

I’d be interested in your views. Of course, if it happens at scale, it could call into question the GP role, but that will need to be the subject of another article.

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3 Responses to “What is the future role of hospital consultants?”

  1. Mark KM says:

    Changes as you suggest Mark will occur but will not be cheaper and so will be inadequate for our ageing population. A lot of Medical and surgical treatments are of little benefit to our patients especially when you subtract iatrogenic complications, HAI’s etc. I think a sensible public debate on rationing is the only sensible long term solution- even America is going bankrupt with its escalating healthcare costs-!

  2. jim conway says:

    Very interesting. I do not think hospital specialists would be interested in such a job, pure geriatritians have vanished and community geriatrics too. If this is to happen it will be the GP.

  3. Mark Newbold says:

    Mark KM – I’m uneasy about rationing, simply because we would not need to consider it if instead we dealt more effectively with waste and inefficiency, and made the productivity gains we know are possible. I feel the same about enforced redundancy – it feels wrong to take it as a relatively easy option we should go for the harder, but less painful options first?

    JIm Conway – interesting debate as to whether these roles will fall to groups of specialists, or to GPs. There are advocates for both!

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