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“Can we afford consultant delivered NHS?”

A review which provides new evidence that a consultant-delivered health service improves the quality of patient care has provoked debate over its affordability and whether the consultant contract is out-of-date.

The report, by the Academy of Medical Royal Colleges (AMRC), cites over 70 relevant studies and written and oral evidence from professional organisations and individuals on the benefits of a consultant-delivered care throughout the week.

But it warns that to deliver this gold standard the NHS would be unlikely to be able to afford the required increase in consultants.

However, the BMA argues that the UK cannot afford not to provide consultant-delivered care and that everything the AMRC makes a case for could be delivered within the terms of the existing consultant contract.

The report says the key benefits of consultant-delivered care are: rapid and appropriate decision making; improved outcomes for patients; more efficient use of resources; better access for GPs to the opinions of fully trained doctors; improved patient expectation of access to appropriate and skilled clinicians and better training for junior doctors.

But to achieve consultant expansion the NHS has to address the affordability of an increased number of doctors coming through training. Since 1995 the number of consultants has doubled from 18,000 to 36,000 and the number of trainee doctors has risen from 27,000 to 51,000.

If current trends continue there could be an increase of over 60% in the fully trained hospital doctor headcount by 2020. If all eligible doctors become consultants this could raise the consultant pay bill to £6 billion, £2 billion more than the 2010 bill.

The report says that delivering a meaningful consultant-delivered service would require changes to traditional models of service delivery and some “reshaping” and “layering” of consultant careers and working patterns.

It says: “It could be argued that the funding of such consultant expansion is a priority for the country. However, the realities of the current economic climate and, in particular, the financial pressures on the NHS make this unlikely.”

Dr Ian Wilson, deputy chairman of the Consultants Committee, said the report added new evidence to the case for a ‘consultant-present’ service the BMA and many other organisations had been arguing for over many years.

“While some people say we cannot afford a consultant-based service I would argue we can’t afford not to have one – given the consequences of reduced quality, poorer outcomes and increased risks if you don’t have one.”

He pointed out that a shift towards providing more consultant-delivered care had already occurred in some areas of the country and in some specialities such as paediatrics, obstetrics and anaesthetics

“It doesn’t need a new contract. Everything the Academy is arguing for is completely deliverable within the terms and conditions of the existing consultant contract,” said Wilson.

He said a new guide to consultant job planning produced jointly by the BMA and the NHS Employers was now available to give trusts and consultants all the support they needed to deliver change.

“When we work together we can deliver profound and sustainable change. This report adds a huge amount to the debate about a consultant-present service. It is really well thought through and now needs to be properly debated, planned for and paid for,” said Wilson.

Prof Terence Stephenson, AMRC vice-chair, said: “The weight of evidence makes it clear that it can no longer be acceptable for some patients to have to risk poorer outcomes because consultants may not be available at some times of the day or week.

“This will mean changes to the working patterns of consultants but also to how services need to be staffed and configured in a local area to provide safe care.”

Read The benefits of consultant delivered care.

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10 Responses to ““Can we afford consultant delivered NHS?””

  1. Alastair Deery says:

    Cellular pathology has been a “consultant present” specialty always and yet because of the national education-led changes in the central appointment and allocation of trainees has had to allow less and less valuable apprenticeship style training over the last two decades. The notion that “training” will improve alongside increased numbers of less well trained consultants with candidly less and less experience with each new crop flies in the face of what has actually happened at the “coalface” over these last decades. The lack of availability of consultants in many clinical services has little to do with their actual numbers but rather the natural reaction that has occurred due to the loss of identity of individual consultant teams and wards and the estrangement of nursing arrangements. Any fix requires radical revision of existing hospital nurse management.

  2. Umesh Prabhu says:

    It is pleasing to see that we are now debating this important question. Of course, fully trained and competent doctors are always able to provide much better service than any other staff. But the question is can the country afford it and is it necessary to be 24 hours a day and 365 days a week.

    I am confident that if we have consultant delivered service from 8 am to 11 PM and then provide consultant lead service between 11 pm to 8 am with the current arrangement then it would be a good value for the money for the Trust that too when NHS has such a financial pressure. Of course, that doesn’t. mean those patients who come after 11 PM don’t deserve the best care but this would be a good value for the money and cost effective for the NHS.

    It is equally important for consultant to change their mindset and to provide 7 days a week service. Of course, consultants should be properly rewarded for this.

  3. Tom Goodfellow says:

    In my department (radiology) we have been advocating 7 day working for ages, but all the focus seems to be on “consultants” and their availability during the weekend to scan patients.

    But a CT/MR scanner does dot run itself. It requires reception staff to greet patients and book them in, porters to collect inpatients from wards, nursing staff to monitor very ill patients, radiographers to run the kit and clerical staff to collate and issue reports.

    So the costs in running a radiology department 7 days a week in a reasonably efficient way is far greater than just the cost of the poor consultant. This is why managers always refuse to support this, and so we bumble along with an “on call” emergency service which has simply grown hugely over the years.

    Until they fund it adequately then dream on!

  4. Supersub says:

    I really do worry about some of the Royal Colleges blindly accepting the idea that (a) patients admitted on a weekend have worse survival because of poor secondary care and (b) having round the clock, 7-day a week consultants will fix it.
    Despite Terence Stephenson’s reference to the “weight of evidence”, it is actually quite poor evidence, particularly in the medical specialties. Mainly retrospective, HES-based data that is riddled with coding bias and other flaws. The few well-designed prospective studies (eg recently published paper on emergency endoscopy at weekends) have not shown significant outcome differences between weekends and weekdays.
    Apart from anything else, patients admitted at weekends are generally sicker on admission, due to a whole range of factors – not least poor access to primary care, lack of social services, district nursing, etc.
    If it’s really “important for consultants to change their mindset and provide 7 days a week service” as Umesh Prabhu asks, then I’d like to see our Primary Care colleagues do the same – along with social workers, health visitors, district nurses, radiologists, laboratory pathologists, hospital administrators, clinical nurse specialists, a full complement of junior medical staff, ward nurses and the many other factors we are denied at weekends.
    The expense of all this would be eye-watering. Perhaps the great and the good at the AMRC can give us a cost-effectiveness analysis?

  5. K Tewary says:

    A consultant delivered care is certainly been a hot topic for last few years. As with any other change this also has got many benefits as described above. However there are few cons as well which carefully needs to be balanced-

    It has been practiced at many hospitals by now and there is data available showing improvement in terms of an improved patient management, filter off unnecessary admissions, and a better recognition and hence management of sick children. It will probably count for about 1 out of 4 patients who will benefit with a senior delivered care in comparison to a middle grade. Yes, there would be a senior led opinion for GPs, however in practice there are not many phone calls for discussing patient after 8 or 10 PM.

    There are certain cons as well which needs to be carefully looked at.

    Certain specialities with intensive work such as paediatrics and obstetrics arealready not so popular specialities. .There is dearth of trainees and more and more graduates are fancied towards specialties where there is less work load, less out of hour’s active working pattern, better work life balance, and probably a better remuneration. This drive will further put the shift away and few years down the line we may come to a position where existing consultant pool is finishing and there is no regular influx to bridge the gap.

    Apart from direct patient care, a consultant’s week also includes many other activities which are indirectly related to patient care such as looking at the results, responding to patient’s/parent’s queries on phone, making pathways for patient’s care and many others. This needs to be made sure that there is fine balance between a direct care and indirect care as both are equally important. Out of hours stay should not jeopardise the day time activities for a consultant.

    Lastly there should be enough pool of consultants if they come to provide out of hours care. The possibility of this look bleak in current financial situation. The existing consultant body is already stretched to the end .Expecting more from them may completely break the stick and collapse the system unless properly and carefully resourced and planned.

  6. drsupport says:

    A serious dilemma for doctors to resolve, which does not engender public sympathy, is the appearance that they are paid a generous full-time wage for delivering a clinical service only 50 – 70% of the working week. This, no doubt, contributes to discontinuity of care and low involvement of many consultants in direct patient care. To illustrate this situation:
    Have we actually seen a consultant yet in the new Junior Doctors series? So far the ‘bosses’ have been registrars.
    Why are some consultants still only doing a once-weekly ward round?
    Why are some F1s doing solo unsupervised ward rounds on a Friday of patients who won’t see a consultant till the following Wednesday?
    It is unlikely that more funds will be put in, so health professionals need to work with managers to ensure better use of human resources. Doctors should expect extreme scrutiny of SPA time from now on, as taxpayers will need to be convinced of the return on their investment in SPA time.
    Further, compared to doctors in other EU countries, UK doctors appear relatively overpaid, especially GPs, many of whom don’t need to put in more than 5 session these days to earn a very handsome salary, with the rest of the week as free-time. This at a time when those in the private sector feel they are working harder for less money to pay taxes to keep those doctors in their cosy, protected positions.
    I fear the public is not in the mood to hear doctors bleat about needing more pay to deliver a basic health service when they perceive most as part-timers, with weekday time off to earn a second income in the private sector. Doctors should keep a finger firmly on the public’s pulse, as they will otherwise appear as greedy and out of touch as bankers and politicians.

  7. joshek says:

    that the removal of junior doctors from the centre of care delivery and their replacement by consultants is the de-facto end of the supply chain of properly trained doctors seems to escape the advocates of this madness completely. as for cost: a few more rounds of pay freeze will make consultants cheap. no problem whatsoever there.

  8. drmmd says:

    I’m not sure where Drsupport works but it is not typical of most NHS consultants the majority of whom work far beyond their contracted hours. I suspect that the reason he or she has not seen anyone beyond the rank of SPR on the Junior Doctors series is that most of us are not self-publicists who wish to be seen on national television as an ego boost.

  9. pete says:

    Of COURSE we cant afford to have all the ‘do-ers’ swanning around on consultants’ salaries! We need to get RID of the false aspiration we presently offer to all specialist medical trainees that they’ll automatically achieve the autonomy of consultancy. New consultants are now so green, so poorly experienced (and therefore similarly trained) that they need to be supervised and mentored by their seniors for some years. We need to get rid of the ‘flat-topped’ specialist career structure where once a doctor becomes a consultant then he/she is clinically untouchable/fully responsible and replace it with a pyramid structure with the most senior clinician in a department at the top. This is the NORM throughout continental Europe and in the USA. Sorry, but that’s the price of our crazy training system and of EWTD.

  10. Malcolm Morrison says:

    This, of course, begs the question: What is a consultant? Certainly the role, and life-style of a consultant has changed enormously since the birth of the NHS. Should all specialists (holders of CCTs) be ‘consultants’? Or should a department have a ‘head of service’ and be manned by ‘specialists’ – with trainees being supernumary?

    If it takes approx. 8 years to train a ‘specialist’ and they then practise for approx 32 years, this means that, to have a proper balance of trainees to ‘trained’ doctors, there can only be ONE TRAINEE (of ALL grades) per FOUR trained doctors – quite a reversal of the present situation!

    Certainly trainees need to learn to deal with emergencies; but they should not be relied upon to provide the ’emergency cover’ – and thereby use up all their EWTR (48) hours so doing!
    Retired Orthopod

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