Moving towards consultant delivered care
Authors: Helen Jaques
Publication date: 01 十一月 2011
Helen Jaques looks at the arguments and models for increasing consultants’ involvement in service delivery
Traditionally most hospital care in the United Kingdom has been delivered by trainees, especially at night and at weekends. In 2000, however, the then ruling Labour Party set out proposals in the NHS Plan to move towards a consultant delivered service in hospitals, facilitated by a 30% rise in the number of consultants. Ten years later John Temple, former president of the Royal College of Surgeons of Edinburgh, made a similar request in his review of the effects on training of the European Working Time Directive. Professional organisations are also increasingly suggesting that consultants should be at the forefront of hospital care.
The most important benefit of having consultants delivering a larger proportion of care is that it improves outcomes for patients. Consultants are better at diagnosis and at technical procedures than junior doctors as a result of their level of training and through sheer dint of experience, says Ian Wilson, deputy chairman of the BMA’s Central Consultants and Specialists Committee. The evidence backs him up: the 2007 report on trauma services by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) found that consultants were much more likely to make an appropriate initial response to a trauma patient than were senior house officers and specialty registrars (96.9% versus 88.3% and 76.5%).
As such, consultant led care is arguably more cost effective in the long term because patients are more likely to get the right diagnosis and the right treatments first time. “Consultants at face value cost more, no doubt about that,” says Dr Wilson. “But if you get things right first time, and the evidence is that’s what consultants do, there are fewer follow-on costs, fewer unnecessary investigations, and much more effective use of resources.” There’s also evidence that consultants are more efficient than junior doctors at delivering care—a paper published this year in the Emergency Medicine Journal found that consultants in emergency departments saw more patients, admitted fewer, and had a faster turnaround than junior doctors.
Finally, care by consultants, the most highly qualified members of the medical team, is what patients want. The Royal College of Surgeons’ patient liaison group describes the consultant role as a “quality kitemark” for patients, representing a certain level of training, qualification, and experience that provides assurance to patients that they are getting the best advice and treatment available.
Moving towards consultant delivered care is not just an issue of improving quality, however, it’s also demanded by changes in the service and crucial for ensuring the sustainability of hospitals. The biggest service issue is the European Working Time Directive, which limits the number of hours doctors are able to work to 48 a week. This limit includes time spent on call, even if the doctor is asleep, so is hitting junior doctors, who are responsible for most out of hours care, particularly hard.
“There aren’t the man hours at junior doctor level that there were three years ago,” says Andrew Goddard, director of the medical workforce unit at the Royal College of Physicians. “Hospitals had to get the consultants involved simply to maintain the service.” In addition, the increase in consultant numbers implicit in moving towards a consultant delivered service will free up juniors’ time for training and will mean more consultants on hand to provide teaching and supervision.
Consultant delivered care will mean different things for different specialties—a “high intensity” specialty such as obstetrics and gynaecology is going to need a different approach from a specialty such as dermatology—but for most specialties it involves greater input by consultants at evenings and weekends. It’s important to take heed of the language used in describing this change in service delivery, though, warns Dr Wilson. “Consultant delivered care implies consultants delivering all of the care face to face and actually doing the doing,” he says. “The BMA uses the concept of consultant based care to explain that it isn’t necessary or appropriate for all care to be delivered in all circumstances at all levels by consultants.”
Last year the Royal College of Physicians spoke out about the inadequate input from consultants on the wards out of hours, which it believes is contributing to substandard care in weekend and evening admissions. The solution put forward by the college is for a consultant physician to be on site for at least 12 hours a day, seven days a week, in hospitals that admit acutely ill medical patients. Planning cover for between 11 pm and 7 am is a more complex issue, “simply because of the cost of it,” says Dr Goddard. “There isn’t the number of consultants around in order to be able to deliver that,” he says. “Also, the cost of getting consultant delivered care in the middle of the night is very expensive because of the consultant contract. Even if you had the numbers, and we don’t have the numbers to start with, it would be extraordinarily expensive to get consultants to deliver care overnight.”
Obstetrics and gynaecology
Labour wards run at pretty much the same level of activity 24 hours a day, yet many maternity wards do not have a consultant available round the clock. The negative effect on outcomes is clear: research published last year found that women who delivered out of hours had a 17% higher risk of neonatal death than those who gave birth during the normal working week. “Patients want the highest quality care,” says Ian Currie, honorary secretary of the Royal College of Obstetricians and Gynaecologists. “We aspire to do that through the day; why in high intensity specialties should that stop at night?”
In 2007 the college released a report that recommended specific levels of consultant presence on the basis of the size of a maternity unit. Large units (those with more than 6000 births a year), for example, should initially provide at least 60 hours of consultant obstetrician presence a week (for example, 8 am to 8 pm consultant resident cover), increasing to 168 hours a week—that is, 24 hours a day, seven days a week—by 2010.  
The college is now renewing its call for 24 hour consultant cover on labour wards, which Mr Currie says is needed to meet the growing complexity of the case mix, the increase in operative birth rates, and the reduction in availability of trainees caused by the Working Time Directive. He accepts that this model may take time to implement, however, given that it will require a considerable rise in the number of consultants, something that looks unlikely given the current financial climate in the NHS. Instead the college recommends that the number of maternity units be reduced and the proportion led by midwives increased.
Like obstetrics and gynaecology, paediatrics is an acute, high intensity specialty where the level of activity is the same throughout the 24 hour period, so the need for more involvement by consultants more of the time is similarly strong. The Royal College of Paediatrics and Child Health looked at the issue of acute paediatric care in 2009 and suggested—on top of an expansion of the number of consultant paediatricians—a consultant resident on-call model in which four programmed activities of a 10 programmed activities consultant contract would be spent on call. This year the college developed the concept further by suggesting cutting back the number of paediatric inpatient units in the UK and increasing the number of consultants to ensure that children admitted are seen by a senior doctor as soon as possible.
“Reading between the lines, what we’re talking about is consultants being available for 13-14 hours a day and ideally being available for two handovers,” says David Shortland, vice president of the Royal College of Paediatrics and Child Health. Again, as in obstetrics and gynaecology, the model will vary with the size of the unit: small paediatric units may have to use a resident on-call model.
“Using consultants to deliver some or all of the middle grade care in smaller units is attractive; consultants quite like working it, and it’s relatively quiet when you’re on call at night,” says Dr Shortland. “The big problem is that using consultants to deliver care in bigger centres is innately less attractive because it means that consultants could be resident on call and be up all night working. In paediatrics, consultant delivered care may mean that from the age of 33, when you become a consultant, you will be resident until you retire at 68.” Instead the larger centres should have a higher number of trainees, he says, and consultants should be present more during the day but shouldn’t have to act as registrars on resident on-call shifts.
Convincing consultants to adopt these new working patterns is a “tough sell,” says Dr Wilson. Many will have presumed that by the time they reach consultant level they’ll have a more favourable work-life balance and be required to do night shifts less often, yet the concept of consultant delivered care suggests the opposite. However, Dr Goddard believes that there’s a general acceptance among present medical consultants for the need for seven day working. “We are all happy that we need to be working on Saturdays and Sundays during the day because the health service doesn’t stop at the weekend,” he says. “But there is resistance to consultants being resident overnight because the evidence that we can make a huge amount of difference at 4 am is not there in many specialties in medicine.”
There’s also the perception that consultant delivered care is expensive, as it’s not cheap paying a consultant to be resident on call overnight. “The reality is that although upfront costs may look more, the knock-on costs of not doing this—of not having highly motivated, highly skilled, appropriately paid doctors doing much more frontline work—are vast,” says Dr Wilson. “Even at current pricing it would likely work out no more expensive and possibly cheaper to have senior doctors there much more quickly.”
There’s also the issue of covering the day to day work of an on-call consultant to make sure that consultants working on the emergency take, for example, can dedicate their time to that task without being distracted by their other duties. The Royal College of Physicians specifically advises that consultants dealing with the admission of acutely ill medical patients should have no other duties scheduled during this period and that the daily consultant medical ward round should be done by a second doctor if the on-call consultant is busy on the acute medical unit.
Consultant delivered care is an inevitability that the profession should engage with rather than resist, believes Dr Wilson. “We’re going to have to think very differently about where we have senior doctors, because there is a need for them working much more at the coalface and there is a need for much more out of hours work to cover emergency and acute admissions,” he says. “It’s about evolution rather than revolution, but the speed of change is such that we cannot just ignore it and say we can carry on as we always have.”
Competing interests: None declared.
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Helen Jaques news reporter