Carol Black spoke on challenges facing the medical profession, mainly from her perspective as President of the London Royal College of Physicians and with the insight of a past medical director and a member of the NHS Modernization Board. She walked us through the globalization arguments and stressed the evolving demographic, epidemiological and social trends—aging population, ethnic diversification, changing patterns of disease, and consumerism. Age-related chronic disease, preservation of health and prevention of disease are becoming the main drivers, for which the traditional primary/secondary/tertiary healthcare structures are no longer. appropriate. She predicted greater emphasis on managing chronic conditions in the community (hardly an new concept) but in a planned, structured and integrated way (a bit more novel). Although she didn’t mention it as such, ‘plurality of provision’ is part of the scheme.
The RCP has clear interests in both acute and chronic care. It has recently published a working paper on Acute Medicine which aims to ensure that hospitals receiving medical emergencies are appropriately organized and staffed with physicians who are not merely competent but highly skilled in managing acutely ill medical patients, and for whom the medical ‘take’ is not a simple diversion from their specialty work but a major part of their (professional) lives. As a rheumatologist, Carol Black is particularly sensitive to chronic disease management issues, and her college is a partner in the recent publication Clinicians, services and commissioning in chronic disease management in the NHS with the Royal College of General Practitioners and the NHS Alliance. This makes recommendations on joint working, clinical leadership & governance, and service redesign.
Uniquely among the Royal Colleges, the RCP has lobbied hard over the impact of the European Working Time Directive (EWTD) and particularly the SIMAP (rest in hospital = work) and Jaeger (immediate compensatory rest periods) rulings will have on our ability to sustain a safe and effective service in all hospitals after August 2004. Shift pattern working is not universally popular, especially amongst middle grade juniors and there are concerns for continuity of care and handover. Smaller hospitals will find it particularly difficult, and consultants will be increasingly drawn to the front line: probably no bad thing for patients, if only there were enough consultants. Various hospitals have looked at different staffing patterns and cover at night with some success. A major concern is that the changes in patterns of work may reduce opportunities for learning, though some data suggests that in larger hospitals with sufficient staff, shift patterns and night schemes may actually increase the proportion of time worked in daytime shifts, when there tends to be more training opportunities.
