8 Appendices

Appendix IV - FUTURE STAFFING REQUIREMENTS - CONSULTANTS
(Source: 'Physicians Working for Patients' Royal College of Physicians of London - draft 2000)

• Nephrology section based on detailed data from South Wales, Yorkshire and Newcastle provided to joint RCP (London)/Renal Association Committee.

• The report describes only the work in nephrology recognising that 60% of nephrologists also provide services in acute general medicine (GIM). Where this is the case the number of physicians required for the renal service is 1.4 x the number of WTE nephrologists.

• The report sets out the work generated by a population of 1 million.

PATIENT CARE

Inpatients
A team of 6 consultants will have responsibility for patients with newly diagnosed renal disease and patients with end stage renal failure either acute or chronic starting dialysis, patients admitted with complications of dialysis or transplantation and for vascular and peritoneal access surgery.

Outpatients
It is suggested that a consultant nephrologists can see 8 new nephrology patients or 15-20 follow up nephrology patients in a 3 1/2 hour clinic sessions (1 notional half day - NHD). He/she can see 6-8 patients for dialysis follow up or 14-16 patients for transplant follow up, or 12 pre dialysis patients.

It is suggested that a junior can deal with 50% the workload of a consultant and when present the consultant has to allocate time for supervision.

Procedures
The procedures and skills which consultants are expected to pass on to their juniors include renal biopsy and temporary vascular access.

On-call
Calls to other units and from outside the hospital are received both during working hours and out of hours. The average time to see a new acute referral is 45 minutes excluding the need for temporary vascular or peritoneal access.

SUPPORTING ACTIVITIES

These include:

• Teaching, training and audit
• Continuing professional development, clinical audit and clinical governance
• Research
• Administration
• Management
• Professional advisory work

FACILITIES NEEDED AND CONSULTANT TIME REQUIRED TO PROVIDE SERVICE TO 1 MILLION POPULATION

Inpatients
A population of 1 million requires 36 inpatient nephrology beds and an extra 8 beds per million population in regional transplant units. 12 NHD's are required per week.

Outpatients
There need to be facilities to accommodate 1,800 new nephrology patients and 17,000 follow up visits which includes patients on dialysis, transplanted or in the pre dialysis phase. New patients require 6 consultant NHD's weekly and the follow ups 35 consultant NHD's weekly.

DIAGNOSTIC AND THERAPEUTIC PROCEDURES

Renal Biopsy
The report estimates the need for 240 native kidney biopsies and 15 transplant biopsies per annum. In a transplant centre the need is 100 per annum (30 per million). Since some are undertaken by radiologists it is estimated that this work requires 1 NHD per week of consultant time.

Access for Dialysis
The report estimates the requirement for 100 AV fistulae and 50 peritoneal dialysis catheter insertions per year, 100 permanent central venous line insertions and 400 temporary central venous line insertions per million of the population per annum. These activities require 2 NHD's per week of consultant time.

On-call
Calls to other centres and departments amount to 700 per annum. This work consumes 3 NHD's per week. In addition, the management of critically ill patients in the ITU requires 2,600 visits per annum consuming 5 NHD's per week of consultant time.

SUMMARY
A total of 65 NHD's are required for patient care. Most supporting activities have become mandatory. If 6 consultant nephrologists are employed to cover the 65 NHD's required for patient care (assisted by trainees, Staff Grade positions and an Associate Specialist), then 29 NHD's are required for supporting activities.

WORKFORCE REQUIREMENTS
The calculations outlined above indicate a need for 94 NHD's which would be satisfied by 9.4 WTE nephrologists. This would equate to 13.2 consultant physicians if the present pattern of 60% of consultants undertaking GIM (30% of their time) assists.

Approximately 27% of the total staff consist of trainees and in addition Staff Grades and Associate Specialists (typically one for each per million population served) also contribute. If trainees work at 50% of the rate of consultants then they would cover 40% of the work reducing the WTE requirement from 9.4 to 8.1. The Staff Grade and Associate Specialist would reduce the need further by 2 from 8.1 to 6.1 WTE per million population. This gives a current need of 316 WTE consultants in nephrology for England and Wales.

There are only 164 WTE nephrologists. With the expected increase in workload in nephrology the requirement is estimated to be 390 WTE in 2006 and 439 WTE in 2010. These figures give a current need of 1 WTE nephrologist for 160,000 of the population and by 2004 1 WTE nephrologist per 130,000 of the population.

If calculated in terms of physicians involved in GIM then the current requirement is 442 physicians (1 per 117,000 population ) increasing in 2004 to 546 physicians (1 per 95,000 population).

A growth rate of 11.3% per annum over the next 4 years is required to achieve these figures.