The registrar's reflections - November 2016

Welcome to the first registrar’s blog which will hopefully become a regular series of articles (or blogs if you prefer) for fellows of the RCP.

Those of a certain vintage will remember ‘Pyke’s Notes’ in College Commentary, and these pieces are aimed at being a long-overdue successor. For those who do not remember, either because they are too young or too old, David Pyke was the RCP registrar from 1975-92 and was renowned for his humorous and all-knowing view of RCP-related matters. At the outset I need to state that I am not in Pyke’s league so please don’t get your hopes up too much. However, I will try and present a mixture of important news relevant to physicians as well as stories and insights picked up from around the UK and the rest of the world by myself and other RCP officers. I will also keep fellows abreast of the important issues discussed at RCP Council.

The blog is aimed primarily at consultants in the NHS (both active and retired) but will be sent electronically to all fellows in the UK and internationally so will hopefully be of interest to all. Other RCP members will be able to read it after a delay of one week but I am keen that FRCPs should get first sight. FRCP is a badge of excellence and peer recognition but it must also be seen to have some clear advantages over other forms of membership. One of the great things about being RCP registrar is getting early knowledge of things happening in the NHS and the world of medicine. I hope this blog will allow fellows to get similar early sight.

I will try and feature some key issues from RCP committees, Council, updates and finish with something upbeat to help us all remember how brilliant medicine is. But enough preamble, on with the show.

Tariff price changes (or when 118 may not be a helpful number)

What a completely underwhelming choice of first topic I hear you say, but if I can convince fellows that NHS commissioning is basic need-to-know stuff for consultants I will be a happy man. The RCP has an ‘expert advisory group on commissioning’ (EAGOC) which I am lucky enough to chair. This group includes representatives from many specialties, NHS England, NHS Improvement and NHS Digital.

Those outside of England can relax a bit and watch the carnage of post-Lansleyism with a wry smile but for all in the UK it will not have escaped your notice that NHS finances are under unprecedented pressure. NHS Improvement is trying to move what little money there is around to fit with patient needs. One of the areas up for review is outpatients and the money hospitals get paid per episode (the tariff). These tariffs are detailed in Section 118 of the Health and Social Care Act and are currently being consulted on for the next 2 years.

The current plan is to pay more for new patients and less for follow-ups. The logic behind this is that patients are better served by not coming back repeatedly to see (expensive) consultants when they don’t need to. I’m not sure where this idea comes from because the patients I see in clinic are increasingly complex and multi-morbid whereas new patients seem to have milder and milder symptoms, but let's keep going. The tariffs for single consultant appointments (as opposed to multiprofessional appointments) for the next year are shown below as applicable to medicine. If your specialty doesn’t appear don’t worry it is covered in some tariff somewhere and my advice will be the same. Figures are the tariff in GBP that a CCG has to remunerate a trust for each new or follow-up consultation.

Looking at this table it becomes obvious that unless most physicians change their new patient:follow-up ratio fairly radically their hospital is going to lose money. This isn’t true for all (hepatologists and rheumatologists can breathe easy) and those trusts providing specialised services are probably OK. Furthermore block contracts and STPs (Sustainability and Transformation Plans) may alter your local picture. However, most patients are likely to suffer as many will be discharged back to their GP and then need to be referred back with delays and loss of continuity of care as a result (or worse).

I’m a gastroenterologist in a ‘large DGH just become small teaching hospital’ and per clinic I personally (ie when I have no trainees in clinic which is quite often) see around 120 new patients and 360 follow-ups per year. Doing the maths my hospital will be around £12,000 worse off per consultant clinic. Multiply that by the number of consultants and clinics and it means that at best in gastroenterology we’re going to have a harassed business manager and at worst we’re going to lose a specialist nurse or two.

So what do you need to do if this affects you? Firstly talk among your colleagues to agree if this is something that will affect your department. Secondly, find out who is the nominated responder for your trust to this national tariff consultation as only they can raise an objection on behalf of your trust. This person is probably the finance director but if not they’ll know who it is. Thirdly knock on their door and convince them there is a problem and the tariff needs changing. They will need to get your CCG(s) to agree and also reply to the consultation.

Time is pushing – the consultation closes on December 6.

All of the above shows the current system doesn’t work for the way we run outpatients these days. The EAGOC is just embarking on a bit of work to help the NHS get better information on outpatient activity to support payment methods that is appropriate to our patients but that will not be completed until next year. It must also be said that we could probably do things a bit better and this work is an opportunity to focus on improving the quality of medical outpatient services as a whole. I would be happy to hear from anyone who has done some innovative work in this area.

Medical student numbers

UCAS has just released its data on medical school applications for this year (2017 entry). This is important as there has been much concern that numbers will have plummeted due to the junior doctors crisis although it is also of some personal interest to me as my daughter is thinking of doing medicine. It is also something the ‘committee of ethical issues in medicine’ asked me to look at so thanks to UCAS for doing the hard work for me.

A few bits of background information are useful first. Total applications in 2015 were 82,034 for 7,424 places which leads to the oft-cited ‘one place for eleven applicants’. However these numbers include multiple applications by students and the number of individual applicants was 20,100 and success at gaining a place depended on country of origin. Success rates were 40% for UK applicants, 10% for EU applicants and 20% for non-EU applicants.

The 2017 UCAS data are just for applications but are interesting nonetheless. The headline figure is that total numbers have fallen by about 5% from 20,100 to 19,210. The detail is worth looking at, though, as first-time applicants from the UK are almost the same at 12,150 compared to 12,090, and numbers are actually higher than 2015. The biggest drop in new applicants is in EU and other non-UK applications falling by 16% and 6% respectively.

So this suggests that medicine remains an attractive career choice for UK students but uncertainty post-Brexit has impacted on applications from elsewhere. Your political view will determine whether you think this is a good thing or a bad thing.

The future of the Federation of Royal Colleges of Physicians

This has been a big issue for Council this year and members should have received a message from the president about the current situation last week. I had written this bit of the blog before that message went out but it is probably worth reiterating.

The RCP’s four main visible outputs to members and fellows are the MRCP exam, CPD diary, curricula and annual workforce census. All of these are produced in collaboration with the Edinburgh and Glasgow colleges under the auspices of the ‘Federation of Royal Colleges of Physicians’. Many fellows will know this already but many may not (I certainly was blissfully unaware of the Federation until I became more involved with the RCP). The working agreement between Federation members has been under a memorandum of understanding but this MoU comes to an end at the end of this year and is no longer fit for purpose.

The RCP therefore is in the process of trying to set up a ‘community interest company’ (CIC), a common practice by charities to apply a more formal structure to business, to deliver the above outputs and is negotiating with the two Scottish colleges over its structure. Unfortunately we have been unable to agree final terms as yet and negotiations are ongoing. However we will ensure that the four outputs will continue without disruption and if need be establish a CIC on 1 January 2017.

Medical advances from updates and lectures

Autumn is a busy time for regional updates and the president and I have been to Loughborough, Belfast and Birmingham already. The talks have been varied but I have picked up the following things that will hopefully be of interest to fellows. I’m happy to be corrected if I have misinterpreted the lectures.

CT coronary angiography seems to have now become clearly established as the primary test in investigating chest pain with exercise testing becoming a thing of the past. There is debate about exactly who should have a CT depending on risk (and the recent NICE guidance has become rapidly out of date as experience grows) and 30% of patients have incidental findings such as lung nodules. As the proud possessor of an incidental lung nodule myself I am relieved to be in such numerous company but it does raise issues about how to manage such findings.

Obstructive sleep apnoea syndrome is more common than I thought with 2-4% of middle-aged men affected. Most patients perform more poorly on standardised driving tests than those over the alcohol limit and this may be responsible for US truck drivers having the third highest occupational mortality. Polysomnography is the test of choice and helps differentiate OSAS from central apnoea.

Hyperlipidaemia has featured a lot in the past month. I had not heard of Akira Endo before but he is the observant person who discovered statins by noticing (in a Flemingesque way) the inhibition of cholesterol synthesis by rice mould. Not to be outdone by good old-fashioned observation molecular biology is now paying dividends in the understanding and treatment of hyperlipidaemia. PCSK9 (which binds to LDL to prevent cholesterol uptake) mutations are implicated in forms of familial hypercholestrolaemia and monoclonal antibodies to PCSK9 have shown benefit in cardiovascular outcomes and a useful alternative to those who get severe side effects with statins.

Another fascinating talk was on the genetics of diabetes. Glucokinase deficiency is apparently the cause of raised blood glucose in 5% of young ‘diabetics’. However this glucose level is carefully regulated and doesn’t result in any long-term cardiovascular damage. Therefore not only does treatment not really work to reduce glucose levels in these patients it isn’t needed. The speaker also described the very interesting case of 56 year old Theresa who was initially diagnosed with type 2 diabetes but failed to respond to oral treatments. It eventually transpired she had type 1 diabetes and needed insulin. The diagnosis of diabetes was delayed as she thought her weight loss was secondary to the pressure of her job (as Home Secretary at the time) but it demonstrates the difficulty in differentiating between type 1 and type 2 in older adults. It seems that there are as many people presenting with type 1 diabetes over the age of 40 as there are under but the large tide of obesity driven type 2 diabetes often obscures them. Features that should make you think of type 1 in these over 40’s are presentation with DKA, insulin requirement, a slimmer build and perhaps ‘high office’.

Talking of slimmer builds, the Harveian oration in October was given by Sir Stephen O’Rahilly on the topic of obesity. I’ve seen many talks on obesity over the past few years and have been a bit confused by the varying takes of speakers on the contribution of genes, society and interplay with diabetes. Sir Stephen’s oration provided clarity and humour. Twin studies suggest that 70% of obesity can be explained by our genes and this provides a resilience for some against the obesogenic environment. The brain is the main effector arm of these genes and appetite, it seems, is outwith our control. The adipocyte is also a key cell and its rather unassuming histological appearance defies its crucial role in fat distribution and propensity to the metabolic syndrome. However, the basic tenet remains that calories in and calories spent define weight and we cannot avoid the stark truth that we are what we eat (and drink).

And finally….

Two terms I have not heard before cropped up in talks this month, ‘eminence based medicine’ and ‘the free range elderly’. The former describes the ongoing belief in a treatment based on the prominence of those who espouse it and the latter describes those of an advanced age who remain active and don’t trouble the NHS. I aspire to listen less to the former and become one of the latter.

I am more than happy to have feedback on this blog and if there is any topic that you would like covered in a future review please let me know.

Dr Andrew Goddard, RCP registrar

You can read more Registrar's reflections on the RCP website, and follow Bod on Twitter @bodgoddard for regular updates.