Published: 03/06/2004, Volume II4, No. 5908 Page 28 29

The Royal College of Physicians has called for acute medicine to be made a specialty in its own right, arguing this would help address the inexorable rise in emergency treatment. Andrew Cole examines some trusts' attempts to meet growing demand

The number of acutely ill patients flowing into Norfolk and Norwich University Hospital's medical assessment unit has risen inexorably in recent years. Last month it saw over 1,500 patients, more than double those treated just nine years ago.

The growth mirrors a steady national increase in emergency medical admissions over the past decade.

And it makes consultant in acute medicine Dr Paul Jenkins even more convinced that hospitals like his are the only sensible way forward.

The hospital has a dedicated assessment unit, staffed by a multidisciplinary team, which sees all acutely ill patients whether from accident and emergency or direct GP referral.

Most patients are assessed and transferred or discharged within 18 hours of arrival and they are guaranteed the expert attention of a consultant or registrar within one hour. 'If It is urgent I will see the patient almost immediately, ' says Dr Jenkins. 'Otherwise I will review their case after they've been seen by the juniors.'

His philosophy is simple - that the sickest patients deserve to be seen by expert doctors. 'Too many are being seen by doctors in training who are not necessarily supervised by senior doctors with the particular skills required for acute medicine - that is, resuscitation, acute diagnosis and management.'

All that could be set to change following the publication last month of a Royal College of Physicians report calling for acute medicine to be made a specialty in its own right. It proposes that by 2008 all acute trusts should have a dedicated area for acutely ill patients with appropriately trained staff and at least three consultants with primary responsibility for acute medicine.All patients should be assessed within four hours and be seen by a consultant physician within 24 hours.

In addition it calls on trusts to develop a comprehensive emergency admissions policy. The practice of managing acutely ill patients on non-medical wards is unacceptable, it says, and poses significant clinical risk to the patient.

The report is a response to the relentless rise in medical emergencies, combined with the trend for increasing specialisation among many consultants, says college president Professor Carol Black (see First Opinion opposite). 'In British medicine physicians have tried to do their specialism and then in addition they've done the oncall acute medicine on a rotation basis.Acute medicine has always been the thing you do on the side, ' she alleges.

Throw into the equation the forthcoming reduction in junior doctors' hours and the increase in training commitments, and something has to give.

'It is our belief that trusts should consider it as important to have a unit of acute medicine as to have a cardiology unit, ' says Professor Black.

If nothing is done, she warns that consultants will become increasingly stressed and gaps could start to appear in the service. 'I suspect that we could muddle through, but it would not be good for consultants or patients.What is more, juniors will look at what is happening and say 'I am not going to do this, I want a life'.'

So far, the report has been well received. Emergency access czar Professor Sir George Alberti was closely consulted in its preparation, and the NHS Confederation has welcomed the recommendations. 'Effective acute medicine requires skills from a range of specialties. This move would see patients receiving the level of expert care they need, especially in light of the European workingtime directive, ' says policy director Nigel Edwards.

And perhaps surprisingly, consultants do not seem to see the emergence of a new specialty cutting across theirs as a threat. Consultant physician Dr Tanzeem Raza, who heads the Royal Bournemouth Hospital's acute admissions unit, says that although some consultants feared being deskilled when the unit was first set up seven years ago, 'most people now feel it complements their work.Nobody feels that We are treading on their toes'.

The unit, run by three consultants, sees all acutely ill patients within 12 hours of arrival and is popular with GPs, many of whom refer patients directly. 'They get a quick answer about what's wrong which helps them make decisions, ' says Dr Raza.

But there are hurdles.One is the time it takes to train new consultants, and that the new sub-specialist training programme for acute medicine only began last year.

The Royal College of Physicians report calls for the extra consultants - perhaps 900 in all - to be in place by 2008, but Professor Black acknowledges that some parts of the programme are likely to take much longer. At the moment there are only around 100 consultants whose main or sole specialism is acute medicine. A Department of Health spokespersoan said medical specialty numbers would be expected to grow by at least the 900 envisaged for acute medicine by the college, but it would be for local trusts to decide how they should be deployed. 'The detailed planning and decision-making on posts must be a decision for the local NHS.'

Allan Cole, medical director at University Hospitals of Leicester trust and chair of the British Association of Medical Managers, believes one of the biggest challenges will be attracting new recruits into the specialty, given that it will be a demanding area of practice, but without the satisfaction of following the patient through.

But for managers, perhaps the toughest nut to crack will be bed management. The report wants trusts to produce contingency plans for when all acute medical beds are full as well as identifying a dedicated area plus appropriate staff to take on these patients at times of extreme pressure.

This is ambitious even in hospitals that already have a dedicated acute medical unit.Dr Jenkins admits that because of the pressure on beds elsewhere, the median stay on his assessment unit has risen from six-eight hours to around 18.

Dr Cole believes greater flexibility could be the answer. 'If we have 100 medical patients on so-called surgical wards, then we should be relabelling them as medical wards. The bottom line is that they are beds.'

Nevertheless Professor Black remains convinced that dedicated care is the way forward. 'It makes very much better sense than trying all the time to deliver both acute and specialist care under increasing pressure and feeling you're not doing either very well.'

Further information

Acute Medicine: organisation and training for the next decade. www. rcplondon. ac. uk

To contribute articles to HSJ's clinical management section, please e-mail ann. dix@emap. com

Key points

There is urgent need for reform in the care of acutely ill medical patients.

Problems are being compounded by rising admissions, the reduction in junior doctors'hours and changes in training.

Care should be delivered in acute medical or assessment units by dedicated teams specialising in acute care, according to a new report by the Royal College of Physicians.