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Royal College of Physicians, London

News & Views

Acute patients in need of senior doctor care

A new survey from the Royal College of Physicians of the way care for very ill patients is managed in England, Wales and Northern Ireland recommends that hospitals need to increase the availability of senior doctors in acute admissions units, particularly at weekends. Previous studies show that a consultant-delivered service is best for patient treatment and recovery.

Representatives of 126 hospitals from 109 different Trusts or equivalents completed the survey – 114 from England, 6 from Northern Ireland and 6 from Wales.  The survey did not cover Scotland.

Despite recent improvements in the care of acutely ill patients, many are only seen once per day in a formal ward round instead of the recommended two daily ward rounds.  In three quarters of the acute medical admissions units accepting patients directly from GPs, the unit runs out of beds, so the report recommends that there are sufficient beds in future to ensure that very ill patients gain appropriate access to acute admissions wards.

bookie2Nearly half (48%) of consultant physicians responsible for assessing and treating patients on their arrival at the acute medicine ward still have to do routine clinics or other parts of their job at the same time as seeing the urgent patients.  The RCP has recommended for the first time that any hospital admitting acutely ill patients should have a consultant physician on-site for at least 12 hours per day, seven days a week, who should have no other duties scheduled during this time.

Only 3% of hospitals provided weekend cover from consultant physicians specialising in acute medicine for 9 – 12 hours and none for over 12 hours. Nearly three-quarters of hospitals in the survey had no cover from consultant physicians specialising in acute medicine over the weekend.

Dr Jonathan Potter, Clinical Director of the RCP’s Clinical Effectiveness and Evaluation Unit, said: “Despite improvements in facilities and staffing,  hospitals still need to address working arrangements to ensure that senior doctors are readily available to provide a consultant led service in acute medical admissions units seven days a week.”

In an accompanying statement, RCP President Sir Richard Thompson said that patients deserve better care at night and at weekends.  He stated that many hospitals did not have enough senior doctors present to care for patients out of hours and at weekends, and that new working patterns would be needed in future: “Despite major improvements in the care of acutely ill patients which were led by the RCP following our major report in 2007, patients are still not getting the care they deserve at night and at weekends. Too many junior doctors are covering too many very ill patients, and this has to change.  Our evidence shows that a predominantly consultant-delivered medical service is the best way to improve patient care.”

Doctors are already working long hours – the latest census of the Federation of the Royal Colleges of Physicians of the UK shows that consultant physicians are working an average of 50 hours a week, which is four and a half hours more than their contract.  More than half of those surveyed were working longer than the 48-hour limit set by the European Working Time Directive.  A previous RCP survey released in April also showed that junior doctors were covering an average of 61 patients overnight, but one junior doctor was covering 400 patients.

Because consultant physicians are already working longer hours than their contract for, the recommendation means that instead of increasing the amount of hours worked overall, job plans will need to change to reflect the different working patterns and must include arrangements to ensure adequate rest.  The statement builds on previous RCP surveys, audits and reports on acute medicine, which have led to improvements in the way acutely ill patients are cared for.

The RCP will be seeking an urgent meeting with Secretary of State for Health Andrew Lansley to discuss the issue, and will be opening discussions with organisations responsible for doctors’ employment.


  1. Papers illustrating poor care at night and at weekends in hospital:
  2. An acute problem? A report of the National Confidential Enquiry into Patients Outcome and Death, 2005.
  3. Caring to the end? A report of the National Confidential Enquiry into Patients Outcome and Death, 2009.
  4. Bell CM, Redelmeier DA. Mortality among patients admitted to hospital on weekends as compared with weekdays. N Engl J Med 2001; 345: 663-668.
  5. Aylin P, Yunnis A, Bottle A, Majeed A, Bell D. Weekend mortality for emergency admissions. A large, multi centre study.  Qual Saf Health Care 2010; 19: 213-217
  6. Barba R, Losa JE,Velasco M et al. Mortality among adult patients admitted to the hospital on weekends. Eur J  Intern Med 2006; 17:322-4

Published on: December 9, 2010

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