Service contribution and cost–effectiveness of specialist registrars in NHS trusts: a survey and costing analysis
Editor – The recent paper by Dafydd et al1 is a welcome attempt to quantify the service contribution of specialist registrars. However, the cost calculation is more complex. The paper focuses more on financial modelling for surgical registrars; independent operations and high volume outpatient clinic consultations lend themselves more easily to cost analysis compared with less interventional medical specialties, eg endocrinology or elderly care medicine.
In contrast to high volume surgical/orthopaedic clinics, outpatient clinics in many of the medical specialties may require at least 30 minutes for new patients and 15 minutes for follow-up patients (significantly longer in some specialist clinics), allowing registrars to see a maximum of about 9 patients per clinic, without necessarily attracting a higher tariff. Other additional factors to medical registrars’ time in clinic include on call duties, annual/study leave, regional training days and inpatient specialty consultations. A recent audit of ten respiratory specialist registrars at a major teaching hospital revealed a mean 38.4 respiratory clinics attended per year (or just below 0.75 clinics per week) despite them being rostered consistently for two clinics per week when available to be listed (unpublished observations), equating to less than seven outpatients per week or approximately £55,000 per year (assuming a 50:50 mix of new patients and follow-ups).
Procedure lists for respiratory trainees are affected by changes in training, eg 31.4% attrition rate in bronchoscopy procedures following the European Working Time Directive or 65 per year equating to £11,375 per year (assuming 50% of procedures are independent and £350 per bronchoscopy).2 In total, this example estimates £66,375 per year for a respiratory registrar compared with £700,000 for a surgical registrar. How to compare value though? Moreover, this does not include inpatient specialty referrals, ambulatory care consults or other procedures (eg chest drains, indwelling pleural catheters, thoracoscopy or EBUS-TBNA) that might attract higher tariffs,3 or contribution to the acute medical take,so the calculation becomes ever more complex. What about the quality of service contribution not just the quantity?
In summary, attempting to quantify service contribution by specialist registrars in the NHS is laudable but the calculations and quality metrics are complex, especially for specialist physicians in training in less interventional specialties. What are the best markers: patient quality of life measures, patient/relatives complaints/compliments, time taken/number of tests to get the correct diagnosis? Until such time as these markers are identified, costs will tend to favour surgical/interventional specialty registrars but further work is needed in this area.
Conflicts of interest
The author has no conflicts of interest to declare.
- © Royal College of Physicians 2016. All rights reserved.
References
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- Dafydd DA
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- Medford AR.
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