In recent years the pressures within acute medicine have intensified. In particular, the dual pressures of a reduction in acute beds and ineffective workforce planning have led to a multitude of inter-related problems. The acute workload has increased significantly, there has been less time to engage in medical training and quality of care has been compromised. Research by the College suggests that the time spent by consultant physicians contributing to acute and general medicine is not taken into account in workforce planning.

One manifestation of this has been a significant, sustained, increase in the number of medical patients boarded out to non-medical wards, resulting in reduced quality of care. Ultimately, this increases attrition from and the attraction of medicine as a career, and the vicious circle is perpetuated (see diagram below).

Vicious circles in the acute medical specialties
The vicious circles in the acute medical specialties

Inappropriate admissions

The College is keen to state from the outset that no consultant physician wants to admit a patient to hospital unless it is absolutely clinically necessary: pressures on acute beds mean that only patients who are in urgent need of medical care are admitted.

We are concerned that a damaging misperception is emerging regarding the level of inappropriate admissions to hospital, and that two unproven principles are now generally accepted: that care of patients outside acute hospitals will be at least as safe and effective as hospital care, and that it will be better value for money.

While the aspiration to reduce acute hospitalisation of older people is laudable, there is still limited evidence on the effectiveness of interventions aimed at reducing unplanned admissions. In these circumstances, it is vital that the promotion of admissions avoidance, particularly of older people, does not restrict appropriate access to best care at times of medical need.

The ambition to reduce reliance on the acute sector should not be pursued to the detriment of the quality of patient care. We must not allow patient safety to be compromised by the implementation of this approach without clear, established evidence that the care of patients outside acute hospitals will be as safe and effective as hospital care. We support shifting care closer to home but not at the expense of quality.

Integration of health and social care

Managing patients with long-term or chronic conditions is one of the biggest challenges facing the NHS in Scotland, and health and social care integration have great potential in this regard. Collaborative working is vital to make integration a success as the new Health and Social Care Partnerships become fully operational. It is important that, where appropriate, patients are treated in a community setting and are empowered to be active participants in their own care where possible.

It is important to recognise that there should be a structure of decision making which fully involves clinicians. Failure to properly engage senior clinicians in decisions about clinical services, which too often are made with non-clinical input, could mean services and clinical outcomes are adversely affected.