Today’s consultant physician manages inpatients who are older and have more comorbidities and a greater complexity of acute illness than in the past. Since the inception of the NHS in 1948, life expectancy in the United Kingdom has increased by 18% and 16.7% for men and women, respectively.1 Half of those aged over 60 years have at least one chronic illness, and this proportion will increase over the next 20 years as the population aged over 85 doubles.2 These demographic shifts place increasing strain on a service that is required to deliver £20bn (€24bn; $32bn) of efficiency savings by 2014.

In a linked article (doi:10.1136/bmj.e652), Wachter and Bell describe the transformation of the organisation of hospital care in the United States and UK over the past 15 years.3 Although changes in US and UK hospital care have been shaped by the structure and culture of the respective healthcare systems, common drivers of change include increasing costs, a need to provide quality care, and restricted resident (US) and junior doctor (UK) hours. The result in both systems is strikingly similar; a new cadre of generalist physicians who are equipped to meet the complex acute care needs and changing demographics of patients newly admitted to hospital has emerged. …