Four Steps to Rebuilding Emergency Medicine By Gordon Miles, Chief Executive The College of Emergency Medicine
Hardly a week has gone by in 2014 in the UK without there being a mention in the Press about the challenges facing Accident and Emergency Departments (A&Es) in the NHS. Some of the news is quite sensationalist but the underlying themes are that there are supply and demand issues in play that contribute to making the situation very challenging: the numbers of patients attending A&Es is increasing whilst the workforce is below its full compliment.
However, the situation is driven by multi-factorial issues as I shall explain. It is not simply the case that those experiencing a medical emergency or trauma come to A&E but there is a wider patient flow drawn from a wide range of conditions and to whom the definition of emergency may be quite different to a strict medical definition. The brand of A&E is a powerful one and its ‘offer’ which is to be seen within 4 hours provides reassurance to the public and a service they value. The recent CQC survey results show 80% of those 40,000 people surveyed report almost 8 out of 10 rating their overall experience as good. (www.cqc.org.uk/content/accident-and-emergency-survey-2014)
Before I discuss the challenges facing A&Es and the solutions we at the College of Emergency Medicine are advocating in more detail it may be helpful to first provide you with an understanding of the College of Emergency Medicine and its role. The College is established to advance education and research in Emergency Medicine. It is a membership organisation and has some 5,000 Members and Fellows who are Emergency Medicine Physicians working largely in the UK and Ireland, although some 9% of its membership works elsewhere in the world. It is responsible for setting standards of training and administering examinations in Emergency Medicine, for the award of Fellowship and Membership of the College as well as recommending trainees for their Certificate of Completion of Training in Emergency Medicine, so allowing them to enter the specialist register of the General Medical Council. The College works to ensure high quality care by setting and monitoring standards of care and providing expert guidance and advice on policy to relevant bodies on matters relating to Emergency Medicine.
It is the policy agenda for Emergency Medicine that is now such a campaigning issue for the College. As our President puts it: the future of high quality patient care cannot be guaranteed without sufficient workforce and resources being in place. That means it is right for the College to speak out in support of the specialty to argue for improvements in patient care resulting from addressing the underlying factors facing the place where our Members and Fellows work: Accident & Emergency Departments.
The College saw the roots of the problem some years ago and has been campaigning for action over a long period. We have been advocating an expansion of consultant numbers for some time and whilst some growth has taken place it has not kept pace with growing patient numbers. When it became apparent that we needed to raise the volume on our messaging in 2011, we hosted a ‘crisis conference’ to discuss the imbalance between capacity and demand in the emergency departments of the UK. A seminal moment came in our providing evidence to the Select Committee for Health in 2013 on the crisis that was emerging. Then, in November 2013, the College launched the ‘CEM-10’ (College of Emergency Medicine, 2013). This set out a 10 point action plan, it was a defining document focused on a concise, clear and constructive set of proposals, that the College argued would essentially be self-funding. This November the College has updated its call to action with the STEP Campaign. This focusses on four priorities which need to be addressed to resolve the challenges facing emergency departments.
1. Staffing: matching the people resources to the volume of patients, and so expanding the workforce, reducing emigration and improving retention of emergency physicians.
2. Tariffs & Terms: getting the systems that pay hospitals for A&E work to fairly cover the costs involved whilst also getting the rights terms and conditions for the workforce in place to stop the leaching of talent
3. Exit Block: tackling the exit blocks to A&E departments that stop patients flowing on to hospital wards
4. Primary Services: co-locating primary care services with A&Es, a solution recently endorsed by Monitor:
Staffing: Training enough emergency doctors
Key to understanding the capacity/demand issue is a realization that, through the haemorrhage of emergency medicine doctors in the last 4 years, we have lost the capacity to see 750 000 patients per annum in the UK, yet attendances and admissions continue to rise inexorably.
Some emergency medicine doctors choose other specialties, especially general practice and anaesthetics, but by far the greatest losses arise from emigration. In 2013, the Australasian College of Emergency Medicine discovered over 470 emergency medicine doctors working at registrar grade in the emergency departments of Australasia who had trained in the UK and Ireland. While 95% intended to pursue their emergency medicine career, 92% planned not to do this in the UK. It is thus obvious that the problem does not lie with emergency medicine as a specialty per se. The cost of training these doctors to work abroad is in the region of £130m+
The cost of this leaching of talent is compounded by the expenditure on locums to backfill rotas. Last year in England alone, the NHS spent £150 million on locums in emergency departments. The problem has become a vicious circle in which the unequal and never-ending struggle between capacity and demand exhausts and demoralizes staff who therefore seek alternatives. The problem is not simply confined to trainees. Last year, 48 consultants also emigrated. Recognition of this issue has led to Health Education England allocating an extra £50 million to increase the number of Acute Care Common Stem (Emergency Medicine) (ACCS EM) posts by 75 per year for the next 3 years. However, unless we can improve retention, we will simply increase the supply of well-trained emergency medicine doctors to the Antipodes.
Keeping emergency doctors in the UK
How can retention be restored and why do UK emergency medicine doctors leave? The answers lie in how we regard emergency departments in the UK and how we treat emergency medicine doctors. The funding structures for emergency departments are rooted in an out-of-date mindset and ensure that all emergency departments lose money. Consequent underfunding leads to underresourcing and staff that feel under-valued. In short morale is affected.
Pressure also arises from the NHS 4-hour operational standard – a target that is dependent upon two key variables; capable and enthusiastic emergency medicine staff and bed availability. Neither is in plentiful supply and often the equation is in negative balance. Tariff and funding reforms are a major priority for the College and indeed without such reforms, the whole infrastructure underpinning emergency care is inadequate for the task.
Work–life balance is a major issue affecting recruitment and retention. The College is committed to emergency medicine as a 24/7 specialty but sees no reason why its practitioners should not be treated equitably with those who work few or no evenings, nights and weekends. This is not about salaries or special pleading for emergency medicine – the same is true for all high frequency, high intensity specialties. The College believes that a new contract is required for consultants, trainees and specialty doctors that restores fairness by delivering annual leave entitlements prorata with out-of-hours work. This will deliver a workforce fit for purpose both in terms of number and abilities, to match the needs of the UK patient population. The revenue consequences would actually save money. It cannot be over-emphasized that the combined effects of contractual arrangements that penalize both acute trusts and emergency medicine clinicians create a toxic synergy.
Many have called for the 4-hour standard to be relaxed but the College of Emergency Medicine is not one of them. Tempting though it is to regard the standard as a blunt instrument and one which is only a proxy measure for more important metrics such as outcomes, quality of patient experience and resource utilization, it remains the case that these other metrics have yet to have a standardized, readily-measured data set. The College Council recently debated the subject of the 4-hour standard and was unanimous in its support for its retention. Currently fewer than 6% of patients in UK departments remain in the emergency department beyond 4 hours; a figure almost unimaginably better than the situation 15 years ago.
Nevertheless, the challenge of ‘exit block’ is a daily event in the emergency departments of the UK. In effect, the resulting lengthening of time in the emergency department and ambulance queues it is a nosocomial disease with a morbidity and mortality like any other.
Over the past few years, there have been a significant number of national bodies, think-tanks and ‘armchair experts’ who contend that many patients attending an emergency department do not need to be there. In short they argue that this is a marketing problem. A few well intentioned bus advertisements and campaigns will be prescribed by such thinkers. Quite apart from the implied criticism of millions of patients, the most obvious critique of this opinion is the lack of credible available alternatives afforded to patients. The College’s own Sentinel Sites Study has debunked many of these myths and provided unequivocal evidence that only 15% of patients could be safely redirected from triage. This still represents over two million patients annually and is the basis upon which the College recommends a co-located primary care facility with each emergency department.
How big is the problem?
The link between what appear to be modest percentages and large actual numbers in the previous paragraph is obvious. Those who wish to minimize the scale of the problem in emergency medicine always quote percentages. For example, in the year 2012–13, attendances at UK emergency departments rose by ‘only’ 1.7%. The explanation that this equates to 240,326 patients is often omitted, as is the corollary that this workload is equivalent to four average-sized emergency departments and a further 80 doctors. While it is clear that the College is winning the arguments, it is noticeable that the necessary decisions and corrective actions have yet to be taken. Further delay can only mean that the cadre of the willing and able will be further diminished.
The reader might wonder how it is that anyone would choose a career in emergency medicine in the UK or Ireland? Emergency medicine still offers its physicians the opportunity to positively influence patient care and outcomes across the spectrum of ages, disease and injury. Every day, the potential to ‘make a difference’ and add ‘years to life and life to years’ is unparalleled. Whether it is in the ‘life saved’ or the professional and attentive stewardship of a patient's final living moments, emergency medicine offers a compelling career for doctors with a wide range of skills. In many countries, emergency medicine is one of the most popular career options; it is only in the UK has it ranked last for ‘workload’ and ‘work intensity’ as evidenced by the annual General Medical Council training survey for the last 5 years. The College is working with undergraduate bodies, medical schools, deaneries and local education and training boards to remedy this situation and to promote emergency medicine.
Conclusions The current system of emergency care provision needs fixing. A more sustainable system is needed that will be both more effective and more efficient. The College of Emergency Medicine has set out its proposals for tackling the issues. ?