THE College of Emergency Medicine published a startling report yesterday entitled: ‘Stretched to the Limit’.
It was based upon a survey of Emergency Medicine Consultants in the UK which had a 70% response rate (1077 respondents who work in Emergency Departments).
It shows that overall 62% regard the job they are doing running the Emergency Medicine service is unsustainable in its current form and 94% of respondents report that they regularly work in excess of their normal planned hours to help deliver the service.
This has potentially serious repercussions for safe working by senior medical decision makers.
This situation is also reducing the attractiveness of the specialty to new trainees and causing difficulties in retaining doctors and consultants who are leaving the UK in greater numbers as the report shows.
The consultants in the survey also highlighted pressures on their nursing colleagues with whom they work in teams within the Emergency Departments.
These results require urgent action and build upon previous work published by the College on aspects of system design (The Drive for Quality) that are needed to create safe, sustainable Emergency Departments that are presently facing some intolerable pressures due to a combination of reasons.
The authors of the report stated: ‘We are very pleased to be active participants in Sir Bruce Keogh’s Review that will report in the very near future on urgent and emergency care re-design in England.
‘Some aspects of these system improvements are already being implemented in certain parts of the country.
‘Stretched to the Limit will add to the evidence base for this Review and will we hope help lead to solutions for commissioners, clinicians and senior managers in returning stability to our emergency care systems.
‘Equally important are the pressures on senior medical decision makers in the Emergency Department in the other countries of Scotland, Wales and Northern Ireland where similar reviews are on-going or have completed but pressures remain very high.
‘This report is important reading for employers who need to address the issues highlighted in a timely fashion.
‘The problems are complex and require detailed attention to help create sustainable solutions.’
The College makes 3 key recommendations:
1. Immediate action by Executive Boards of Trusts and commissioners to ensure that there is adherence to good job planning for consultants and other medical senior decision makers in Emergency Medicine.
2. An urgent review by the BMA and NHS Employers to consider ways in which safe and sustainable working practices for consultants and other medical senior decision makers in Emergency Medicine can be appropriately recognised, especially for out of hours and night time work to ensure adequate rest and recuperation.
3. It is vital that the Review by Sir Bruce Keogh provides a clear focus to address and improve urgent and emergency care system design to allow safe and effective delivery of care.
The College is also launching a strategy today (for consultation over the next two months) entitled: Protecting a vital resource – how to create a satisfying career in Emergency Medicine.
This will give specific guidance to employers so that clinicians can have sustainable working practices for their working lives with adequate rest and recuperation to manage workloads that are at times the most intense and stressful in medicine today.
Solving these specific problems will also be critical in helping to solve our workforce crisis by creating careers that are satisfying both for the existing consultant and middle grade workforce as well as appealing to the next generation of bright young trainees.
Dr Taj Hassan, Vice President of the College and one of the authors of the report said: ‘This report has major implications for health policy makers, regulators, commissioners and Executive Board of Trusts in the UK.
‘The College is working with its Members and Fellows to help them do all they can in this challenging situation but we need prompt action by relevant stakeholders on the three key recommendations in this report.
‘Senior medical decision makers in Emergency Medicine provide one of the most vital strands in maintaining safety for emergency care systems in the UK.
‘A failure to address these issues will compromise this ability and also further worsen the present workforce crisis affecting Emergency Departments.’
Responding to ‘Stretched to the limit’, Dr Paul Flynn, Chair of the BMA’s Consultants Committee said: ‘Consultants working in emergency medicine face some of the most challenging, high pressured and stressful work environments in the NHS, often with limited resources and gruelling workloads.
‘Unsurprisingly, the result has been fewer doctors choosing to go into emergency medicine and others leaving to work abroad, meaning existing consultants are working flat out to meet rising demand.
‘We urgently need to look at how we can make working practices in emergency medicine safe and sustainable to address this recruitment and retention crisis.
‘That’s why discussions on work-life balance, out-of-hours work, job planning and protecting time for training and development will be central to upcoming contract negotiations between the BMA and NHS Employers. These issues are important to all doctors, and especially important to those working in emergency medicine given their work load and work patterns.
‘The government has a responsibility to ensure patient safety and doctors’ well-being are not compromised by unsafe and unsustainable working practices and the BMA will ensure they don’t shirk this responsibility.’
BMA member Anna Athow commented on the report, saying: ‘The College of Emergency Medicine draws attention rightly to the way that A&E departments are getting busier and are in many cases understaffed, putting enormous pressure on those who work there.
‘Attendance rates at A&Es are going up 3-5% per year so that a fifth of departments in the UK are now seeing more than 100,000 patients per year.
‘Attenders in England have more than doubled since 2004 and have gone up by a million since 2010.
‘The College notes a severe shortage of A&E consultants and suggests that the excess workload and unsocial hours is the cause.
‘These factors affect the recruitment of Higher Specialist Trainees into emergency medicine with vacancy and locum rates of 30%.
‘The report calls for better job planning for consultants.
‘Only 60% of A&E consultants have job plans which adhere to the BMA negotiated norm i.e. have 2.5 sessions for CPD (continous professional development). It is particularly important for A&E consultants to have time to engage in clinical audit and learn lessons from their practice and to teach the junior doctors and other staff.
‘Stretched to the limit emphasises that doctors cannot continue with this pressure of work and are starting to vote with their feet.
‘A note of warning is necessary.
‘The third point of the report looks to the expected Review of urgent and emergency care systems by Sir Bruce Keogh, the medical director of the NHS commissioning board, to “allow safe and effective delivery of care”.
‘This is a dangerous illusion. Keogh is totally committed to wholescale reconfiguration of the hospital system, with the closure of scores more A&E departments and the concentration of care in a few remote larger tertiary hospitals.
‘On 11th September, he said that emergency care for patients with heart attack, stroke and acute asthma can be provided in the patients own home, or in the back of an ambulance!
‘The college of Emergency Medicine’s “Drive for Quality” review May 2013, does state that any hospital with an A&E, must have support from seven in-hospital departments: acute medicine, critical care, paediatrics, imaging, pathology, general surgery and orthopaedics.
‘However it succumbs to the “reconfiguration” notion that A&Es have to close because of the need to save money, admitting that the lack of access and extra travelling time is a risk to patients.
‘It also accepts the new government proposals that more emergency patients should be seen and sent home same day in ambulatory units, so as to prevent their admission to hospital.
‘It is essential the A&E doctors do not allow themselves to be bullied into accepting the closure of A&E departments, or to be used as “gate keepers” to keep patients out of hospital that should be admitted, or to allow their jobs to be replaced by non-medical staff as a cheaper option, which is the other feature of current government policy.
‘For the restoration of proper emergency care, not a single A&E department must be allowed to close.
‘There must be no more bed cutting, in fact hospital beds numbers must be restored so as to prevent the bottlenecks and overcrowding in A&E and stop the outrage of bed occupancy rates of over 85%, which are dangerous.
‘General practice must be funded properly so that GPs can see their patients with urgent conditions in timely fashion.
‘The out-of-hours emergency service needs to be completely revamped and taken back in-house so that properly funded rotas of GPs can answer patients’ needs at night and respond to them appropriately. The devastation of the ambulance services must end.
‘The plethora of privately run urgent care centres staffed by various non medical staff should be closed immediately.
‘None of these things are possible under a Tory government busy destroying our NHS hospitals and GPs surgeries with huge funding cuts and turning them over to the private sector.
‘Doctors must join with other public sector workers in action to remove this Tory Coalition and restore the NHS as a properly funded public service.’