The situation at hand?
The crisis of mounting pressures in English emergency departments culminated in the NHS failing for the past 17 consecutive months to meet its own waiting time targets. Total attendance increased by 5.2% in 2016, appearing to outstrip population growth. In 2013 the NHS Confederation concluded its report into A&E pressures with the recommendation that “the Department of Health and Health Education England launch a national initiative to incentivise clinicians to work in A&E as soon as possible”. Political will exists to improve the lot of emergency medicine doctors.
Why do we need emergency medicine consultants?
Patients present to emergency departments in large numbers and are high risk in terms of morbidity and mortality. They are a complex challenge in that their diagnosis and acuity are unknown and they represent a wide range of ages and levels of comorbidity. They should be reviewed by a clinician with appropriate training and experience. Patients and the public expect this standard of care. The clinical benefit of consultant review in emergency medicine is well established. In a wide range of acute specialties[5-7] including emergency medicine it has been found that delays in access to consultant care lead to increased morbidity and mortality. Evidence from periods of industrial action have suggested that consultant care is associated and decreased length of stay and faster discharge from the emergency department[9, 10]. Seniority of doctor has been found to be associated with improved clinical outcomes for trauma patients, improved mortality for medical emergencies; and senior review has been found to be associated with a reduction in admissions and in inappropriate discharge. Mid-Staffs
Current levels of understaffing in accident and emergency departments are potentially a threat to patient safety. Understaffing is problematic in that that it leads to longer waits for assessment, management and discharge; poorer quality care; the potential for mistakes; and a loss of efficiency when the correct care is not delivered in the first instance. Moreover the greater pressure on doctors contributes to a vicious cycle, in that overburdened clinicians are discouraged further from working in the department or specialty.
Producing emergency medicine consultants
The flow of entrants
[training pathway, actors involved]
Actors in postgraduate medical education
• Hospital trusts
The UK has a dearth of emergency medicine doctors at consultant level. An average of 7.4 WTE consultants per department in 2013 compares poorly with similar health systems such as Australia, which has an average of 14 consultants per similarly sized department. A factsheet published by the Royal College of Emergency Medicine (RCEM) in response to the most recent winter crisis highlighted that there is only one consultant per 11,500 attendances. RCEM recommends 16 hours of consultant cover per day, seven days per week. A report in 2010 projected that with the 852 consultants in emergency medicine at that time it would take until 2025 to reach the 2222 WTE consultants, or 10 per department, required to fulfil that expectation.
Recruitment to the emergency medicine theme of Acute Common Care Stem training (ACCS) is acceptable with a fill rate of 99.4% in 2015 and 98.75% in 2016. However, there is a tendency for trainees to leave the specialty at recruitment stage for higher specialty training (ST4), with only 44% of posts filled in 2012. This suggests a problem in retaining doctors who demonstrated an interest in a EM career at the beginning of their training. Destinations for those leaving the profession include migration, especially to Australia; other ACCS themes such as anaesthetics; and other pathways such as general practice.
The flow of leavers
A few projects have identified factors that contribute to making specialty training in emergency medicine less attractive than other career options. All offer valuable insights into the motivations of EM trainees.[19, 20, 22] These sources and personal communications with trainees suggest that the factors which dissuade them from persisting generally relate to training, morale and wellbeing rather than wage rate per se. Commonly cited amongst these include being unenvious of their senior colleagues’ working patterns and work-life balance, a high proportion of antisocial hours, high stress and dissatisfaction levels, a lack of senior supervision; as well as deskilling, dependence on other specialties, and service provision adversely affecting training opportunities.
[JD contract, banding, push/pull in emergency medicine]
Bridging the gap between service demand and the supply of EM doctors has predominantly depended on hiring locum doctors. In the absence of more recent data, freedom of information requests found that spending on temporary medical staff in EDs rose from £52m to £83m between 2009-10 and 2012-13. A leading commercial provider of medical locums to NHS trusts disclosed that they received on average 3200 monthly instructions to supply EM doctors, contributing the greatest proportion of their business volume at 40% of all requests.
Vacancy and locum employment rates for varying grades of emergency doctor in the United Kingdom in 2012-2013
Vacancy Rate: 8%
Locum Rate: 9%
Vacancy Rate: 12%
Locum Rate: 17%
Clinical fellow and trust grade
Vacancy Rate: 12%
Locum Rate: 17%
Higher specialty trainee
Vacancy Rate: 15%
Locum Rate: 12%
Locums incur higher wages than trust staff. In addition to their excessive cost, substituting with locums to fill rota gaps can be inefficient because of the lower productivity of inexperienced staff who rely on doctors in training more than they can support them, who are unfamiliar with the infrastructure and teams of the hospital, and who bear additional costs because of repeated induction. There is a direct harm to the quality of training if, as observed, locums tend to cover out-of-hours shifts when doctors in training are more likely to be working.
Other methods include asking senior staff to fill gaps in junior rotas at additional expense compared with staffing at the appropriate grade, and occasionally filling senior rotas with less experienced staff, a particularly worrying practice. [Employing doctors from outside the EEA.]
There are significant pressures on emergency departments in England. These pressures are likely to worsen. Workforce issues contribute to these pressures, including a dearth of consultants. The specialty is not attractive even to those who were at one point interested. There is a need to improve the working conditions of junior and middle grade emergency medicine doctors to incentivise the next generation of consultants.
- NHS England, A&E Attendances and Emergency Admissions 2016-17. 2017.
- O’Dowd, A., Hunt acknowledges need to make emergency medicine and general practice more attractive. BMJ. 347: p. f4332.
- <The Way Ahead_Final Dec 2011.pdf>.
- Wyatt, J.P., J. Henry, and D. Beard, The association between seniority of Accident and Emergency doctor and outcome following trauma. Injury, 1999. 30(3): p. 165-8.
- Moore, S., et al., Impact of specialist care on clinical outcomes for medical emergencies. Clin Med (Lond), 2006. 6(3): p. 286-93.
- White, A.L., P.A. Armstrong, and S. Thakore, Impact of senior clinical review on patient disposition from the emergency department. Emerg Med J, 2010. 27(4): p. 262-5, 296.
- <C White Emergency in emergency medicine 2012.pdf>.
- <CEM8238-CEM Medical and Practitioner Staffing in EDs v1.0 (1).pdf>.
- <1.15.1 EMTA survey 2015 Final.pdf>.
- O’Dowd, A., Spending on locums has risen 60% since 2009 in English emergency departments. BMJ, 2014. 348: p. g245.
- O’Dowd, A., Locums make up a fifth of doctors in emergency units at weekends. BMJ : British Medical Journal, 2013. 346.
- <B McPake et al 2014.pdf>.