Emergency in emergency medicine
Authors: Caroline White
Publication date: 11 dec 2012
Emergency medicine is struggling with a recruitment crisis that threatens patient safety. Caroline White looks at the solutions
Emergency medicine is in trouble. The specialty is struggling to keep pace with rising patient demand and increasing numbers of clinicians turning their backs on a specialty with a reputation for relentless pressure and unsocial hours.
Staff shortages at middle and senior grades have prompted a spate of closures of overnight emergency departments over the past year, as hospitals fear for patient safety and the costs of locum cover.
The soaring case load in emergency medicine, which last year topped 21 million in England—up from 14 million in 2003-04—and its increasing complexity have prompted the College of Emergency Medicine to warn that there are simply not enough senior doctors available to provide safe and high quality care.
Preliminary data from the college indicate that locums currently staff 7% of funded consultant posts in England, one in 10 of which is vacant, and almost one in four (23%) middle grade posts, 15% of which are vacant. In October 2012 the head count of emergency medicine consultants in the United Kingdom stood at just under 1400, but the college has calculated that 2222 are needed in England alone to achieve the recommended minimum level of consultant staffing in all emergency departments.
Guaranteeing that a consultant is present 16 hours a day, seven days a week translates into 10 whole time equivalent consultants for the 60% of departments that see well over 60 000 patients a year; 12 for those that see between 80 000 and 100 000; 16 for those exceeding that; and six extra consultants for regional centres that provide major trauma care 24 hours a day, seven days a week.
In 2012 the average number of full time emergency medicine consultants in each department was 6.9, and the college predicts that it will be around 2030 before the recommended quotas are likely to be reached.
Recruiting more doctors
The College of Emergency Medicine argues that increasing the number of emergency medicine consultants will save the NHS money in the long run. But even if trusts are able to fund the pay bill, it’s not clear where these doctors are going to come from.
In 2012 the overall fill rate for the first year of higher specialty training in emergency medicine (specialty training year 4) was 44%—a rise of just 3% on the 2011 figure. And the chances of the upcoming “bulge” of junior doctors suddenly flocking to the specialty look slim. “The nature of the work makes it difficult [for juniors] to engage with peers and seniors, and to feel valued clinically, intellectually, and financially,” says Simon Carley, consultant in emergency medicine at Central Manchester University Hospitals NHS Foundation Trust. “The reality is, if we say, ‘come and work with us,’ we will work you until you almost drop,” he says.
Trainees in emergency medicine complain of insufficient consultant supervision, not enough time for education and training, and a poor work-life balance, a 2011 survey by the Emergency Medicine Trainees’ Association has reported.
“A lot of [foundation year 2] doctors say it’s the most fantastic job that they have ever done, but don’t consider it a liveable career,” suggests Kevin Mackway-Jones, professor of emergency medicine at Manchester Metropolitan University.
The “bullying culture and constant harassment” generated by the government’s target of a maximum four hour wait, the need to make decisions “under extreme pressure,” and the night shifts put juniors off, he suggests, while Modernising Medical Careers has “railroaded” them into making career decisions far too early.
It’s not just getting more doctors into the specialty that is a problem, it is hanging on to those who already work in emergency medicine that is also an issue. If the government gets its way over public sector pension reforms, emergency medicine consultants might be expected to work until the age of 68, which given the demands of the job, could be a strong deterrent, suggests Mackway-Jones.
“Lots of consultants think they won’t be able keep going until 68, working night shifts. We work at least one a week,” he says. “The average age at which doctors leave emergency medicine in the United States is between 45 and 50,” he adds.
Rethinking the training route
Sarah, a foundation year 2 doctor in a large trauma centre in the north west of England, has thrived on the variety and stimulus of emergency medicine and is now thinking of applying for the only route into core training for the specialty—the three year acute care common stem (ACCS).
She says, however: “I am only at the end of my first F2 [foundation year 2] rotation, and now I am supposed to choose what I am going to do for the rest of my career. It’s far too early, and far too difficult to know how I am going to feel three years down the line.”
She thinks emergency medicine should be a compulsory training post. “I have learnt a phenomenal amount and gained hugely in confidence as a doctor,” she enthuses. But the perpetual rolling rota of early, late, and night shifts, interspersed with random days off, left her constantly exhausted and unable to have any life outside work, she says.
“[Emergency medicine] would suit me down to the ground from an enjoyment perspective, but the lifestyle of anaesthetics or intensive care would be much more sustainable as a career,” she feels.
Mackway-Jones admits, “I do over recruit into ACCS training by 25% because I expect people to change their minds.” The fact that ACCS is shared with anaesthetics, acute medicine, and intensive care makes this approach relatively easy to do, he says.
An interim report from the Emergency Medicine Taskforce—set up last year to tackle the growing mismatch between supply and demand in the specialty—thinks that positioning the emergency medicine component of ACCS in year 1 rather than year 3 would help curb the attrition rates. It would boost commitment to the specialty and could up the pass rate for the college membership exam, it suggests.
The taskforce also recommends increasing the pool of eligible trainees by exploring transferable competencies for junior doctors in other specialties, thus obviating the need for them to start from scratch at the beginning of core training if they want to move into emergency medicine. The college plans to review its entire assessment process, including the membership exam.
Maximising the wider healthcare workforce
However, Bill McMillan, head of medical pay and workforce at NHS Employers and member of the taskforce, argues that increasing the number of doctors in emergency medicine is a luxury the NHS can neither afford to wait for nor pay for.
“What’s the point of saying you want a Rolls Royce when you can’t afford it?” he asks. “The consensus is much more about maximising the potential of the workforce, rather than simply growing the number of physicians.”
That means deploying more senior specialist nurses and standardising the competencies required—so they can move around the country easily—and developing the hybrid non-medical roles of advanced clinical practitioners and physician associates. The interim report regards advanced clinical practitioners as “a crucial part of the [emergency department] clinical team of the future,” provided proper educational standards and regulation are in place, while US-style physician associates already feature in several UK departments.
The report also calls for more associate specialist and staff grade (SAS) doctors to boost the pool of expertise in the specialty. “SAS doctors have been left out in the cold, yet they are very well qualified and skilled, and the backbone of the NHS,” says McMillan.
The Modernising Medical Careers programme, which remodelled postgraduate medical education, prompted “a vast number” of middle grade doctors to leave because they realised they had no career prospects in the new system, explains Mackway-Jones. “In our hospital [Manchester Royal Infirmary] we have made a decision to invest in [the SAS] grade, and we now have a lot of these doctors,” he says.
However, boosting the middle grade workforce is likely to require a relaxation in immigration rules. “Our view is that we should make it as straightforward as possible for [these doctors] to come here for a limited period and be trained so that they get something out of it,” comments Ruth Brown, the College of Emergency Medicine’s vice president.
Reconfiguring emergency medicine services
Irrespective of which routes are used to increase staffing in emergency medicine, the issue of rising demand remains and the current set-up might not be sustainable in the long term.
“People don’t come to sit in an emergency medicine department with drunks because they think it’s a good idea. They come because there are no effective alternatives,” says Carley. “That’s partly about opening hours and access to services, particularly if English is not your first language, and GP contracts. We build it; they are going to come.”
The taskforce calls for more GP walk-in centres to be located on site or within emergency medicine departments. It also invites GPs to consider providing prompt access to community urgent care “for as much of the seven-day period each week as possible.” But it is only too well aware that general practice faces “significant workforce pressures” of its own.
Carley thinks that closures are inevitable, with smaller emergency medicine departments becoming urgent care centres that won’t take the full range of cases.
“If you close an emergency department, it’s roughly a rule of thirds. A third [of patients] go to another [one]; a third go to primary care; and a third disappear,” he explains. “The very sick will still come, but those with minor injury and illness will either go to an alternative provider, or just not go.”
He adds: “The 24/7 anything and everything mindset has got to go. And we’ve got to balance the risk to the patient versus the better care they can get at larger centres further away. There’s lots of evidence they will get better care.”
As Brown confirms, the taskforce report is a hugely important step, but the problems facing emergency medicine are complex and long standing. “The report is only the beginning of a lot of work that needs to be done,” she says. “We mustn’t get our hopes up that everything will change in a year.”
The Department of Health has recognised the importance of the taskforce and is committed to keep it going in some form, while the college is planning its own programme of activities to tackle the staffing shortfall. But as Brown points out, there is no guarantee that clinical commissioning groups will buy into consultant expansion, which, she insists, will still be needed no matter what else happens.
“We’ve got a lot of consultants to recruit, but we don’t have any commitment from clinical commissioning groups that they will want to commission consultant led services,” she says.
Competing interests: None declared.
- White C. Taskforce calls for more routes into emergency medicine. BMJ Careers 2012; [Link] .
Caroline White freelance journalist