Evidence submitted by the College of Emergency
Medicine and the British Association for Emergency Medicine (WP
27)
The specialty of Emergency Medicine (formerly
Accident and Emergency Medicine) welcomes the opportunity to submit
evidence to the Committee as part of the inquiry into NHS workforce
needs and planning for the health service. Please see the "Way
Ahead 2005" (www.emergencymed.org.uk) for a comprehensive
summary of the challenges, including workforce planning, facing
Emergency Medicine.
INTRODUCTION
Emergency Medicine (EM) has been at the forefront
in introducing new ways of working and enhancing the roles of
other staff. We have often led the introduction and training of
nurses and ambulance staff in extended roles (eg nurse prescribing,
pre-hospital treatment) and introduced new care pathways based
on changes in processes of care (eg near patient testing, "see
and treat").
The job analysis provided by EM for the A&E
Modernisation Group (Workforce Monograph, DH 1999) has been influential
in government policy in HR. Yet challenges for staffing acute
services have never been greater. Our specialty has a wealth of
first-hand experience and a significant research base in matters
of staffing, especially in role substitution.
How will the ability to meet demands be affected
by financial constraints, the EWTD, international competition
for staff and early retirement?
We would like to provide comment and evidence
in three main areas:
— The challenges of providing 24/7
staffing for acute services.
— The benefits and limitations of role
substitution.
— The financial constraints to workforce
expansion.
1. THE CHALLENGES
OF PROVIDING
24/7 STAFFING FOR
ACUTE SERVICES
1.1 Emergency Departments (ED) are "open
all hours". There is increasing expectation of health care
provision but there are fewer options available to patients at
nights, weekends and during Bank Holidays. This leads to a funnelling
of demand into fewer providers at such times. This has recently
been recognised and the DH wish to extend the availability of
General Practice, pharmacies, and other community-based services.
1.2 Emergency Medicine welcomes this step
but is concerned that the resource required may be very much greater
than the resource released by GPs "opting out" of out-of-hours
cover. Given the current state of NHS finances it is hard to see
how this will be funded.
1.3 Other "new services" such
as minor injury units, walk-in centres, emergency care practitioner
(ECP) schemes all seem to close at night. Many computer triage
tools such as those used by NHS Direct tend to over triage to
the ED for less serious problems (P Gaffney et al. An analysis
of calls referred to the emergency 999 service by NHS Direct,
Emerg Med J. July 2001; 18: 302-304).
1.4 Along with Obstetrics and Paediatrics
we are concerned about the negative motivation of shift work on
recruitment. Emergency Medicine has seen an increasing drift of
Staff Grade doctors to retrain in General Practice. Given the
dual attractions of no out-of-hours responsibility and better
financial rewards, this is an understandable trend. Worryingly
we have had reports of Specialist Registrars also leaving the
specialty for Primary Care. Emergency Medicine, like Obstetrics,
is both highly stressful and exposed to a relatively high number
of medico-legal challenges.
1.5 There has been an inexorable rise in
the numbers of patients attending Emergency Departments over the
past 25 years despite efforts to redirect patients to primary
care. The evidence to date is that increased alternative provision
attracts previously unmet demand.
1.6 We would urge policy makers to consider
these problems. The solutions are not straightforward but CEM
and BAEM are willing to advise on steps that should be taken to
reverse this worrying trend.
1.7 We have worked closely with DH workforce
planning and derived very clear workforce plans that predict the
numbers of EM Consultants required to provide a defined level
of ED service. These models are agreed by the DH. However these
plans will involve significant investment in new Consultant posts
over the next five to 10 years. We are concerned regarding the
current financial problems of the NHS and the ability to meet
such expansion. Please see the attached chart on the outcome of
Consultant recruitment in Emergency Medicine in 2005.
1.8 In the past the NHS has enjoyed a relatively
inexpensive medical workforce. Junior doctors tolerated short
spells of difficult work such as night shifts in the ED as they
received excellent training and experience. Various policy decisions
have led to a change in junior doctors working anti-social shifts.
Furthermore, the expectations of patients have increased requiring
more senior support. This is obviously going to be more expensive.
1.9 EM is hard, stressful 24/7 work. Many
older doctors indicate that they find it increasingly difficult
working through the night, often on an "on-call" basis
with duties the next day. There is a realisation that job plans
will have to accommodate and reflect different Consultant strengths
at different stages of their careers.
1.10 Gender changes in the medical student
population, the EWTD and trends towards more flexible working
amongst doctors also introduce new challenges to conventional
ways of working. The same policies that reduce staff hours also
impose additional constraints on developing a comprehensive specialist
workforce.
1.11 Another challenge is the implementation
of Modernising Medical Careers (MMC). The abbreviated training
linked to more structured competency assessments in the workplace
will require greater supervision. Therefore, both trainees and
trainers will need more time away from service delivery.
2. THE BENEFITS
AND LIMITATIONS
OF ROLE
SUBSTITUTION
2.1 Emergency Medicine has been very proactive
in recognising the skills in other professional groups and in
providing leadership and training to expand roles to fit service
needs.
2.2 Emergency nurse practitioners are a
very good example. Many minor injury units are now staffed with
nurse practitioners with support and advice from local EDs. Many
EDs have developed a minor injury stream staffed by nurse practitioners.
Proportions of patients seen only by nurses vary from 0-20% of
attendances. Nurses requesting x-rays and nurse prescribing have
contributed to safe and efficient care.
2.3 Randomised trials have shown the services
to be safe and popular with patients. The costs are similar to
traditionally delivered medical care of patients with minor injuries.
Patient satisfaction is high.
2.4 Specialist nurse practitioners who care
for patients with chest pain or patients suspected of having a
deep vein thrombosis (DVT) have also been shown to be effective.
2.5 Paramedics acting in the practitioner
role have been shown to be effective in the management of older
people after a fall. Again the costs of the service are similar
to traditionally provided care.
2.6 One of the main limitations is the nurses/paramedics
are most successful working within fairly narrow roles. This is
to be expected given the very much shorter training compared to
an EM specialist. This is not a problem in services with high
volume such as minor injuries or in larger departments with enough
volume of patients with chest pain or suspected DVT to justify
the service. However such systems tend to be provided mainly during
the day. Few minor injury units are open at night. Few specialist
nurse services operate at night.
2.7 We also have seen real problems in implementing
the roles due to lack of investment, especially in training. These
advanced clinical roles require both theoretical education and
practical skill training. Primary Care Trusts (PCTs) seem unwilling
to invest.
2.8 We are concerned about the continuing
lack of any national standard of quality assurance of the clinical
skills of these practitioners. We acknowledge that Mr Andrew Forster
is producing a report of the registration of these roles but we
feel that at present there is no standard of competency or test
of competency. At a time when increasing tests of competencies
are being expected in medical education, it seems odd that there
is little or no such national work regarding practitioner roles.
Work may be underway but these roles have been in existence for
10 or more years.
2.9 We are aware that Skills for Health
has compiled an extensive list of baseline competencies. However
these are mostly at the level of individual skills with little
evidence of how these are synthesised into the clinical processes
needed for patient care. We are also concerned that the level
of competency described is often basic and gives no regard to
the complexity of some tasks.
2.10 One unexpected effect is that the practitioners
will deal with all the straightforward work leaving more complex
problems to be seen by doctors. This is a reasonable model but
it means the intensity of work for doctors has increased. The
complex case is often one with much higher degrees of diagnostic
and therapeutic uncertainty. Without the dilution of work with
"easy cases" doctors sometimes find stress levels to
be increased. In addition, the training of junior doctors may
suffer as they are not exposed to the same spectrum of cases.
2.11 GPs contribute to services in numerous
EDs by providing a more appropriate response to the persistent
pattern of patients attending with problems that could be dealt
with in a primary care setting. In departments where GPs practise
as primary care specialists they see between 10-15% of patients.
Evidence has shown that GPs investigate, prescribe, and refer
less than if the same types of primary care patients are seen
by hospital-orientated doctors.
2.12 Emergency Medical Technicians (EMTs),
introduced in the last five years, perform procedures and selected
investigations that complement the role of the doctor. This has
allowed medical staff to focus on those aspects of assessment
and management that reflect medical training. However, these staff
also need supervision and professional development.
2.13 EM has led the field in promoting role
enhancement and role substitution. While some roles have been
very successful, others have significant limitations. The issues
of 24/7 working remain an issue. The definition of national standards
is long overdue.
3. THE FINANCIAL
RESTRAINTS TO
WORKFORCE EXPANSION
3.1 This has already been referred to above,
but we are concerned that despite the acknowledged need for trained
specialists to provide emergency care, there are difficulties
in funding the training posts in sufficient numbers to provide
the Consultant target agreed with the DH. It remains to be seen
whether the abbreviated training programmes as part of MMC will
partially offset this cost.
The College of Emergency Medicine and the British
Association for Emergency Medicine would be happy to provide further
information on request.
Edward Glucksman
Vice President, College of Emergency Medicine
15 March 2006
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