Health CommitteeWritten evidence from The College of Emergency Medicine (ES 07)

There are currently four key challenges to Emergency Medicine and Emergency Departments in the UK:

1. Rising demand

NHS England reports a rise in unplanned attendances of 7 million in less than 10 years. Annually rising Emergency Department attendances coupled with the lack of staff recruitment ensures that the ratio of doctors to patients has steadily worsened. Embattled Emergency Department staff encounter episodes of care that is far from excellent. The largest rises in attendances have occurred in patients transported by 999 ambulance reflecting the higher acuity and complexity of the increased caseload.

2. Resources

Emergency Care is currently poorly resourced, poorly regarded and ill served by key stakeholders. The current crisis requires bold decision making to deliver a sufficiently large and well trained workforce. Emergency departments are not an “anything and everything” default option. Failure to address these concerns will result in an existential threat to emergency medicine in the UK with consequent harm to the patients EM doctors trained to serve.

3. Lack of Accessible Alternatives

Narrative reports and research demonstrate a lack of access to community, primary care and mental health services out-with the traditional working day. Medicine is a seven day a week enterprise and timely access requires a greater proportion of doctors to engage in Out of Hours Care.

4. Workforce

Workforce recruitment is in crisis. three successive years of only 50% fill rates for Emergency Medicine trainees has resulted in a “lost cohort” of over 200 potential consultants. This loss is permanent and irredeemable. In consequence all UK departments have a significant shortfall in senior trainees, this is compounded by hundreds of vacancies for other middle grade and consultant posts. This shortfall affects service delivery and patient safety on a daily basis. The College has called for a minimum of 10 consultants per Emergency Department and 16 in larger units.1

The pressure on those in post is relentless and demoralising. Trainees and Consultants alike struggle to maintain morale when forced to work within and deliver care on the very margins of safety. This creates a vicious circle of recruitment and retention failure.

Submission

1. The role of community and primary care services in the delivery of emergency healthcare, and the appropriate structure for service delivery to meet the demands of different geographic areas particularly sparsely populated rural areas

1.1 The College endorses the notion that primary and community care is where the majority of healthcare is currently delivered and where it should remain. However access is perceived by patients to be inconsistent and uncertain. Patients attend Emergency Departments with conditions that they appreciate are not emergencies as such, but the lack of appropriate face to face alternatives leaves them little choice.

1.2 Experience and evidence to date demonstrate that education and/or signposting are unlikely to remedy this situation. Furthermore patients have a not unreasonable expectation that they should be able to seek medical advice and treatment without absenting themselves from work.

1.3 Primary care should be available 365 days per year to all communities—the number of hours provided would be proportionate to population. Provision would vary from a few hours per day in very rural areas to 16 hours per day in urban areas.

1.4 The College is aware of evidence of significant benefit in the following initiatives:

1.5 Triage of all attendances to an Emergency Department with “front- door” streaming of patients to primary care or emergency care as appropriate;

1.6 GPs working alongside Emergency Department doctors and emergency nurse practitioners within the same team.

1.7 The College is concerned particularly with regard to three vulnerable groups:

1.8 Patients who are residents of nursing homes are frequently brought to the Emergency Department for assessment and investigation when care may be more appropriately managed in their place of residence. The assessment of 999 calls from nursing homes by a GP prior to dispatch of an emergency ambulance would benefit this patient group substantially.

1.9 The frail elderly are often transported to the Emergency Department by default rather than because such departments best serve their care needs. The provision of seven day community based multidisciplinary teams that could be accessed by the ambulance service would enable more bespoke and patient centred care, reduce 999 transfers and ED attendances.

1.10 Patients with both acute and chronic mental illness attend Emergency Departments seeking help. This help requires both experience and expertise, the former being by far the most important and yet scarce. All Emergency Departments should have access to, and timely attendance of, trained mental health workers

1.11 The College recommends all service provision and reconfiguration should be evidence based. Whenever such evidence does not exist, schemes should be piloted and independently evaluated.

2. Progress towards moving some minor injury and urgent care services out of A&E and into more accessible community settings

2.1 The College acknowledges the valuable contribution to out of hours care made by minor injury units and walk in centres. Lack of consistent opening hours and resources (eg X ray facilities) ensure they are sub-optimally used.

2.2 Moreover where geographically practical these should be co-located with the Emergency Department. This allows patients to present, confident that they will be seen by the most appropriate and first available person. In addition duplication is avoided and cost effectiveness is increased. Staff can be easily rotated to enhance skill acquisition and retention.

2.3 The College knows that patients attend Emergency Departments for a variety of reasons. Departments should be configured to address these patient needs by streaming them to different providers without the need for a further journey, telephone call or referral. It is unreasonable to expect all patients to self assess the acuity or significance of their illness or injury.2

2.4 Currently recruitment and retention of both medical and nursing staff to Emergency Departments is in crisis. Vacancies and locum spend are unacceptably and unsustainably high. Many experienced nurses are taking employment in minor injury units, or as practice nurses where the working environment is more acceptable. Co-location of out of hours services can reduce the burden on Emergency Departments and allow staff rotation to less acute areas to reduce burn-out.

2.5 Where services have been established but without co-location there has been no significant reduction in ED attendances but a significant loss of highly experienced staff. This has occurred in many locations including Manchester and Portsmouth.

3. The range, severity and incidence of conditions that can be treated within an accident and emergency unit but not managed at an urgent care centre.

3.1 Emergency Medicine departments exist to address the medical needs of patients who experience an acute and severe medical condition or symptom. Thus non-acute problems (symptoms present for days) or non-severe (not preventing work, education or activities of daily living) are best assessed and treated in more appropriate settings (minor injury units/GP surgeries/hospital out-patients etc).

3.2 Emergency Departments are tasked primarily with the diagnosis and treatment of time critical interventions; these include, but are not limited to, the assessment of symptoms such as acute chest pain, breathlessness, bleeding, loss of limb function, unconsciousness, severe pain and these in turn reflect conditions such as stroke, seizure, myocardial infarction, haemorrhage, pneumonia, sepsis, major trauma, bone fracture, abdominal and gynaecological emergencies.3

3.3 Such conditions represent the majority of admissions from Emergency Departments . Those who are not admitted are discharged and frequently require follow up in out-patients or by their GP. 

3.4 This key acute role is predicated on properly trained emergency medicine doctors and nurses, access to investigations (radiology, haematology and biochemistry) 24/7 and the co-location of anaesthesia, orthopaedics, surgery and paediatrics.

3.5 Major improvements in mortality and morbidity arising from stroke, trauma, sepsis and myocardial infarction have been contingent upon Emergency Department participation and leadership in and of rapid assessment, acute care pathways and disease specific networks. The unique skill set of the Emergency Physician is assessing and managing a range of undifferentiated cases and the level of multi-tasking required.

3.6 Emergency doctors are uniquely able to correctly identify who needs admission and who can be safely discharged across the full breadth of acute presentations

4. The prospects for better integration of ambulance services with primary care under the new commissioning regime established in April 2013

4.1 The time target culture has led to unintended consequences of poor resource utilization. Only a small proportion of 999 calls are transported to hospital using lights and sirens. Moreover there is a complete lack of integration or coordination with community services. Crews often recognise that patients could be better managed by GP review in the home (in particular those residing in residential and nursing homes) but cannot get rapid access to GPs. Ambulance services need to be encouraged and supported in their moves to develop the skills to assess and leave patients and empowered to trigger the attendance of other services eg GP, community nurse, social services.

5. The ability of ambulance services to continue to meet increased emergency demand whilst contributing to the Nicholson challenge

5.1 Ambulance services are struggling at present with demand and need to have the tools that allow them to more effectively triage patients and access support systems that avoid conveyance to an Emergency Department. Some ambulance services achieve non-conveyance rates of almost 50% but there is significant unexplained variation both between and within services.

6. Experience to date of the transition from NHS Direct to the NHS 111 service

6.1 The college supported the concept of NHS 111 as an opportunity to recognise the breadth and depth of local services and ensure patients were appropriately signposted.

6.2 Unfortunately the lack of alternatives to Emergency Department disposition has ensured that the system has added to the ED burden when faced with a demonstrable lack of alternatives or capacity.

6.3 Telephone triage even in expert hands is likely to result in more patients than clinically necessary attending an Emergency Department—especially when there are no credible alternatives.

6.4 To be effective telephone triage requires the patient to speak to the advice giver and requires the patient to make objective assessments of their own symptoms. This substantially disadvantages many patient groups.

6.5 The College repeats its assertion that all process and systems changes should be evidenced based before widely implemented.

7. The implications of the shift away from determining the success of ambulance services via indicators based on response time to the new measures designed to assess clinical effectiveness

7.1 The College welcomes this strategic shift. We welcome the opportunity to review the evidence.

8. The causes of delays in handover from ambulances services to A&E or transfer between different levels of urgent care, and actions required to eliminate them

8.1 There is substantial evidence in the literature that correlates hand-over delays to exit block from Emergency Departments. Hand over delays seldom occur other than when significant numbers of patients have completed their ED care and are awaiting a bed to become available on a ward.

8.2 Reducing the need for conveyance to hospital by provision of alternatives and enabling 7 day a week discharges from hospital are the most effective strategies to enable a patient centred approach to both arrival and departure from hospital.

8.3 The College emphasises the concept of “flow” as a pre-requisite to efficient, safe and effective care of patients in Emergency Departments. If patients are unable to exit an Emergency Department at the completion of their assessment, investigation and treatment both they and subsequent arrivals are disadvantaged.4

9. Clinical evidence about outcomes achieved by specialist regional centres, taking account of associated travel times, compared with more generalist hospital based services

9.1 The College endorses the notion that not all services can or should be provided in all hospitals and rationalisation of provision is long overdue. Political realities confound such decisions.

9.2 The associated costs, both direct and indirect need to be factored in to any analysis to ensure money invested in such centres does not disadvantage other patient groups.

9.3 Concentration of expertise in one centre rapidly leads to a loss of specific skills and expertise in smaller units. This phenomenon is seldom researched or evaluated with a consequent risk of bias in the analysis of overall benefits

9.4 Over triage of patients is well documented in all the regional trauma centres. This results in patients ending up in hospitals without access to their medical records, and where their care may be paradoxically delayed whilst more severely injured patients are prioritised.

10. Aspects of care which are likely to improve by being located in regional specialist units and the risks associated with removing services from existing A&E provision

10.1 Urban areas are most suitable for centralisation of services. Clinicians can work in more than one unit thus retaining skills, patients are not geographically or psychosocially disadvantaged and economies of scale are maximised.

10.2 In rural areas significant clinical benefit is lost as a result of increased transport times and none of the advantages stated for urban areas pertain.

11. The effectiveness of the existing consultation process for incorporating the views of local communities in to A&E service design

11.1 The Lay Committee of the College is disappointed and unconvinced by recent examples of community consultation eg Lewisham.

11.2 The complexity of the issues relevant to service design are frequently understated and ill considered. Consultation must be informed if it is to be meaningful. Such a process can only be successful if it is presented, conducted and concluded in a non-partisan manner.5

11.3 The paucity of detailed accurate information is a function of the endemic poverty of ED IT systems.

12. The ability of local authorities to challenge local proposals for reconfiguration under the revised oversight and scrutiny powers included in the Health and Social Care Act 2012

12.1 The College is unaware of any examples of this in practice. The College acknowledges that the need for better integration with social services mandates scrutiny of health proposals by local authorities

In addition to the subject headings upon which we were invited to comment the College invites the Select Committee to consider the following points:

13. Financial sustainability

13.1 The College has argued for appropriate remuneration of Emergency Department activity and emergency admission activity. The former is remunerated by a tariff wholly unfit for purpose. Resuscitation is remunerated at a lower value than a routine out-patient attendance. Admissions are remunerated at a marginal tariff of 30% of the full tariff for all admissions above the total recorded in 2009.

13.2 Failure to remunerate appropriately has prevented Acute Trusts from adequately resourcing departments and is further evidence that Urgent and Emergency Care is not valued.6

14. Safety

14.1 Emergency Department overcrowding is associated with increases in both morbidity and mortality. There is increasing evidence of this in all health care systems.

15. The future

15.1 The current “perfect storm” as evidenced by the mismatch of demand and capacity, under-investment (both capital and revenue) and lack of alternatives has exacerbated the problems of recruitment and retention of both medical and nursing staff. Without a workforce Emergency Medicine and Emergency Care will cease to exist

15.2. The College has recently published “The Drive for Quality.”7 This presents current data establishing the shortfall in service provision and provides evidence based recommendations.

May 2013

1 “The Way Ahead” http://secure.collemergencymed.ac.uk/code/document.asp?ID=6235

2 Harry Longman Chief Executive of Patient Access

3 http://www.collemergencymed.ac.uk/asp/document.asp?ID=5458

4 Emergency Department Crowding: Time for Interventions and Policy Evaluations. Emergency Medicine International Volume 2012

5 Secretary of State Rules of Reconfiguration www.gov.uk/government/uploads/system/uploads/attachment_data/file/147776/dh_118085.pdf.pdf

6 http://www.england.nhs.uk/2013/05/09/sup-plan/

7 “The Drive for Quality” The College of Emergency Medicine 2013

Prepared 23rd July 2013