In focus: Emergency Medicine

A&Es have a uniquely high public profile – but often for the wrong reasons. Richard Bagley investigates how the Royal College of Emergency Medicine is trying to change the focus.

“Around the world emergency medicine is one of the most sought-after professions,” says Jon Bailey, president of the Emergency Medicine Trainees’ Association (Emta).

But in the UK, he complains, many embarking on a career in A&Es can’t see how they will keep on into their fifties, let alone reach the ever-rising full pensionable age.

Bailey, who is addressing an audience of trainees alongside HCSA general secretary Eddie Saville, argues that proposals put forward by employers fail to recognise the intense pressures

in the discipline, a relatively small but uniquely high-profile area of clinical medicine.

There are “components missing,” says Bailey, not least due to the fact that emergency medicine often involves being confronted with frequent and complex cases with minimal information.

The intensity of different roles are not recognised sufficiently and there are no real measures by which to judge the differences, he complains, adding: “A third of the workforce is talking about leaving the profession – if that’s not a measure of intensity I don’t know what is!”

Yet despite the challenges Royal College of Emergency Medicine president Clifford Mann, who leads Emta’s “parent” organisation, remains fairly upbeat about the progress made – with the college acting as a focal point to help employers and policy-makers recognise the challenges and possible solutions within England’s A&Es.

The college is a relative newcomer, only receiving royal status in January 2015 following its creation in 2008.

In recent years it has witnessed progress.

But while drop-out rates and an overseas exodus among those entering the sector have slowed, a raft of recommendations that the college deems key to easing the pressure on emergency departments remain unmet.

The title of two key reports co-produced by RCEM reflect these challenges, from 2014’s Prescribing the Remedy to last year’s Ignoring the Prescription.

The former contained 13 recommendations aimed at easing pressure on A&Es, including the co-location of community teams and primary out-of-hours facilities on-site, something which last year was still absent from 60 per cent of hospitals.

Other key goals included systems to prevent cases that could be dealt with elsewhere landing in emergency departments, as well as sufficient staffing to handle attendance peaks rather than average load.

In his foreword to Ignoring the Prescription last year, Mann noted: “In almost all cases a majority of commissioners, providers and systems have not acted.”

In a stark assessment based on a survey of clinical leaders, its findings suggested that a third of hospitals still did not have senior clinical decision-makers deployed routinely for prompt assessment of all new patients.

More than half of departments were not assisted by senior decision-makers from in-patient teams at times of peak activity.

When it came to the goal of seven-day services set out by the government, the college found that more than 80 per cent of emergency departments were not supported by fully functioning back-up services due to a lack of senior clinicians, lack of full diagostic support or a lack of access to specialists.

Tariffs which actively punish A&Es by underfunding “excess” attendance remain in place, while “only 4 per cent of acute trusts have introduced innovative terms and conditions that support equitable work-life balance” for clinicians.

Mann explains that at the same time attendances at emergency departments increased by 371,864 in 2014, a 2.6 per cent rise equivalent to six medium-sized A&E departments – representing an attempt to “put more and more people into a smaller pot.”

He advocates additional metrics to reflect the health of emergency departments that go beyond crude data on waiting times, although warns against removing the four-hour waiting target for care.

Reporting a daily discharge to admission ratio, too, would “act as an early warning system” in hospitals.

Nevertheless Mann is upbeat about getting the college’s views heard despite the slow pace of change.

Public pressure means that the future of acute and emergency care remains in the spotlight, appearing prominently in NHS England’s Five Year Forward View, and the focus of the best-practice report Safer, Faster, Better, aimed at commissioners and front-line providers – guidance backed by the RCEM and which Mann labels a “very good document.”

It enshrines many of the recommendations made by the college, but this time bearing the NHS England stamp and endorsed by organisations including Monitor and the NHS Trust Development Agency.