From an elderly woman brought in with breathing difficulties, to a young motorcyclist with traumatic head injuries, to the frightened parents accompanying their desperately sick baby, most people who come to the emergency department are at a crisis point in their lives. That so many patients are stabilised and go on to recover is testament to the quality of care, knowledge and skill of the emergency physicians, nurses and junior doctors who work in the department.
But in recent years, emergency departments have themselves been facing crisis. Despite the growing signs of a system under strain - overcrowding, long waits and staff shortages - the pressures on this vital service are unrelenting. The Royal College of Emergency Medicine (RCEM) is concerned that that too much time and resource are being spent fighting fires when a more systematic approach is urgently needed to address staffing levels, hospital systems and support best practice.
'Emergency care is absolutely integral to the fabric of the NHS,' says RCEM President, Dr Taj Hassan. 'We have to be immediately available 24 hours a day, 365 days a year.' However, he explains that the service is simply not equipped to cope with the rising level of demand, with worrying implications for patient safety.
'Over the last two decades there has been a steady rise in attendances at emergency departments, irrespective of every strategy to try and divert patients. The number of attendances has risen steadily by between 1.8 and 2 percent at least per year for the last 15 years. In the last six years alone, the number of attendances in England alone has risen by 1.5 million. That is the equivalent to the workload of about 14 large emergency departments!
'Added to that is the increasing complexity of work in emergency departments and a reduction in the number of beds we have in our bed base, which has been cut by approximately 10% over the last six years. It is widely recognised that the bed occupancy rate should sit at around 85% for there to be enough resilience in the system to cope with surges in workload caused by things like flu or the norovirus. However, occupancy rates are now routinely over 92-95%.'
Problems with social care provision are placing even more stress on the system. 'Typically, around 10% of hospital patients are medically optimised but we can't discharge them because there isn't the right social care package in place,' Taj says. 'If we can't get patients back into the community and we haven't got enough beds in the hospital then the emergency department becomes a very crowded environment. That causes attrition among nursing and medical staff but more importantly it has the potential to cause harm to patients: in effect the emergency department is the canary in the mine.'
The RCEM's concerns are borne out by official figures. The latest A&E figures for England show 2,006,000 attendances in September 2018, up 4.1% on the previous year. The number of emergency admissions in September 2018 (511,000) was up 4.9% on the same month in 2017.
Meanwhile, the Care Quality Commission's new State of Care report noted that, 'Our reviews of local health and care systems found that ineffective collaboration between services affects access to care and support services in the community, which in turn leads to increased demand for acute services. It means a struggling acute hospital can be symptomatic of a struggling local health and care system.'
Emergency care is absolutely integral to the fabric of the NHS
Pressure on emergency departments inevitably compromises the quality of patient care throughout the hospital, says Taj. 'There are probably about 10 studies internationally that clearly describe the effect on patients in terms of mortality and morbidity. For example, delays to assessment, delays to pain relief being given, delays to antibiotics being given will have a cumulative impact. Of course, if the emergency department is crowded then the hospital will be too which means there is an added risk of infection. That can lead clinicians to take the risk of discharging patients prematurely who then bounce back into the system.
'And from a medico-legal perspective, the more crowded the environment in a department, the greater the risk of human error leading to harm which subsequently manifests in increased complaints and litigation.'
In fact, the latest NHS Resolution Annual Report reveals that in 2017/18 the majority of claims by number now came from the emergency medicine specialty. While the trend in new claims had been heading downward in the last five years, new emergency medicine claims increased 7% to 1,395.
For Taj, the rise in claims against emergency departments is frustrating and symptomatic of a wider concern. 'By not fixing the problem at source, we are probably wasting more valuable NHS resource as a result in terms of added claims,' he argues. 'It's the same story with staff attrition in emergency departments, which is caused by working conditions and leads hospitals to spend around £400 million each year to hire more locums and agency staff to fill the rota gap. Ultimately, the whole thing is manifestly unfair because we are wasting valuable resource on fighting the symptoms, rather than trying to address the core issue.'
The RCEM, which represents over 8000 members working in the specialty, has been calling for a clear strategy and funded implementation plan to improve NHS emergency medicine. In early 2017, it produced its own manifesto of measures to improve care and quality:
- an expansion in consultant numbers with posts structured to allow good recruitment, retention and prevent career 'burnout'
- additional training posts for at least four years
- an increase in bed numbers to combat 'exit block' and overcrowding, alongside better social care provision and community care packages to maintain flow in the hospital system
- co-location of services such as frailty teams, pharmacists, mental health specialists and GPs for minor illness to better stream patients and reduce pressure
- a four-year workforce plan to reduce annual spending on locum agency staff.
The College has already made significant progress, agreeing an ambitious workforce strategy with NHS England, Health Education England and NHS Improvement in October 2017. 'It has been fantastic really because that now gives us clarity about how our senior clinicians' roles will be expanded over the coming years - we are also working with colleagues in the devolved nations to agree a similar plan' Taj comments.
The strategy is divided into three key components; expanding the workforce, reducing attrition in medical training and improving staff retention. 'Training numbers will significantly rise for the next four years,' Taj says. 'However, the training programme in EM is a pretty tough business with an attrition rate of up to 40% over the six years. We want to cut that by at least half so we are putting in place a range of strategies such as more flexible working, more dedicated clinical educator programmes on the shop floor with face-to-face teaching. And I think we'll be the first specialty to develop a dedicated leadership programme for every trainee as they progress through their training.
'Our specialty has one of the highest rates of work-related stress and burnout in the profession and it has worsened in recent years because of the conditions in hospital emergency departments. We obviously need to fix the system, but we also need to support existing staff so we have a sustainable workforce.
'That's why the third part of the workforce strategy involves taking care of senior emergency physicians so they have adequate time off to rest, recover and recuperate, effective job planning, and support. I think good systems recognise and value staff and as a result, you get more productive staff which, of course, leads to better patient care.'
The workforce strategy builds on the work that the RCEM has already done to transform the specialty, which only celebrated its 50th anniversary in 2017. 'The reality is that emergency medicine is actually flourishing, with a 400% rise in emergency physicians in the last 15 years,' Taj says.
'That has transformed our ability to have a consultant present on the shop floor to support junior medical and nursing staff for at least 16 hours a day. When I was a junior doctor, emergency medicine really was delivered by junior doctors, whereas now we have at least one consultant and in big departments you will have two or three consultants on duty at any one time. That is a phenomenally different paradigm that we should celebrate.'
Alongside the clinicians, Taj reveals there has been a 500% increase in the number of doctors in academic posts. 'We are very lucky to have this burgeoning sub-speciality within emergency medicine, where people can ask the right questions in terms of system design, therapeutic interventions and acute diagnostics,' he adds.
One important area of research is finding ways to improve patient flow in hospitals and the RCEM believes that quality indicators are an important way of measuring flow and performance, particularly the four-hour standard. This states that 95% of patients should be admitted, transferred or discharged within four hours of their arrival at an A&E department (similar versions of the standard apply across the UK).
According to NHS England, the standard was last met in July 2015 but the RCEM believes it remains achievable; an important way to highlight problems such as exit block; and a powerful lever to protect patients and drive improvement in services.
'People think, quite wrongly, that it's a four-hour A&E target,' Taj says, 'but it is actually a very powerful and sophisticated metric that measures the performance of a hospital, not just the emergency department. High-performing systems have enough beds and it is seen as everyone's responsibility to ensure that the patient gets into the hospital and then back into the community. By contrast, poorly performing ones blame the target and try to avoid breaching the standard by pushing patients into a corridor - there is no quality in that.
'Such gaming is wrong but the fault is in the way the standard is managed and implemented, not the standard itself. The College is currently doing good collaborative work through the Academy of Medical Royal Colleges (AoMRC) to encourage other specialties to take ownership of the four-hour standard and I think there has been some positive initiatives to develop out-of-hours access for patients.'
Inevitably, emergency departments will continue to be at the sharp end of many of the challenges facing the NHS. However, Taj remains enthusiastic about the speciality and advises medical students and junior doctors to visit the RCEM website for more information and has this advice: 'Accept the fact that there will be stressful moments - that's the nature of the specialty and we are developing more strategies to support staff. Ultimately, if you enjoy variety, if you enjoy seeing your patients get better under your care, and you enjoy teamworking, then emergency medicine is a fantastic career choice.'
Interview by Susan Field.
Dr Taj Hassan
Dr Taj Hassan is a consultant in emergency medicine at the Leeds Teaching Hospitals NHS Trust and also president of the Royal College of Emergency Medicine (2016-2019).
He has previously held posts at NHS Improvement as associate medical director for urgent & emergency care, national RCEM lead for ambulatory emergency care and co-author of the national Directory of Ambulatory Emergency Care, vice president of the RCEM and was director of e-learning at the College (2005-2012), leading on the development of the e-learning platform that is now RCEMLearning.
He has led on the development of the new strategy RCEM Vision 2020 which focuses on the key themes of staffing, systems & support. His major interests include EM system design, creating workforce resilience & sustainability and developing leadership skills for emergency physicians.
See more by Dr Taj Hassan