Emergency medicine in the UK is facing its biggest challenge since its inception in the early 1970s.
Patients have continued to make use of emergency departments in ever increasing numbers; on average one in three people in the UK now attends an emergency department each year.
These departments have met the challenge of this substantial increase in workload but have also embraced new technologies and treatments. Better awareness of time-critical interventions has meant that emergency medicine is at the forefront of therapies to improve outcomes for a wide range of emergencies, for example survival after sepsis and ischaemic stroke. Emergency medicine practitioners have developed new competencies, such as focused ultrasound and non-invasive ventilation, thereby improving diagnostic capabilities and improving therapies.
‘With too few trainees entering the specialty to even maintain current levels, many departments will be unsafe’
However, workload has outstripped physical space and medical manpower, producing significant problems. This has been highlighted in the General Medical Council’s trainee survey and NHS Employers’ own review.
In consequence, emergency medicine has become less attractive to trainees and this has meant increasing numbers of rota gaps, many of which are filled by trainees working overtime and consultants “acting down”. The onerous nature of these additional shifts further reinforces the view that emergency medicine, while interesting and challenging, is unlikely to fulfil most junior doctors’ ambitions of a sustainable work/life balance, and so a vicious circle is created. Some have suggested that one way to address this problem is to “reconfigure”emergency departments by merging one or more on to a single site. While no one would argue that the status quo is the ideal configuration of emergency departments in the UK, the simplicity of the reconfiguration solution belies many difficulties.
In large urban hospitals, it is almost absurd to imagine that two departments with an annual attendance of 100,000 each could be merged on to one site - even if it were geographically acceptable to most parties. The capital resources to build sufficient space are too constrained and the lead time too great.
In rural areas, geographical challenges are significant and the consequent pressure on ambulance services would again mean substantial investments would need to be made.
Politicians and commissioners need to be mindful that while the clinical arguments for “expert” care and “optimum facilities”can be made, they are only directly significant to a small percentage of emergency department attenders. Most patients’ requirements are less acute and more modest; for them the burden of increased travel times may be unacceptable.
Currently the problem of manpower is acute and therefore urgent solutions may not be ideal solutions - in consequence, individual trusts with more than one emergency department have suggested a hybrid model where both function as emergency departments most of the time but one ceases to do so after 10pm or midnight, with all serious cases diverted to the other site. This arrangement is feasible in urban areas and can allow rotas to be better staffed.
The argument is often made that many patients attending emergency departments could be managed in less acute settings. In the case of minor injuries units this may well be true although the financial viability of these units is attributable to the perverse tariffs apportioned to emergency department and minor injuries unit attendances rather than any evidence of financial benefit to the NHS as a whole.
The NHS and emergency medicine face a “tipping point”. With too few trainees entering the specialty to even maintain current workforce levels, many emergency departments will become unsafe. Partial or full closure will then occur. The consequent increased demand on adjacent emergency departments risks a domino effect of demand-led failure.
Only concerted and integrated initiatives by national bodies, including government, regulators and higher education bodies, can hope to extricate emergency medicine from the vicious circle of inadequate capacity. The College of Emergency Medicine is engaged in constructive dialogue with these national bodies and will support any evidence-based initiative to enhance recruitment and stabilise demand.
Success is vital to return emergency medicine to a specialty attractive to doctors capable of working in a challenging environment and to enable the delivery of excellent care to patients whose illnesses and injuries require the skills and facilities of emergency medicine clinicians and emergency departments.
Dr Clifford Mann is a registrar at the College of Emergency Medicine.