Emergency Medicine in a changing world

Will we have a safer more responsive emergency care system when we come out the other side of Covid? I have to believe we can, but it needs us to keep pushing. It is entirely possible that we will be in a third wave before the much-anticipated vaccine has any significant impact on our ability to deliver healthcare and as every week goes by the challenges for the health service increases. We will need to be determinedly efficient and effective to ‘Build back better’ for the simple reason that we will not be able to afford anything else.  The future we need to work towards is one where every healthcare encounter is of value with the right patient in the right place being seen by the people with the right skills. We must not waste resources on duplication because of poor communication, silo working because of old ways of doing things, or trying to cure things when prevention would have been the right way to go. Health inequalities have been a theme of Covid-19  but were already a clear  sign of a health system not meeting its population needs There are twice as many attendances to A&E departments in England for the 10% of the population living in the most deprived areas as those living in the least deprived 10%.  What that responsive Urgent and Emergency Care system should look like is an area of debate. Should Emergency departments be open to all comers whatever the acuity of the problem because we are the only truly 24/7 ‘lights on’ service available to the public or should we encourage the provision of suitable services for those with urgent but non-emergency problems so that we as Emergency Physicians can focus of emergency care? I think by now most of you know my views on this, but I recognise that there are those who feel differently.

My belief is that our job is to deliver  an emergency medicine  service that is high quality, evidence based (as much as possible) safe and efficient to the acutely ill,  acutely injured,  acutely distressed, acutely scared, acutely in need and acutely vulnerable. The service needs to be adequately funded so that we can deliver this care in a timely way to get patients treated or reassured without hesitation, deviation, or repetition. To do this we need a major culture change which recognises the importance of emergency care delivered by both us and by our inpatient colleagues. The way hospitals are funded for emergency attendances and admissions needs to reflect the work done and not always be treated as the poor relative of elective work. This has led to very few inpatient team consultant job plans having any provision for delivering unscheduled care. Changing this would go a long way towards the changing the dynamic of hospital priorities.  The Emergency Department as perpetual supplicant in need of ‘help’ and giving others work but they will kindly come and see ‘your’ patient is a narrative that is needs to stop. I am pleased we managed a joint statement with the RCP, SAM (Society for Acute Medicine) and RCGP and I am going to keep pushing for the operationalisation of each of the points agreed in it.  (https://www.rcem.ac.uk/RCEM/News/News_2020/Improving_medical_pathways_for_acute_care_The_Royal_College_of_Emergency_Medici.aspx)

In the short term this is one of the most important

All hospital specialties must prioritise patient flow and work to eliminate delay. Specialty referrals need a rapid response and a management plan that minimises unnecessary admission. This will enable us to quickly move patients from ambulances to be managed in safe areas.

Supporting our colleagues to deliver this culture change will need us to be magnanimous at times but I hope it will result in long term gains with a better working experience and better patient care.

The Emergency Department has always been a great place to learn. We have lots of Foundation doctors, EM trainees- doctors and nurses, EM non trainees- doctors and Physician Associates and some trainees from other specialties such as Primary Care not to mention medial students. They all pass through our departments and add gloriously to the multidisciplinary team that is Team EM.  Many move on after their time with us, but it often stands us is in good stead as they remember what it is like at the frontline later in their careers. They understand uncertainty and risk and crazy ‘never seen that before!’. But there is a problem, and this is that it means we have a perpetual churn of staff.   I believe that this is no way to run the high-quality service the public deserves. We need to move to having a permanent staff presence that is adequate for the service requirements of an Emergency Department. By having staff with departmental memory, we will make the service safer, jobs more satisfying and improve training.  By adequate numbers of permanent staff I mean that we have enough Consultants, Senior specialist  grades (who will hopefully have a proper contract soon)  our ACP and ENP colleagues and physicians associates and the senior  nursing team as well managers. In particular I think we need to move away from the situation where the manager role in the Emergency Department is often a notch on the bed post of a trainee manager showing that they have done ‘acute’ so that they can now move on up the career ladder. By committing to the idea that a high risk clinical area should be staffed by clinicians fully trained in Emergency Medicine I believe we would make it easier for senior doctors to stay up to date in their practice and for trainees to be trained properly. By trying to mix service and training all the time and sacrifice training when the system is stressed – much of the time- sets us up to have the problems we currently have. We are too reliant on the clinical skills of senior EM trainees who have a huge amount of unacknowledged responsibility. Now too many of our patients are only seen by a clinician supervised by a trained or higher ‘training’ emergency medicine clinician.

There is data out there to help us understand what services we should have in the Urgent and Emergency Care system in our local area. Understanding population needs is key to raising quality and efficiency going forward. For example, the English programme GIRFT EM in the shape of Cliff Mann and Chris Moulton has recently done a series of regional events. They say that the work of an Emergency Department is determined by 4 main factors-  the size, the age profile  and the level of deprivation of the catchment population plus  the availability of alternative sources of urgent care in the locality.  Understanding these factors for your local population will change how you think about the staff that you need in the ED. Co-location of Primary care may be a priority in a deprived area, upskilling of staff and close working with frailty may be vital in a department where large numbers of elderly patients are seen while inner city departments may need access to youth workers, toxicology skills and knowledge, homelessness workers and mental health teams. So, we can profile our staff to match the local needs but where does this leave trainees and training? The obvious point is that trainees are the permanent staff of the future, but they need to be trained and we are too dependent on them delivering service. If we can push for a future where we largely have enough clinicians to deliver service and enough faculty to deliver training, I believe we can be in a much better place. A key step is to persuade our organisations that spending huge sums on locums makes no sense. We need to explain the quality and safety benefit of a stable EM workforce that is valued. Next, we need to look at our job plans and stop just having DCC and SPA. Delivering training on the shop floor needs focus and time allocated- easier to do if you have enough staff delivering the core clinical work. This is hard in ‘difficult to recruit places’ but the Clinical Educators scheme shows the value of transparent teaching time.   I suggest we must ask for the resources we need to do the difficult high risk job of Emergency Medicine, work with our acute colleagues so patients get the best we can offer, support  our inpatient specialty colleagues to get allocated time to unscheduled care and separate out faculty time so that we can train the clinicians of the future to be the best they can be.  And while Covid continues to reveal the problems of chronic underfunding in the NHS we must keep pushing for a better future in Emergency Care.

Dr Katherine Henderson, President of the Royal College of Emergency Medicine & EM Consultant at St Thomas’ Hospital

This is an extract from the Emergency Medicine Journal – Supplement, December 2020 ed.