Emergency Medicine UK : CEM - Workforce 2001

The College and BAEM have reviewed future manpower requirements for A&E Medicine. Changes in the practice of our specialty and patients' needs, coupled with the threat of large reductions in SpR numbers, have prompted this process. The publication of the NHS Plan has thrown down further challenges to the medical profession of changing the structure and function of consultant work and service provision. Officers of CEM and BAEM feel it is urgent that the specialty develops a coherent workforce planning strategy.This document aims to stimulate discussion and constructive comments are welcome. Officers of CEM and BAEM believe that the previous "Way Ahead" recommendations are no longer an option. This document has been agreed by officers of both organisations, and we feel it is ready for wider discussion with Fellows and Members. Please send comments to the College office.

A detailed option appraisal considered four scenarios for the senior medical staffing of A&E Departments to be achieved over 5-10 years.

BAEM and CEM officers consider that the previous 'Way Ahead' guidance no longer meets the challenges of the modern NHS.

BAEM and CEM recommend a radical option of increased 'shop floor' consultant presence, 12 hours a day, 7 days a week.

At least 8 full-time Consultants are required to work such a rota.

There should be different types of posts with a varying balance between clinical and other responsibilities (i.e. managerial, teaching, research).

The BMA should negotiate fair rates of pay for evening and weekend working.

To provide a first class Emergency Medicine Service within the framework of a coherent emergency system.

That patients will have access to a senior clinician (Consultant, NCCGs, SpRs) at all times who will either provide the care or directly supervise the care.

To attract, retain and motivate high quality staff.

To allow local flexibility where lower patient numbers would not justify that senior cover should be provided exclusively by A&E (however, the principle remains that patients should have access to senior medical advice at all times).

BACKGROUND

The last strategic review of medical manpower planning for A&E was the BAEM document "The Way Ahead" (1998). When this document was drafted the assumption was made that the A&E workforce would follow the pattern of the previous 15-20 years, i.e. a service that was provided mainly by Senior House Officers (SHOs) with Consultants providing supervision, teaching and management skills for departments. It is universally recognised that the creation of the A&E Consultant has transformed a previously poor service. However the environment in the NHS has changed even since 1998 and given the new NHS Plan the pace of change is going to be even greater. This review will examine the changes and the new demands that this brings to the practice of A&E Medicine for Consultants and SpRs.

CLINICAL PRACTICE

Over the past decade there has been an annual rise in absolute numbers and a higher dependency of patients attending A&E departments. There has been a steep increase in the numbers of medical emergencies attending. The causes of this change are complex and inter-related but the following facts may help explain this change:

Increase in numbers of elderly, especially very elderly, in the population.

Increase of numbers of elderly living alone in the community.

Increase in the use of the 999 ambulance service.

Decrease in acute hospital beds resulting in blocks to direct admission

Risk transfer (in an increasingly legalised and litigious society individuals and institutions will seek to transfer risk to another body)

Increase in the number and complexity of time sensitive treatments for common acute conditions (e.g. thrombolysis)

All of these factors bring more work to the A&E department. The incidence of major trauma is falling, but the huge rise in medical workload threatens to swamp many A&Es at times of peak activity.

CHANGE IN MEDICAL TRAINING

Major changes in postgraduate training are coupled with an increasing expectation that SHO staff should perform less of a service role (NHS Plan). The fear of making errors and litigation is now a major factor in the practice of many doctors. However, the inexperienced SHO faced with the full variety and complexity of A&E medicine finds it increasingly difficult to make decisions on their own. This requires more senior advice and input.Another major change is the increasing specialisation of hospital staff. For example the Royal College of Surgeons of England has stated that it feels that General and Orthopaedic surgeons no longer have the breadth of training that allows them to look after patients with head injury. There is a clear recognition that A&E staff have more skill in this area (1). The specialty of A&E has matured with senior staff recognised as experts in emergency medicine.

GOVERNMENT STRATEGY

This has been set out in the NHS Plan and we await the publication of a review of emergency care. However there are a number of clear messages:

EMPLOYMENT MARKET, LEGISLATION, EXPECTATIONS.

An organisation's best asset is its workforce. The quality of an A&E service is almost totally dependent on the expertise, commitment and motivation of the staff. The effects of changes in medical training are discussed above but there are shortly to be major changes in the arrangements for out-of-hours work for junior doctors. This may not impact so much on A&E where the full shift pattern has been the norm for many years but it will certainly reduce the availability of junior staff in other specialties for out of hours work.There is a shortfall in the number of doctors available. There are major crises in nurse recruitment in almost every city. A&E work is hard, has peak activity at antisocial times and is physically and emotionally demanding. The A&E clinician has to think fast, be constantly alert and very flexible. This makes it a challenge to the young who are stimulated by the learning opportunities and the ability to make a real difference to acutely ill patients. However it is recognised that shift patterns, especially night shifts, become harder to sustain as practitioners grow older. If the work patterns in A&E are seen as very unrewarding and unattractive, recruitment and retention of staff will become increasingly difficult.There are a number of legislative and political initiatives to make work more family friendly. However A&E is a 365 day a year activity, often with peak staffing requirements at unpopular times (weekends, nights, public holidays). While there is no doubt that some flexible working can help retain staff, there is an increasing recognition that every one must play a part in the unpopular parts of any rota. The key to proper manpower planning is to give staff enough incentive to work unsocial hours. This is not necessarily financial. Many A&E staff would cite staff shortage at weekend and nights as the main problem in motivating people to work these shifts. The rest of society places a premium on 'quality time' and this is reflected in increased rates of pay for work in the evenings, at nights and weekends.

The Government has indicated that it wishes to review the Consultant contract. However negotiations have been taking place for two years with little progress. Therefore this document uses the present consultant contract as the basis of planning but acknowledges that this may change. It is not the part of this document to enter into detailed discussions over contractual matters but BAEM will seek advice from the BMA.

1. No change - To keep to the numbers of consultants recommended in "The Way Ahead" document.

2. To move to a consultant/senior supervised practice (at least 12 hour/day 7 days a week Consultant presence in the department).

3. To move to 24 hour consultant presence.

4. A innovative solution similar to option 2 but with varying job plans (Initial proposals were even more radical but were dependent on renegotiation of the consultant contract).

The service is SHO based with some middle grade service provision and supervision. It is consultant led (supervision/training/management with service input into review clinics and some new patient work, heavy on call commitment,)

Recommended staff levels are outlined in the "Way Ahead" document. A typical department seeing 60,000 new patients per annum would have 4 Consultants and 17 "service equivalents". At present this might include two SpR, two staff grades and a variable number of SHOs (should be 15) Obviously few departments come up to these standards, but then few departments can provide the quality of service that we would want for patients.

This model has worked moderately well in the past and departments with this level of staffing have been able to return reasonable quality.

Sustainable in the short term.

Disadvantages

'No change' is not on the Governmenta's agenda. We cannot recommend a 'no change option' which will jeopardise the specialty's future and not enhance patient care. Training, experience, Government policy and clinical governance issues all point to a change in the role of the SHO from service to training.

Society and Government policy indicate the need for greater consultant input.

If this model is accepted, the numbers of Consultants needed would result in a cut in SpR numbers with only 15 new posts from 2005. This would mean many departments would have no SpRs, and that the service and supervisory role currently undertaken by SpRs would need to be filled by either more Consultants or expansion of the staff grade/associate specialist grade.

This model is not sustainable in the longer term. There are increasing demands on all experienced staff for supervision but also for an increasing proportion of new patient work.

Large numbers of other staff would be needed to take up service shortfall.

Doubt about availability of increased numbers of high quality Staff Grade doctors willing to do a lot of out-of-hours/night shifts

MODEL 4 - INNOVATION

As the Government's agenda is to radically change the NHS, then we foresee that a radical change will be needed for consultant contracts. The present Consultant contract has served the NHS well although it is recognised that the great majority (95%) of Consultants work well in excess of their contracted hours. Previous studies have shown this to be 53 hours for all specialties and in a recent survey of A&E consultants, an average of 68 hours per week. Such workload is only sustainable with a professional flexible contract. All indications are that the government wishes to have a much clearer contract.The current contract is based around a "session of 3.5 hours" with 11 sessions per week. In the past 5-7 sessions have been regarded as "fixed" and the others flexible, often one session being allowed for on call commitments.In A&E the move to have fixed 'shop floor' sessions is becoming necessary in many departments as is the need for out of hours and weekend cover. Many departments are trying such systems but it is clear that with only three consultants it is difficult to provide anything other than 9-5 Monday to Friday cover. Larger departments work some out-of-hours shifts but these are locally negotiated.A radical change to the consultant work pattern would require a major overhaul of the consultant contract, but this will take time for the BMA to negotiate. While we would like to use 4 hour sessions and defined rates of pay for out-of-hours work, we feel initially we must work with existing contracts and terms and conditions of service. However, some principles need to be clear:

During clinical sessions consultants would be present on the 'shop floor' and would supervise junior medical staff, provide advice and support for nurse practitioners and would see new patients.

There would be extra pay for work in the evenings and weekends (rates to be negotiated). Night work should be unusual but should attract even higher rates of pay and time off.

If a consultant works at weekends they must have time off the next week.

Consultant posts would not all have the same job plan. Some might have more teaching/research/administrative roles. Basic payment would need to be higher for those undertaking greater clinical roles given the proportionally more time spent working evenings/weekends.

Examples of job plans with differing roles are shown in table 2. Note: Roles may change according to age, and pay is calculated using current BMA recommendations for out-of-hours work but future pay is dependent on BMA negotiations

In medium sized and large departments (40,000-60,000 new patients per annum and > 60,000 new patients per annum respectively)

In a medium sized department providing 12 hour a day, seven days per week cover the consultant staffing mix might be as follows:

Annual/study/bank holiday/duty leave requirements mean that at any one time two Consultants will not be available for clinical work, thus reducing the weekly available sessions to 40. There would need to be 5 sessions per week for review clinics and if applicable 7 sessions for observation ward work. This would leave 28 available clinical sessions (28 required for 10.5 hour/seven day cover with 'double cover' for one session each day or 14 hours per day single cover).This would leave 28 available clinical sessions (7 days a week, 4 sessions per day, each session being 3.5 hours). Since 4, 3.5 hour sessions totals 14 hours a day, this could be worked in different ways:

Small departments would not have sufficient workload to justify this model. Local arrangements would need to be put in place to ensure that patients have the same access to senior opinion. There would need to be much more call on the inpatient teams to provide increased support to A&E. In large hospitals the inpatient teams often are over stretched and find it difficult to ensure a timely response. In these departments there would be three consultants providing a Consultant led service but with an on call service out of hours.

It is clear that there will have to be very significant SpR expansion immediately if this model is to be achievable.If Option 4 is adopted it will result in a need for 1,350 Consultants by 2010. This is based on 140 A&E Departments with 8 consultants and 60 with 3, and includes an allowance for academic posts and part-time working. This would require an immediate expansion of the SpR grade with SpR numbers reaching a peak of 700 by 2006.

Advantages

Move towards the vision of more responsive Consultant delivered service.

Much better access to senior opinion for patients.

Enhanced training and supervision for staff in training.

While all consultants are equal, the job plans differ.

Those doing more unsocial hours are paid more and have time off.

Increased support for Nurse Practitioner services to reduce need for referral.

Almost immediate impact on service due to SpR expansion but cost spread over 10 years.

Disadvantages

Move from normal Consultant contract. BMA advice needed.

Move from normal work patterns for consultants.

Increased financial incentives dependent on BMA negotiations.

Summary

Option 4 scored highest in the options appraised. Option 1 was thought to be non-sustainable. It would result in poorer access for patients to senior opinions when they most need such help, it does not fit with the government�s vision of a new NHS and it means SpR numbers would be reduced to 50-75 (from current levels of over 300).

In this model there would be an attempt to provide senior presence 24 hours per day, with increased numbers of consultants providing this cover 12 hours per day 7 days per week. Other shifts could be filled by SpRs, Staff grades or Senior SHO posts. In smaller hospitals there may need to be other arrangements for the provision of experienced cover out of hours. In this model there would be much greater supervision of inexperienced staff, although some departments may wish to move to a base where many more experienced staff were providing the service (e.g. nurse practitioners).

To fulfil this model there would need to be at least 8 wte consultants. These consultants would make a service contribution although the main role would be supervision and management of complex cases. This would allow a 1:4 weekend rota (a consultant cannot work a 8 hour day shift and then be on call overnight, this would be unsafe. Therefore one consultant would be in the department while the other would cover the nights on call.) Given the need for prospective cover it is unlikely that a more frequent rota would be sustainable in the long term. Consultants undertaking evening and weekend work would expect enhanced payments for this unsocial hours working. This would be in addition to time off in lieu of such working.

Advantages

Patients have increased access to senior opinions.

More patients seen by fully trained permanent staff.

Starts to address many of the problems of the current system. Starts to use other members of staff such as nurse practitioners.

Better training and supervision of SHO.

Senior medical back up for Nurse Practitioner service.

Allows 1:4 weekend rota with adequate time off for unsocial hours.

Allows 1:4 weekend rota for middle grades.

Gives recompense for unsocial hours working.

Offers choice if Consultants wish to work longer/more unsocial hours then this would be paid.

Major change in Department staffing patterns.

Dependent on employing enough Nurse Practitioners and Staff Grades.

Nurse Practitioner remit more restricted on night shifts due to casemix.

Dependent on enough Consultants being available.

May not be cost efficient in smaller departments with insufficient throughput of cases.

Consultant/ Nurse Practitioner provided service.24 hour, 7 day Consultant and Nurse Practitioner cover.

Majority of patients seen by trained staff.

Training posts have much reduced service commitment.

Huge increase in Consultants needed.

Would need huge increase in SpR numbers to train this number of Consultants.

Huge increase in Nurse Practitioners.

Very flat and in some ways top heavy staffing structure.

May be hard to achieve numbers of patients seen with these "unsocial hours rates".

Highly unlikely the Government would support the cost of this structure.

UK accident and emergency medicine: CEM - Workforce 2001

BACKGROUND

CLINICAL PRACTICE

CHANGE IN MEDICAL TRAINING

GOVERNMENT STRATEGY

EMPLOYMENT MARKET, LEGISLATION, EXPECTATIONS.

Disadvantages

MODEL 4 - INNOVATION

Advantages

Disadvantages

Summary

Advantages