UK accident and emergency medicine: CEM - Workforce 2004

CEM - Workforce in Emergency Medicine 2004

Contents Page

Summary. 2

Introduction and strategic context. 3

The skills needed in EM. 5

Styles of Emergency Medicine Consultant work. 6

How should we calculate staffing needs. 7

Examples of staffing profiles of smaller, medium and large departments. 8

Consultant work patterns. 11

Specialist Registrar work patterns. 13

Appendix 1 Justification of numbers of patients seen by different staff. 14

Appendix 2 Sensitivity analysis ( how the numbers of staff required vary with varying work rates). 15

Foreword.

This document has been prepared by the College of Emergency Medicine and the British Association for Emergency Medicine as part of the process of updating "The Way Ahead".

Enormous changes are occurring at a rapid pace. Given the central importance of staffing CEM and BAEM have decided to make this document available to Fellows and Members as soon as possible. Comments are welcome by email.

Summary

1. The workforce requirements of Emergency Medicine are going through a period of great change.
   
2. It is clear that "one size will not fit all". The variables of case mix, availability of support staff, local procedures and emergency department overcrowding due to prolonged wait for hospital beds will all impact on the efficiency of staff and the rate that they can see patients.
   
3. Emergency departments are still heavily dependant on junior doctors for the direct provision of care. The proportion of new patients seen by juniors in decreasing. Proposed changes in training envisaged in "Modernising Medical Careers" will have a major impact on the numbers of patients that these doctors will see. This document has used current training patterns to gauge the workload of junior doctors as this is the only evidence we have at present.
   
4. Changes in training which reduce the service input of junior staff will seriously affect the provision of emergency services. There is little evidence that there is a large pool of trained workforce who might be able to fill any deficits.
   
5. Consultant roles are changing. However in smaller departments with 3 wte or less consultants, the role will be to provide clinical supervision, organisation, training, and management to the department. The major input to patient care will be in the supervision of other staff, running clinics and the care of the seriously ill and injured. Consultants will see new patients but they should not be included in the calculations for staff numbers.
   
6. In larger departments, consultants will spend a greater proportion of their time in seeing new patients. A consultant on a 10 programmed activity (PA) contract, 5 of which are direct "shop floor" cover, might see 800 new patients per year with an average case mix.
   
7. Numbers of consultant staff per unit will depend on the type of service required. All departments should have a minimum of three consultants. In departments with average case mix, one consultant per 12,000 patient attendances should be able to provide the clinical leadership, clinical supervision and educational supervision required. Medium sized departments (40,000-70,000 patients per year) should have up to six consultants and large departments (70,000+) should have more than six consultants.
   
8. If some of the changes suggested in "Modernising Medical Careers" are implemented, the clinical and educational workload on consultants will increase by about 50%. This will require a review of the numbers of consultants required for a given level of service.
   
9. With only three consultants it is not possible to schedule clinical cover for even 40 hours per week. 6 wte consultants should be able to provide 12 hours daytime cover on weekdays and 6 hours at weekends.
   
10. An average SHO with 44 clinical hours per week, seeing an average case mix of patients might see 3,000 new patients per year. This might be as little as 2,000 in some departments with a "heavy case mix".
    
11. It is an aspiration that all Emergency Departments will have 24 hour cover by experienced staff. It will take a minimum of 8 SpRs to provide this level of cover (32 clinical hours per week).
    
12. An SpR working a 48 hour per week contract with 8 hours training time and 3 months secondment time should see 1,300 new patients per year.
    
13. A experienced emergency medicine doctor working in a straight "service provision" role with no responsibility to supervise, no teaching role and working 32 clinical hours per week might see 2,800 new patients per year (average case mix).
    
14. A minor injury nurse practitioner working 37.5 hours per week might see 2,500 new patients per year.
    

Introduction

Proper staffing of the whole Emergency system is the single most important factor in providing an appropriate, timely and clinically effective service to patients. A large number of new factors have emerged that have changed the staffing of ED and a number of further changes of great magnitude are about to impact on the NHS that will present great challenges to emergency systems in the future. It is clear that Emergency Medicine is going to play a pivotal and increasing role in the emergency system and will require a well trained and motivated workforce if the ambitious targets in the NHS Plan are to be met.

Emergency Medicine consultant numbers have increased allowing a much greater involvement in clinical work in many departments. This trend will continue. Consultants have always been involved in supervision, training and in the resuscitation room they are now providing more front line direct patient care. They are also being involved more in "clinical management" roles of managing patient flows and directing staff.

There has been a great expansion in numbers and scope of practice of Nurse Practitioners and Nurse Specialists and Nurse Consultants. In some departments 25% of the workload may now be managed by nurses. However these staff still require senior medical advice to assist with the unusual or difficult case.

Changes in Junior Doctor Hours of work, training and educational requirements and increasing complexity of work in the context of an increasingly litigious society, mean that SHOs see fewer patients than previously. With increased requirements for clinical governance and more senior support available they are to be able to ask for advice more often.

Specialist Registrars (SpRs) make a major contribution to supervision, teaching and the clinical work of the department. The shape of the training programme may change with more training taking place in the ED.

Some departments in large inner city areas with less availability of primary care have successfully employed GPs. The trend in the future may be to co-locate out of hours primary care near to the ED to allow triage of patients to the appropriate facility. These Out of Hours centres will be the responsibility of Primary Care Trusts and are probably best managed by primary care.

Box 1

Changes in work roles of clinical decision makers over the past 5 years.

The political and clinical face of emergency care is being shaped by a number of Government Policies that will present major challenges to the present structure of ED.

The pressures imposed on the provision of emergency cover in acute hospitals by the EWTD and changes to the training and education will pose great challenges to all hospitals but will have special implications for smaller units. In "Keeping the NHS Local" the DOH has signalled the end of the "District General Hospital", with the full range of supporting services, that has been the corner stone of the secondary emergency care structure. Some units will lose 24 hour surgical cover, others will have much reduced surgical cover. Some may have minimal on site medical cover.

The new GP contract will have a major impact on the whole emergency system. It appears that the majority of GPs will probably opt out of the responsibility for the provision of out of hours primary care and it is not clear how this gap in going to be filled.

Modernising Medical Careers.

While the proportion of new patients seen by SHOs has fallen significantly over the past five years, Emergency Departments are still heavily dependant on these doctors for the provision of service. The Government has developed a broad strategy to change training, "Modernising Medical Careers". The specialty of Emergency Medicine has been at the fore front of training junior doctors in generic skills and in the care of the acutely ill patient. Indeed in 1993 BAEM published a competency based curriculum for SHOs that included team working and communication skills. Emergency medicine is well placed to meet the educational needs of the second Foundation year.

However these changes potentially could have a huge impact on the operation of emergency departments. The figures used in this document are taken using the current norm of 6 month SHO jobs. No clear model has emerged for the second Foundation year. Some suggestions such as moving to 4 month rotations will seriously reduce the rate that SHOs will see patients. It will increase the training and supervision demands on middle grade and consultant staff. The additional demands of induction, mentoring and assessment of 3 or more groups of SHOs per year, are huge.

Summary

Therefore this document will look at the competencies needed to provide an Emergency Medicine service, the types of staff that will fulfil these roles and give some indication of the numbers of staff that might be needed. The proportions of various types of staff will vary according to local conditions.

What skills are needed to staff an Emergency Department?

The clinical work in Emergency Medicine can be divided into various skills. This helps to understand the requirements of a department. This was the approach taken by the A&E Modernisation group (Workforce Monograph, DOH 1999).

Every department will need these skills. The numbers and types of staff delivering these skills will vary between departments. It is common for Emergency Department staff to work down the skill level eg a consultant will be able to work at most of these levels and will often do so when the department is busy. However this is not the best use of the consultants higher level skills, is not cost effective and other staff are unable to act up to cover a consultant role.

Figure. Job analysis for the Emergency Department.

• Complex leadership tasks

These tasks will be in many aspects of the department�s work. Management, education and research need dedicated time to take these agendas forward. All departments will have a basic requirement for management and educational leadership roles. Increasingly the skills of EM consultants are being sought as managerial leaders of emergency care systems, medical director roles and ambulance Trusts. At present not all departments will have a need for a research leadership role.

• Complex multi-tasking roles

This is the hallmark of a consultant. They need high level knowledge, skills and attitudes across the whole range of clinical problems presenting to the department so they can provide supervision, advice and support to the rest of the staff and key clinical skills to the seriously ill and injured. They also have a wider appreciation of the legal, ethical and managerial context of Emergency Medicine work and are able to apply this to the clinical situation. They have clinical management and leadership skills.

• Clinical decision makers

This is the main work unit of the department. They make a clinical assessment of the patient, decide on appropriate investigations, treatment and disposal. Most of the time they will work autonomously, especially in the management of routine cases. The level of autonomy and need for supervision is a function of experience and training. Consultants are autonomous, SpRs, Staff Grade and Associate Specialist (SAS) doctors, and nurse practitioners are largely autonomous in the care of routine cases. SHOs will require a lot of training and supervision, especially early in the course of their post. However because SHOs derive great training and educational benefits from emergency medicine and because the period of hard, unsocial hours work is time limited to six months for most, they are willing to accept the rota.

• Clinical Skills staff

A consultant will have most if not all the clinical skills the department needs. However many of these skills can be taught to other staff and allow freeing up of medical time.
Taking blood, siting IVI, routine wound care, can all be taught to other types of staff. These staff provide the practical skills base to the department.

• Non Clinical skills staff

Reception and administration staff, clerks, secretaries, porters, security staff all have key roles in the smooth functioning of the ED. They will have non clinical specialist skills essential to the proper management of the department

ED consultant styles of working

CEM and BAEM published a document on the future of consultant staffing in ED in 2002. This has been updated to take into account the new consultant contract. The numbers of consultants needed in any given department will depend on the type of consultant cover required.

• Command and control- large part of the job plan involves non clinical management roles, teaching, audit and research. Clinical roles mainly involve supervision, second opinions, care of the critically ill patient.
  
• Clinical Managers- Continuous physical presence in the clinical area, directing patient flows, directing staff, care of the critically ill and direct clinical supervision.
  
• Clinical decision makers- Front line work seeing patients, "see and treat", advanced triage, perhaps not the best use of consultant time to be only employed in this role (but consultants may need to do this as part of a varied working week).
  

Command and control.

This would be the commonest model in the past and may still be the most cost effective model for small departments. A department needs certain fixed times to be spent on management, education and audit, irrespective of the size of department. With only 3 consultants these roles will take up a significant part of the job plan. Clinical roles would typically be for 5 shop floor programmed activities per week. The other 2.5 clinical programmed activities will be taken up by clinics, patient related administration (notes, results, complaints). This allows a maximum of 9 am - 5 pm consultant cover Monday to Friday. With this level of staffing it may be difficult to cover all clinical activities during annual leave or other absences.

Clinical Managers

The main role is the management of patient flows around the department. This may be advanced triage or actively directing the work of the junior staff. This is becoming the work pattern in large multi-consultant departments

Clinical Decision Makers.

This is a role that all consultants would undertake but to use them in this role exclusively is not the best use of a consultant�s skills. Given the current numbers of consultants and expected rates for consultant expansion it is impossible to envisage a consultant provided service.

How should we calculate staffing needs?

The concept of "workforce equivalents" in the last "Way Ahead" document, while subject to debate, proved very popular. It seems difficult to reduce the professional tasks of an emergency medicine doctor to stark numerical terms but this approach does provide a starting point for the calculation of staffing requirements. Until very recently most departments were unable to reach the types of workforce levels suggested by previous documents, usually due to financial constraints.

Waiting time targets.

Would these levels of staff guarantee meeting targets? Meeting the 4 hour target is a complex issue. There is good evidence that the main determinant of ED waits is patients waiting long times for admission. No matter how well staffed the ED, if there are long delays for admission the efficiency plummets. Also larger departments have greater problems in managing work rates.

These figures are based on staffing data at a time where ED were staffed to meet 90% 4 hour targets.

Meeting a 98% target is going to present major challenges for emergency systems and clinicians and managers will have to engage in local debate about the resources required to meet individual targets. To meet a 98% target an EM department would need to be staffed at above average levels to cope with peaks in demand. It is also essential that the whole of the rest of the hospital co-operates to ensure speedy management of acute cases.

Definition of a workload unit.

Recent evidence from emergency departments reveals that on average, SHOs might see between 2,000 and 3,000 patients per year. This document will use 3,000 patients per year as the "workload unit". This is a fall from previous years but is based on direct evidence. The reasons for the change are likely be multifactorial but include a change in the demographics with medically ill and more elderly patients and less minor injury work, less experienced SHOs plus more time spent in formal training, especially real time clinical training.

These figures can only be used as an approximation as unit size, policies, support staff, delays for admission will all impact on the rate that staff can assess and treat patients. Appendix 2 presents a method for recalculating numbers of staff required where the work rates of staff in your unit do not match those in this document. (Appendix 2, Sensitivity Analysis).

(Justification of these numbers in given in Appendix 1.)

1 WORKLOAD UNIT (wlu)= 3000 PATIENTS PER YEAR

NP New patients.

Normal case mix indicates an average admission rate of 15-20% with full numbers of minor injury and paediatric injury cases.

Heavy case mix indicates large numbers of ambulance and trolley cases, more complex moderate illness and less minor injury or paediatric cases

1. Workload includes the clinical management of the department and supervision of other staff.
2. This figure is for comparison purposes only it would be a unsustainable job description for a consultant.

Examples of staffing for Emergency Departments.

The best way to provide Emergency Department staffing will be for local Emergency Care Systems to decide. As a minimum there should be access to a consultant led ED which has adequate staff to produce all the outputs required (including teaching, management and research).

Smaller units (less than 40,000 total attendances per year)

Example 40,000 patients per year = 13 workload units

(Average case mix- 15-20% admissions, 25% paediatric cases, 50% adult minor injury cases)

Level of service- Minimum of three consultants who would enable mainly "command and control" model. It would not be possible to guarantee shop floor cover for 8 hours a day, five days a week. It would take 3.5wte to do this. On call rota.

Middle grade. A minimum of 8 doctors would be needed to provide 24 hour cover. This may not be economical or clinically justifiable as the numbers of patients at night might be small. There may be need to consider this role as "middle grade doctor for hospital" role. This will further complicate the workforce calculations as obviously a middle grade covering the hospital cannot be seeing new patients in the ED.

Clinical Decision makers.

This is made up of work provided by middle grade staff, SHOs, and nurse practitioners.

Numbers may vary with skewed case mix.

ENP � 2,500 patients per year (minor injury)

SHO- 3,000 patients per year (normal case mix)

Middle grade- 1,800 (SpR 1,300, SAS 2,400 patients per year (normal case mix))

Given the lack of clinical time consultants should not be added into this calculation.

Middle grades 8x 0.6 wlu = 4.8wlu (assuming ED work only)

SHO 6 x1wlu= 6wlu

ENP 3 x 0.8 wlu= 2.4wlu

Total 13.2 wlu

(note while some flexibility around the distribution of staff might be possible, the groups are not interchangeable, for example most ENPs are trained in minor injury care or other specialised roles , they would not be able to take care of other types of cases or provide high level support to other staff across the whole range of ED workload)

Medium units (40,000- 70,000 total attendances per year)

Level of service Minimum of six wte consultants who would provide 5 programmed activities of direct shop floor cover. 12 hour per day weekday cover, and 6 hours per day weekend cover. On call rota.

Middle grade. The minimum of 8 doctors would be needed to provide 24 hour cover. Essential in a department of this size and throughput.

Example -70,000 patients = 23 workload units

(Average case mix- 15-20% admissions, 25% paediatric cases, 50% adult minor injury cases)

Clinical Decision makers

This is made up of work provided by middle grade staff, SHOs, and nurse practitioners.

Numbers may vary with skewed case mix

ENP � 2,500 patients per year (minor injury)

SHO- 3,000 patients per year (full case mix)

Middle grade- 1,800 patients per year (full case mix)

Consultant 500-1,000 cases per year + direct supervision.

Workload calculation 70,000 = 23wlu

Consultants 6x 0.25wlu = 1.5wlu

Middle grade 8x 0.6wlu= 4.8wlu

SHO 11 x1wlu = 11wlu

ENP 8 x 0.8wlu= 6.4wlu

(note while some flexibility around the distribution of staff might be possible, the groups are not interchangeable, for example most ENPs are trained in minor injury care or other specialised roles, they would not be able to take care of other types of cases or provide high level support to other staff across the whole range of ED workload)

Large units (70,000-100,000 total attendances per year)

Level of service Minimum of eight wte consultants who would provide 5 programmed activities of direct shop floor cover. 12 hour per day weekday cover, and 8-12 hours per day weekend cover. On call rota.

Middle grade. The minimum of 8 doctors would be needed to provide 24 hour cover. Essential in a department of this size and throughput. It is likely that the volume of serious cases will require double cover for long periods of the day/evening and while 8 is a minimum 10 is more likely to result in a quality service.

Example-

100,000 unit- average case mix =33 workload units

(Average case mix- 15-20% admissions, 25% paediatric cases, 50% adult minor injury cases)

Clinical Decision makers

ENP � 2,500 patients per year (minor injury)

SHO- 3,000 patients per year (full case mix)

Middle grade- 1,800 patients per year (full case mix)

Consultant 500-1,000 cases per year + direct supervision 2000 cases per year.

Workload units per 100,000 =33

Consultants 8x0.25wlu= 2wlu

Middle grade 10x0.6wlu= 6wlu

SHO 18 x 1wlu = 18wlu

ENP 9x0.8wlu = 7wlu

Total 33wlu

(note while some flexibility around the distribution of staff might be possible, the groups are not interchangeable, for example most ENPs are trained in minor injury care or other specialised roles, they would not be able to take care of other types of cases or provide high level support to other staff across the whole range of ED workload)

Summary table of EXAMPLE staffing with departments with average case mix.

Consultant work patterns in Emergency Medicine.

The last two years have seen great changes in the work of Emergency Medicine Consultants.

• Much more clinically based.
  
• The adoption of new ways of working such as clinical area management and see and treat.
  
• Extension of hours beyond the normal working week.

The new consultant contract has given a framework for this work.

The contract envisages a 40 hour working week, or 10 programmed activities.

It is important to realise that it is becoming increasingly obvious that "one size does not fit all" in terms of working patterns for consultants. The following is an attempt to describe reasonable patterns of work that will make the job sustainable and provide maximum levels of clinical input. It will be for the management and the consultants in each department to determine the best pattern of clinical working.

Assumptions

Consultant Availability

A consultant will have 6 weeks annual leave and 10 bank holidays per year.

They will need 10 days of study leave per year.

They will need 10 days of duty leave per year (mainly for teaching ATLS/APLS/ALS). Some consultants will need more duty leave and this would be negotiated in job plans.

This is 12 weeks per year when the consultant will not be available for the rota.

Therefore the consultant is available for work 40 weeks per year.

Departmental non clinical requirements.

There are a number of requirements that a department will have irrespective of size. These may increase in larger departments. These figures are calculated using current working patterns. If changes in SHO work patterns change (eg to 4 month jobs), then the supervisory work and teaching requirements will increase by at least 50%.

Clinical Director
- 3 programmed activities

Teaching organisation
- 2 programmed activities (may be up to 4 in large teaching depts)

Non clinical duties of consultants
- 2.5 programmed activities per consultant.

Consultant duties

5 programmed activities front line clinical work

2.5 programmed activities patient related work (CDU, clinics, patient related admin, x-ray meetings etc.)

2.5 programmed activities non clinical work

It is possible that consultants may elect to contract for extra clinical programmed activities. Obviously of all consultants in a department contract for 12 programmed activities, the clinical cover could be increased.

Some consultants may negotiate a different mix of sessions in respect of other management duties. This will need to be considered on an individual departmental basis.

Sample rotas for departments.

Small, three consultant department.

Available programmed activities per week 30

Take away leave programmed activities (20%) -6

Take away "base requirement" programmed activities -5

Take away non clinical programmed activities (2.5/cons) -7.5

Take away emergency on call worked -1

Clinical programmed activities available 10.5

Thus a three consultant department would have clinical cover for 8 hours a day, Monday to Friday most of the time. However this would include all clinical activity, including clinical administration, clinics and ward work. There is not enough consultant time to have a "shop floor" presence.

There is not enough consultant time to insist on evening or weekend clinical programmed activities. Some departments with lighter teaching/ management loads may be able to introduce some evening working.

Equally a Trust may wish to pay for extra programmed activities for management or clinical work.

A six consultant department

Available programmed activities per week 60

Take away leave programmed activities (20%) -12

Take away base requirement programmed activities -5

Take away non clinical programmed activities (2.5/cons) -15

Take away emergency on call worked -1

Clinical programmed activities available 27

This would allow;

• Clinical consultant programmed activities 12 hours a day Monday to Friday (15 programmed activities)
  
• Double cover 4 hours per day Monday to Friday (5 programmed activities)
  
• 6 hours cover Saturday and Sunday (4 programmed activities)
  
• Additional consultants in departments on non clinical duties 4 programmed activities per day Mon-Fri.
  

An eight consultant department

Available programmed activities per week 80

Take away leave programmed activities (20%) -16

Take away base requirement programmed activities -7

Take away non clinical programmed activities (2.5/cons) -20

Take away emergency on call worked -1

Clinical programmed activities available 36.

This would allow;

• Clinical consultant programmed activities 12 hours a day Monday to Friday (15 programmed activities)
  
• Double cover 8 hours per day Monday to Friday (10 programmed activities)
  
• Triple cover 4 hours per day Monday to Friday (5 programmed activities)
  
• 9 hours cover Saturday and Sunday (6 programmed activities)
  
• Additional consultants in departments on non clinical duties 4 programmed activities per day Mon-Fri.
  

Specialist Registrar work.

It is likely that the SpR training in Emergency Medicine will change. With increasing expertise in EM departments, the requirement for "secondments" will diminish. Equally it is important to protect training time. An SpR would expect 4 programmed activities a week for training and private study (to include SpR training day). Over the course of the training they may require out of department training (eg anaesthetics, ITU, paediatric medicine). However the period of out of department training would be less than the 15 months in the present training. It is likely that this should be a maximum of six months.

This would allow 32 hours a week for rota work.

They would have 8 weeks holiday a year (6 weeks + 10 bank holidays).

This means the SpR would be available for work only 44 weeks per year (1320 hours). At one patient per hour new + supervision of junior staff, 1,300 patients.

(Traditional model- 48 hours per week, 8 hours training gives 40 clinical hours per week. 31 weeks per year (11 secondment, 6 weeks annual leave and 10 Bank Holidays, two weeks study leave (in addition to protected teaching/educational time). This gives 1240 hours per year, New patient 1 per hour- 1,240 per year patients+ clinical supervision.

SpR = 1300 patients per year).

APPENDIX 1

Justification of numbers of patients seen by type of staff.

Information provided by the British Association for Emergency Medicine shows variation in the numbers of patients various grades of staff will see per hour. This variation will be explained by case mix and departmental procedures.

SHO 1 to 2 patients per hour.

ENP 1 to 2 patients per hour (minor injury)

Middle grade staff 2 patients per hour (patient care duty only)

Middle grade staff 1 patient per hour (patient care and supervision of junior staff)

Consultant 1 patient per hour (patient care and supervision of junior staff and clinical case management)

SHO- 44 clinical hours per week, six weeks holiday per year (including bank holidays), 1 week study leave. 3,000 patients per year (1.5 patients per hour). This is very dependant on case mix. If dealing with minor injury only, the rate might be 2 patients per hour but if dealing with major cases, only one patient per hour.

Consultant-, 5 (20 hours) programmed activities per week, 40 weeks per year = 800 hours per year.

If the "shop floor duty" includes clinical supervision of juniors and the new patient area the consultant might see 800 patients per year. If the consultant has no other supervisory duties they might see 1600 cases per year (two patients per hour, average case mix).

This is based on a 10 programmed activity contract, 5 programmed activities of direct clinical "shop floor" supervision, 2.5 programmed activities other direct clinical care including allowance for on call care, clinics and observation ward work, clinical administration, and 2.5 other supporting activity.

Consultant-, 5 (20 hours) programmed activities per week, 40 weeks per year, only engaged in direct patient care, average mix of resus/majors/minors work - 1,600 patients per year (two patients per hour).

Consultant , 5 (20 hours) programmed activities per week, 40 weeks per year, only engaged in minor injury work and fully supported by appropriate support workers, (this is for example and is an unrealistic job plan) 2,400 patients per year (three patients per hour).

Staff and associate specialists- 32 clinical hours per week. 44 weeks per year. 2,800 patients per year. (two patients per hour), minor injury 4,200 patients per year (unrealistic for example only) (three patients per hour).

Specialist Registrar- This will depend on the type of training programme. The traditional model envisages that 25% of the time will be spent on "secondment" and will not be available for clinical work. In the future it is envisaged that they will spend most of the time training in the emergency department.

Traditional model- 48 hours per week, 8 hours training gives 40 clinical hours per week. 31 weeks per year (11 secondment, 6 weeks annual leave and 10 Bank Holidays, two weeks study leave in addition to protected training time). This gives 1240 hours per year, New patient 1 per hour- 1,240 per year patients+ clinical supervsion.

New model- 48 hours per week, 16 training hours, 32 clinical hours. 42 weeks per year (6weeks holiday,10 bank holidays, two weeks study leave in addition to protected training time). At one new patient per hour, 1344 patients).

These are almost identical.

SpR = 1300 patients per year.

Minor injury emergency nurse practitioner.

37.5 hours per week, 6 weeks holiday (including bank holiday),one week CPD.

2,500 patients per year 1.5 patients per hour.

As departments diversify the case mix of patients will change. Even now the casemix in a large urban centre with a nearby primary care centre, a minor injury unit and separate children�s emergency department will be different to a unit with none of these alternative facilities.

The figures do not take into account any other activity such as specialist clinics, clinical decision unit work, ward work or other clinical activity. Baseline allowances are made for management, teaching and audit. No allowance is made for proper research. Staff time for these activities would need to be added.

Appendix 2 - Sensitivity Analysis

The work rates of different staff will not be constant between departments. We estimate that an SHO working in a department with average case mix might see 3,000 new patients per annum. However we have evidence that in some departments this figure might be only 2,000 patients per annum or even lower. The following information looks at the effect of different workrates on our staffing figures.

This table shows the effect if the workrate in a particular Emergency Department is different from those estimated in this document.

In this document we have estimated that an SHO will see 1.5 patients per hour. For every 0.1 patients per hour that this rate of seeing patients changes, we need � 0.4 wlu in a Small Unit, � 0.7 wlu in a Medium Unit and � 1.2 wlu in a Large Unit. If the change in workrate is greater than 0.1 then the three right hand columns need to be increased proportionally (ie. Doubled for a change in workrate of 0.2 etc).

The table shows that if we are wrong about the Consultant workrate it will make very little difference to the overall model. If we are wrong about the NP or SpR workrate it will make only a moderate difference to the overall model. However if we are wrong about the SHO workrate it will make a large difference.

Worked example:

If the SHO workrate in a Medium Unit was 0.5 patients per hour slower, equivalent to 2000 patients seen per year per SHO (rather than the 3000 assumed in this document), the number of SHOs required would increase by 3.5 (5 times 0.7), that is from 11 to 14.5.