There is a severe mismatch between demand and capacity in the Urgent and Emergency Care (UEC) system. The unparalleled levels of demand placed on EDs has not been met with sufficient investment into the NHS. EDs now sustain other parts of the system and are the first port of call for many patients, despite not always being the most appropriate place to receive care. The pandemic has exacerbated many of these challenges and there is an urgent obligation to plan for the future healthcare needs of the UK. Eliminating overcrowding must be the number one priority.
Emergency Medicine is the field of medicine that is practised at NHS EDs and is based on: “the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of episodic undifferentiated physical and behavioural disorders; it further encompasses an understanding of the development of prehospital and in hospital emergency medical systems and the skills necessary for this development.”
The RCEM CARES campaign provides solutions to address these pressing issues so that ED staff can deliver safe and timely care for patients. The campaign focuses on five key areas: Crowding, Access, Retention, Experience, and Safety.
The RCEM CARES campaign provides solutions to address these pressing issues so that ED staff can deliver safe and timely care for patients. The campaign focuses on five key areas: Crowding Access Retention Experience Safety Click on the tabs below to find out why each is important and what needs to be done.+ Crowding
Crowding is a consequence of exit block. This is usually because an acute hospital does not have enough beds to admit their patients.
Crowding existed long before the coronavirus pandemic and has returned to EDs across the UK. The loss of beds within hospitals is a key contributing factor: since 2010, over 29,000 hospital beds have been removed from the system. The UK has one of the lowest numbers of beds per capita in comparison to OECD nations. Lack of adequate bed stock results in ED crowding and ambulance handover delays.
A lack of adequate social care further impedes patient flow. While medically fit to leave, patients may need help to recover in the form of a social care package, which may not be immediately available. This means that their hospital bed is unavailable to the next patient, resulting in further ED crowding.
Crowding is not only inhumane and undignified for patients; it is also dangerous. Studies show that patient mortality increases when there is ED crowding and long delays to admission. Data in the GIRFT Emergency Medicine report showed an increase in the Standardised Mortality Ratio associated with ED delays beyond 5-6 hours from time of arrival. Their logistic regression model found that of those patients delayed by 8-12 hours in the ED, there was an associated 30-day morality rate for 1 in every 67 patients.
Crowding additionally has an impact on staff morale as ED staff are less able to provide safe, timely and efficient care to their patients, and any subsequent patients who attend the department.
EM Clinical Leads
EDs should be a safety net for the patient, not the safety net for the system. EDs have a powerful brand for offering round-the clock care. Many patients go to their ED having tried – and failed – to get timely care and treatment elsewhere. EDs are increasingly providing care for patients who may have been better served elsewhere and Emergency Medicine staff are not trained to care for these patients. Access to care is variable across the health service. The best and most cost-effective healthcare systems in the world are based on a strong primary care system; patients appreciate timely care, ideally with someone who knows their history. For primary care to be effective, capacity needs to match demand. Deprivation is the single most important factor in determining ED demand: the most deprived communities use ED services significantly more than the least deprived communities. These areas additionally have poor provision of primary and preventative care. This results in EDs sustaining other parts of the health and social care service.
Phone First services have the potential to improve patient experience and reduce crowding in EDs. However, these must be robustly evaluated, with the results and data published in full so we can understand patient behaviour and the impact on ED presentations. This must go hand-in-hand with an increase in clinical validation of these services and an increase in alternative provisions across the UK that services can direct patients to.
Patients should only attend hospital when it is essential, or when the clinical value outweighs the risk. Progress must be made in adopting a consistent, expanded model of Same Day Emergency Care (SDEC) and Ambulatory Emergency Care (AEC), which are available twelve hours a day, seven days a week.
The NHS is struggling to cope with a workforce crisis and there is an urgent need to improve retention of staff working in EDs. EDs went into the pandemic understaffed. Understaffing means our workforce suffers from burnout – more so than other specialties – leading to many staff leaving the specialty. Due to the intensity of the working environment, staff are now choosing to work less than full time. This creates a sustainable career but creates additional workforce demands. The pandemic placed enormous amounts of pressure on Emergency Medicine staff. The second wave was particularly challenging, with its peak coinciding with the height of winter pressures. As we emerge from the pandemic, EDs continue to face unprecedented levels of demand. Our workforce survey carried out in May 2021 found that three quarters of respondents (74%) have considered changing their working patterns, with half (50%) indicating they are planning on reducing their working hours in the next two years. This poses significant challenges for the functioning of our NHS – a challenge that needs to be tackled urgently by policymakers. Additionally, workforce models are predicated on insufficient numbers of trained clinicians – who are expected to deliver safe care – whilst quality assuring the actions of staff in training. Trainee staff form the majority of any ED workforce and are also expected to deliver quality assured care.
We recognise that Black, Asian, and minority ethnic staff have very different experiences of the NHS across the UK as a workplace. We urge NHS leaders to create an inclusive and equitable organisational culture and work to address incivility and bullying that exists in the NHS. RCEM’s RespectED campaign – developed in line with Civility Saves Lives – aims to raise awareness of incivility and bullying between colleagues. The campaign is a call to action to ask ED staff to address their own behaviours and proactively tackle bullying and incivility in EDs.
The changes in pension taxation in 2019 resulted in experienced Consultants reducing their working hours causing rota gaps. Future pension reforms must avoid these perverse incentives. Staff and Associate Specialist and Specialty (SAS).
This important staff group needs sustainable career development as set out in the BMA SAS Charter.
Recent initiatives increasing flexibility in training have decreased resignation from training rates but have also reduced the overall WTE workforce. Less than 50% of trainees completing training are directly taking up Consultant posts. We have improved training but not Consultant working.
What is the solution?
Medical Directors and Heads of Nursing
EM Clinical Leads
Patient experience should be at the heart of any world class health and social care system.
In England, the CQC survey shows that patient experience in EDs is overall “very good” with many patients expressing confidence and trust in the doctors and nurses examining and treating them. However, there is certainly room for improvement in the patients’ overall experience when attending an ED. Many of our existing EDs are too small, run down, and in need of repair. With rising attendances and admissions, the physical size of many hospitals and EDs have not increased. Most are now stretched beyond the capacity they were initially designed and resourced to manage. This is a poor environment for patients, especially for the frail and vulnerable.
Addressing the estates backlog must take priority over building new hospitals. Although the £5.9 billion capital funding announced by the Treasury is welcome, NHS England is facing a £9.2 billion estates backlog. Similarly, in Scotland, while many EDs are in good condition, additional funding is required to physically expand EDs, so they are able to meet demands placed on them. Any new rebuild must take on the principles of the Smart ED, which is sustainable and supports a positive patient and staff experience. The GIRFT report identified 28 EDs that require a complete rebuild or redevelopment in order to function adequately at their current level of demand. A third of EDs are too small to manage their current workloads effectively.
We acknowledge that different patients experience care offered in EDs in different ways. Patients who are suffering a mental health crisis often report having a poor experience, with long waits in an environment that is stressful and stigmatising.
The post-pandemic world will look very different, presenting us with a new set of health challenges. A coherent and joined up vision for the future is required, that considers the health of the nation and of the healthcare service. This must include a plan to end crowding and the need to provide care for patients in a safe environment. To do this, we need to stop allowing our EDs to become overwhelmed and consign winter crises to the past.
This requires long term solutions and greater coordination across the whole health and social care system.
EM Clinical Leads
EDs must become safer places to look after ill and injured people.
Overcrowding and challenging working conditions can result in an environment where errors are more likely to happen. In England, over half of EDs ‘require improvement’ or were ‘inadequate’ in regard to safety. This is associated with expensive and potentially avoidable litigation. Emergency Medicine now accounts for the highest volume of NHS litigation liabilities. In 2019/20 it accounted for 12% of all claims against NHS trusts. The average liability per ED attendance is £19.39. The new Health and Social Care Levy is expected to raise £12bn extra spending a year on health and social care services across the UK. There is a risk that this will fall short of what is needed to facilitate recovery in the health and social care system.
In June 2020, RCEM joined the Medical Royal College community to call for a rapid forward-looking review of the UK preparedness for a second wave of COVID-19. The upcoming public inquiry into the management of the coronavirus pandemic must examine the reasons why the UEC system was ill equipped to meet demand, along with the performance of the UEC system, to enable lessons to be learned for future pandemics.
EDs face considerable challenges ahead. The scale of the elective backlog poses additional demand on EDs as patients may present with emergencies from delayed or cancelled procedures. With covid-19 now endemic in the population, the resurgence of flu and RSV pose additional challenges to providing emergency care.
We need to ensure that EDs can safely manage undifferentiated patients whilst providing emergency care. Timely access to testing will help to support fragile rotas and avoid severe workforce shortages during seasonal pressures.
NHS England and devolved equivalents
There is an urgent need for robust coordination of safety information produced by the new HSSIB, Coroner Prevention of Future Deaths reports, NHS Resolution, National Reporting and Learning Service (NRLS), NICE, and alerts currently available on the Central Alerting System.
EM Clinical Leads
RCEM CARES: Briefing for parliamentarians
RCEM CARES: The Next Phase
RCEM Cares – During the Coronavirus Pandemic
RCEM Cares – yn ystod pandemig y coronafeirws
RCEM Cares – CROWDING – Policymaker Brief for MPs (ENGLAND)
RCEM Cares – CROWDING – Trust CEO Briefing (ENGLAND)
RCEM Cares – CROWDING – Policymaker Brief for Members of Senedd (WALES)
RCEM Cares – CROWDING – Policymaker Brief for MSPs (SCOTLAND)
RCEM Cares – SAFETY- Policymaker Brief for MPs (ENGLAND)
RCEM Cares – SAFETY – Trust CEO Brief (ENGLAND)
RCEM Cares – SAFETY – Policymaker Brief for Members of Senedd (WALES)
RCEM Cares – SAFETY – Health Board CEO Brief (WALES)
RCEM Cares – SAFETY – Policymaker Brief for MSPs (SCOTLAND)
RCEM Cares – Retention – Policymaker Brief for MPs (ENGLAND)
RCEM Cares – Retention – Policymaker Brief for MSPs (SCOTLAND)
RCEM Cares – Retention – Board CEO Brief (SCOTLAND)
RCEM Cares – Retention – Policymaker Brief for Members of Senedd (WALES)
RCEM Cares – Retention – Board CEO Brief (WALES)
RCEM Cares – Access – Letter to Policymakers – for MPs (ENGLAND)
RCEM Cares – Access – Joint letter to Trust CEOs with RCP and SAM (ENGLAND)