The Royal College of Emergency Medicine (RCEM) is the single authoritative body for Emergency Medicine in the UK. Emergency Medicine is the medical specialty that provides doctors, ACPs, and consultants to A&E departments in the NHS in the UK and other healthcare systems across the world. The Royal College works to ensure high quality care by setting and monitoring standards of care and providing expert guidance and advice on policy to relevant bodies on matters relating to Emergency Medicine.
Introduction
Emergency Departments (EDs) are the only part of NHS Wales that offer a truly round the clock service, seven days a week. The COVID-19 pandemic has exacerbated the pressures felt in our EDs, with staff and patients having to physically distance, beds taken out of the system and staff having to wear restrictive PPE. This has all put considerable strain on staff, who provide care in already challenging circumstances. RCEM Wales’ manifesto outlines our ambition for better emergency care in Wales, putting patients back at the heart of the system. Ensuring EDs are adequately resourced to deliver crucial services are, now more than ever, integral to a well-functioning healthcare system.
RCEM CARES: Our action plan for better emergency care in Wales
Eliminating crowding in Welsh EDs must be the number one priority of any incoming Government. EDs are stretched to the limit, with staff having to care for patients alongside managing the COVID-19. If crowding was unacceptable before the pandemic, it is unconscionable now. The incoming Welsh Government must commit to addressing the following:
Crowding and corridor care
With a lack of beds, capacity, and adequately managed flow, hospital services do not have the resources to match the demand being placed on Welsh EDs. Admitting patients into a hospital bed in a timely way has become increasingly unachievable. As a result, patients are staying in EDs for too long, and consequently are being moved out of cubicles and into non-clinical spaces such as corridors, so that EDs can continue to function.
Crowding is a consequence of exit block, whereby patients who have been assessed in EDs are unable to be admitted or transferred, often because another part of the hospital does not have enough beds to admit their patient to. The reduction of bed numbers in acute hospitals over time has contributed to this, resulting in patients receiving care in corridors, which is both unsafe and inhumane. The pandemic has further exacerbated this issue, resulting in a loss of beds to maintain physical distancing in inpatient areas. Over 47,000 patients waited 12 hours or more in 2020; this represents 16% of all attendance. To put this into context, only 8% of attendances waited 12 hours or more the previous year (2019).
Nobody should be waiting 12 hours in an emergency department but especially so in a year where the threat of infection and the risk to patient safety was at an all-time high. With COVID-19 still present in the community, EDs have had the twofold challenge of managing both crowding and COVID-19 in their departments. This presents a further avoidable risk of death from a COVID-19 infection acquired in an ED for patients and staff.
Recommendations:
1. Restore the staffed acute bed capacity to pre-COVID-19 levels. Moreover, increase bed numbers to achieve 85% bed occupancy in hospitals, to maintain flow in EDs. We estimate that an additional 262 beds are required in hospitals across Wales.
2. Adult social care in Wales faces challenges and requires significant investment to ensure patients are discharged safely and promptly when their medical care is complete. In Wales, this requires an investment of an additional £1.1 billion in social care by 2030/31 to match demand.
3. Ensure that the new Experimental measures effectively promote patient flow and prioritise care of the most seriously ill and injured patients.
Alternative access
Many patients attend EDs having tried – and failed – to get timely care and treatment elsewhere. This has been exacerbated by the continuation, in Primary care, of remote consultations, after the first wave of the COVID pandemic. In this current climate, the need to maintain physical distancing and prevent crowding in our busy departments is highly important. For Primary Care to be effective, capacity needs to match demand.
New models of access to urgent and emergency care, such as call-before-you-walk, are being rolled out across Wales. This model of care is aimed at ensuring people get the right care at the appropriate place, allowing Emergency Departments to focus on the sickest patients, whilst offering care in a COVID-19 endemic world. As pathways to the EDs change and adapt, we must remain mindful of the ways in which this might impact the most vulnerable and ensure that these patients are still receiving access to high quality care.
Recommendations:
1. Expand Primary Care services to provide out-of-hours services in areas of need. Welsh General Practice needs an increase in training places to ensure patients can receive the right care at the right place.
2. Expand co-located acute services around the ED, including frailty, mental health, pharmacy, and Primary Care to support patients being cared for in the best place.
3. Rapidly expand Ambulatory Emergency Care provision across all acute hospitals in Wales and ensure it has the same access to diagnostic services as EDs.
5. Councils must invest in preventative health to support the most vulnerable in society. This includes additional support for drugs and alcohol services, homelessness and immigrant health, domestic violence, and youth violence.
Recruitment and retention
We know that EDs provide the best care when they are adequately staffed. Currently our workforce suffers from burnout (more so than other specialties), attrition, and staff shortages. EDs in Wales have insufficient resources to meet the minimum number of consultants and senior decision makers required per 100,000 attendances.1
Although previous workforce strategies have been ambitious in scope, they failed to outline long-term plans for growing the Emergency Medicine workforce. Additionally, as the pandemic continues, we are acutely aware that COVID-19 disproportionately affects Black, Asian and minority ethnic staff.2
We also recognise that Black, Asian, and minority ethnic staff have very different experiences of the NHS across the UK as a workplace.
Recommendations:
1. The incoming Welsh Government must deliver a long-term workforce strategy for Emergency
1 https://www.nhsbenchmarking.nhs.uk/projects/emergency-care-type-1-2-and-type-3-services
2 We use the term ‘Black, Asian and minority ethnic’ for practical reasons. We acknowledge the limitations of this phrase and recognise the diverse and heterogeneous experiences of people both across and within different ethnic groups.
Medicine with a commitment to recruiting additional staff and addressing shortages in the workforce. Recruitment of Emergency Medicine Consultants should be based on a ratio of one Consultant per 4,000 attendances. At present, that would translate to an additional 120 Consultants in Wales.3
2. Reintroduce the Associate Specialist grade.
3. Deliver additional ED Nurses to address the shortage in the workforce. The skill mix of the ED Nursing workforce should comprise of 30% Emergency Charge Nurses, 40% Emergency Nurses, 10% Foundation Staff Nurses, and 20% Nursing Associates or Clinical Support Workers.
4. Continue with the current recruitment numbers of AHPs and promote the national strategy to support their career development.
Experience
Patients should be at the heart of our Emergency Care system. However, crowding results in a deterioration in the quality and timeliness of care for patients, a loss of dignity, and a loss of comfort. This disproportionately affects children, elderly people, and the vulnerable. Crowded NHS EDs can be a frightening experience for people with dementia or those suffering from a mental health crisis. High demand, inadequate space, and poor departmental infrastructure create a volatile environment.
Across the UK, Liaison Psychiatry teams play a crucial role in the parallel assessment of mental health patients who attend ED, who might also require medical care. Expansion of Liaison Psychiatry must go hand-in-hand with investment in preventative services, Child and Adolescent Mental Health Services, community support schemes, and good telephone triage.
In addition, the COVID-19 pandemic has exposed the alarming levels of inequality that persists in society. We do not underestimate the role that EDs play in addressing health inequalities; the most deprived communities use ED services significantly more than the least deprived communities. Addressing inequalities in health requires cross-governmental working, with all government departments taking responsibility.
Recommendations:
1. Ensure clinical and patient involvement in designs for any plans to build or refurbish EDs.
2. Develop a meaningful quality indicator for patient experience by working closely with RCEM’s Lay Group and patient groups.
3. An urgent increase investment in mental health services, including alternative mental health facilities, Child and Adolescent Mental Health Services, and preventative services.
4. Embed action on health inequalities across all Welsh government departments.
Safety and Space
Overcrowding and challenging work conditions can result in an environment where errors are more likely to happen. This is associated with expensive and potentially avoidable litigation. There is an unprecedented risk in managing the elective backlog presenting as emergencies, along with seasonal norovirus, flu, and COVID-19. We need to ensure that EDs can safely manage undifferentiated patients whilst providing urgent and emergency care and minimising the nosocomial spread of COVID-19. This means timely access to Personal Protective Equipment and testing; EDs employ many staff who have young children and delays in test results for COVID-19, either for staff or those that staff have caring responsibilities for, can create significant workforce problems.
3 RCEM Cares
Recommendations:
1. Carry out a forward-looking rapid review of Wales’ preparedness for successive waves of the COVID-19 pandemic, including the physical environment of EDs. This will help EDs tackle the inevitable challenges of COVID-19, flu, and seasonal norovirus during the winters of 2021 and 2022.
2. Ensure there is adequate stock and access to appropriate PPE for all ED staff for the entirety of the pandemic.
3. Ensure that there is adequate capacity for COVID-19 testing for ED staff (and their households), with quick turn-around times that allow prompt and safe return to work.
4.Ensure an urgent, pragmatic, clinically driven policy for the isolation of health care workers. This should include advice for those shielding post-vaccine, and advice for workers who are asymptomatic contacts, especially if vaccinated.
Contact us
The Royal College of Emergency Medicine’s Policy and Communications team works with politicians and policymakers in England, Scotland, Wales, and Northern Ireland.
We are the first contact point for enquiries on all matters relating to health and Emergency Medicine policy.
Email: tamara.pinedo@rcem.ac.uk Telephone: 020 7067 4814
