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The Royal College of Emergency Medicine has collated information and guidance on the Emergency Department workforce. In this section you will find resources for service delivery, recommendations on expanding the consultant workforce, medical and practitioner workforce guidance and relevant toolkits.

Medical and Practitioner Workforce Guidance

RCEM Workforce Recommendations 2018: Consultant Staffing in Emergency Departments in the UK

Find below the Royal College of Emergency Medicine’s RCEM Workforce Recommendations 2018 / Consultant Staffing in Emergency Departments in the UK:

* Please note that the references to Consultant staffing in the remainder of the historic RCEM guidance has been superseded by the above publication. *

Workforce guidance tools and resources

Find below the Royal College of Emergency Medicine’s workforce guidance tools and resources:

Employing locum doctors

The following resources are designed to provide guidance around locum posts:

As part of the wider workforce strategy launched by The Royal College of Emergency Medicine (RCEM) in 2017, its recommendations for the requirements for appointment to the post of Locum Consultant in Emergency Medicine have been reviewed and updated. The chief reasons for this action are to ensure safety for patients and maintenance of training standards for trainees in Emergency Medicine who might be supervised by individuals in such posts.

We would strongly suggest that, in trusts where individuals who do not comply with this guidance are employed in the role of Locum Consultant in Emergency Medicine, the posts should be reviewed by the Clinical Director, Medical Director and Human Resources Lead. Consideration should be given to the title and grading of the posts so as to reflect the fact that the RCEM requirements have not been met.

The RCEM workforce strategy supports and promotes the development of alternative training routes in Emergency Medicine such as the CESR pathways. This enables the development of doctors who aspire to meet the criteria for appointment as a locum or substantive Consultant in Emergency Medicine whilst expanding the senior workforce in a safe and quality-assured manner.

  • NHS Employers: Guidance on the appointment and employment of NHS locum doctors – A quick summary (Oct 2012) – Read the College’s quick summary highlighting the key information about employing and appointing locums.
  • Full guidance is on the NHS Employers website.

Associate Specialist Grade Position Statement

The Royal College of Emergency Medicine (RCEM) believes that there is a role for the grade of associate specialist. It is important for the maintenance of senior cover within emergency departments and the College believes that it will assist in the retention of senior doctors within the specialty. As such, RCEM strongly supports the principle of its reinstatement in a similar form as before or as an alternatively named grade of senior specialist.

Consultant Working & Job Planning

The following resources within this section are designed to assist with consultant working and job planning. Find below information on:

  • The Consultant Contract and Job Planning for EM Consultants
  • Supporting Professional Activities in Consultant Job Planning (SPAs)
  • SPA Activity Exemplar
  • Role of the EM Consultant On Call
  • Exceptional Circumstances

RCEM Workforce Recommendations 2018: Consultant Staffing in Emergency Departments in the UK

Find below the Royal College of Emergency Medicine’s RCEM Workforce Recommendations 2018 / Consultant Staffing in Emergency Departments in the UK:

* Please note that the references to Consultant staffing in the remainder of the historic RCEM guidance has been superseded by the above publication. *

The Consultant Contract and Job Planning for Emergency Medicine Consultants

The BMA has prepared guidance which provides a broad overview of the principles of the 2003 Consultant contract together with specific advice appropriate for Emergency Medicine consultants. The objective is to enable Emergency Medicine consultants, and thus their patients, to work within and benefit from the 2003 contract. In view of the differences in contract between each of the UK nations the document has aimed to cover the general principles with details based on the English contract and then to highlight specific differences for other nations.

The guidance was prepared by the Emergency Medicine subcommittee of the Central Consultants & Specialists Committee with input from the RCEM Professional Standards Committee. The document is based, with permission, upon the 2005 guidance published by the Association of Anaesthetists of Great Britain and Ireland. Both committees gratefully acknowledge the generosity of the AAGBI in allowing us to benefit from their work.

This is a working document and the BMA and RCEM welcome comments and suggestions for improvement in order to periodically update and revise the guidance as necessary. Please send any comments to or contact the BMA CCSC EM subcommittee.

Supporting Professional Activities in Consultant Job Planning (SPAs)

The Academy of Medical Royal Colleges has published a statement on SPAs (Feb 2010). This includes recommendations from RCEM which reflect issues relevant to Consultants in Emergency Medicine. RCEM welcomes this statement and would note the benefits for patients of Consultants having adequate SPA time to develop and maintain a high quality service.

Further to the Academy statement, Mr Don MacKechnie has written an open letter in response to a number of recent queries regarding the College‘s position on what it considers an appropriate number of SPAs for a new EM consultant post.

The College advocates, as stated in the 2003 contract, that for full time consultants the Job Plan will typically include an average of 7.5 Programmed Activities for Direct Clinical Care duties and 2.5 Programmed Activities for Supporting Professional Activities.

SPA Activity Exemplar

The College provides here a worked example of how to set about calculating the number of hours of non-clinical (SPA) time that Consultants working in Emergency Departments require.

The College remains convinced that to deliver a safe, effective and efficient service each consultant will need at least 10 hours per week engaged in the activities this document describes. The list of activities described is not exhaustive and each department will have some specific local requirements. Similarly some of the activities listed here will not be relevant.

The department described is a mixed Emergency Department (ED) and Major Trauma Centre which sees 90,000 new patients per year. The senior workforce is made up of 12.95 whole time equivalent consultants. Elements of this document obviously relate to local practice and agreement, and to local objectives and stage of development. The total time is also more than that is currently available to the existing team, and prioritisation will be required. However, it is hoped that this exemplar will act as a useful framework, which can be applied to discussions with hospital management teams across the United Kingdom and Republic of Ireland.

Role of the EM Consultant On Call

The Royal College of Emergency Medicine is the professional body responsible for setting standards of clinical and professional practice in Emergency Medicine in the UK. This statement outlines the view of the RCEM on this matter.

Emergency Departments (ED) must have an Emergency Medicine (EM) Consultant on-call at all times. An on-call EM consultant has similar responsibilities to other on-call consultants. In consequence they may be required to:

  • provide direct senior clinical input into serious/complex cases out-with the expertise of other hospital teams
  • provide telephone advice on clinical, medico-legal and ethical issues.

Each ED and hospital should be staffed and resourced to a level sufficient to manage predictable peaks in workload, 24 hours a day, seven days a week.

All hospitals should have clinical and managerial teams on site able to deal with predictable events that may pose a clinical risk to individual or multiple patients, including increased attendance numbers, crowding due to acute bed shortages (exit block) or staffing issues.

Consultants are ‘on call’ to deliver expertise in clinical cases beyond the experience / skill level of resident clinicians. This enables cost effective delivery of senior clinical expertise. By definition therefore, tasks that do not require senior clinical expertise e.g. acting-down to cover staff absence, are not ‘on call’ responsibilities and must be addressed via other mechanisms. Where capacity deficits have created queues, these too should be addressed through standard operating procedures that mobilise other clinicians within the hospital or redirect appropriate patients to medical, surgical or paediatric assessment units. Good risk management should seek to maximise resources available to deal with such problems., and avoid concentrating multiple risks in a single area.

If exit block is considered to be such a problem that the ED is rendered unsafe, then the duty management team including the executive on call and the relevant medical and surgical consultants must attend the hospital. Exit block is a problem of ‘downstream’ capacity – an ED consultant can only mitigate the effects in the ED whilst colleagues seek solutions within the hospital and community.

All escalation policies should follow the guidance published by the Royal College of Emergency Medicine and endorsed by NHS Improvement (England) and the Scottish Government.

The decision as to whether an ED is unsafe should normally be taken by the nurse and doctor in charge of the ED.

UK employment law requires all employees to have 11 hours of uninterrupted rest in every 24-hour period. In the NHS this is to ensure the health and safety of patients as well as that of employees. Compensatory rest arrangements (taken when the above rest periods are interrupted) are very disruptive to ED rotas and as such the need to trigger them should be minimised.

It is particularly unsafe to require any employee with overnight on call responsibilities to work frequently or substantially in excess of their rostered shift times. This is a significant issue for consultants working late evening shifts and then on-call overnight. No employee should be required to extend their shop-floor shift beyond 12 hrs. Fatigue is not a defence when faced with litigation or regulatory sanction.

Exceptional circumstances

  • The on-call EM consultant will provide clinical leadership of the emergency department in the event of a “Major Incident”.
  • Arrangements for consultant presence 24/7 for other forms of alert or escalation protocol are unfeasible given current UK staffing levels.
  • Trusts running separate trauma consultant rotas should have clear guidance in place regarding activation of the trauma team. Ordinarily the trauma team leader role cannot be conflated with other roles or responsibilities.

* For the purpose of this document, the term “consultant” refers to that doctor, on the ED senior on-call rota, who has the responsibility to respond to any telephone calls for advice or to return to the ED for the specific reasons discussed in the document.

Note: Supervision to trainees in Emergency Medicine of ST4 and above, can, normally, only be provided by a consultant who is on the specialist register in Emergency Medicine.

Expanding the Consultant Workforce

Consultant Staffing in Emergency Departments in the UK

Find below the Royal College of Emergency Medicine’s RCEM Workforce Recommendations 2018: Consultant Staffing in Emergency Departments in the UK:

RCEM Workforce Recommendations 2018: Consultant Staffing in Emergency Departments in the UK (revised Feb 2019)

* Please note that the references to Consultant staffing in the remainder of the historic RCEM guidance has been superseded by the above publication. *

The Benefits of Consultant Delivered Care (Jan 2012)

The most comprehensive and focused review into the benefits to patients of consultant delivered medical care has been published by the Academy of Medical Royal Colleges (AoMRC). The review was commissioned by the Academy and carried out by a Steering Group led by Professor Terrence Stephenson (Academy Vice-Chair and President of the Royal College of Paediatrics and Child Health). The review’s Steering Group called for written and oral evidence from professional organisations and individuals. It also commissioned an independent and systematic review of existing literature on the subject which identified over 70 relevant studies published between 1992 and 2011 (although much was from the last 3 years).

On the basis of the best evidence available, the Academy concluded that medical care delivered by fully trained consultant doctors has demonstrable benefits in terms of:

  • Rapid and appropriate decision making
  • Improved outcomes for patients
  • More efficient use of resources
  • GP’s access to the opinion of a fully trained doctor
  • Patient expectation of access to appropriate and skilled clinicians and information
  • Benefits for the training of junior doctors.

The Academy recommends:

  • That the identified benefits of consultant-delivered care need to be taken into account alongside cost implications when considering the future shape of the medical workforce at local or national level
  • Current contractual arrangements for consultants need to be separated from the question of the benefits of consultant-delivered care
  • The benefits of consultant-delivered care should be available to all patients throughout the whole day and the whole week
  • Implementing a full system of consultant-delivered care will require different thinking about consultant working patterns
  • Work should be undertaken between clinicians and employers to map out the staffing requirements and service implications of implementing a consultant-delivered service throughout the week.

This report is not suggesting that it should only be consultants who deliver medical or clinical care. The Academy and Medical Royal Colleges fully recognise and support the principle that successful care depends on a team based approach where a range of healthcare staff contribute to the delivery of a successful outcome.

College recommendations to expand the Emergency Medicine Consultant workforce

The principal focus is to inform Acute Trusts, SHAs, commissioners et al of the urgent need to expand Emergency Medicine (EM) Consultant numbers and highlight the wide-ranging benefits.

The evidence quoted provides compelling support for the investment required and the dividends resulting – including patient safety, quality of care, productivity and crucially in the present financial climate, the affordability agenda from bed days saved, focused use of diagnostics (particularly imaging) and the expensive legal consequences of unsafe discharges. The current number of EM Consultants is woefully inadequate and the comparison with other specialties is telling.

The principles and messages are applicable throughout the UK and ROI, although the data and evidence used in this initial version are mostly from England. This is an organic document and will continue to be refined. In this regard we would very much welcome your comments and any local evidence available describing the impact of increasing EM Consultant numbers, particularly cost benefits.

Baseline Emergency Staffing Tool (BEST)

About BEST

This tool has been developed by the RCN Emergency Care Association (ECA) and Faculty of Emergency Nursing (FEN). As EDs are constantly evolving and new ways of delivering care emerge the tool will be revised annually to ensure it has taken account of such changes. The 2013 review showed a strong correlation between BEST outputs on workload and locally held data sets on attendance. The review also showed the importance of users understanding the assumptions made by the tool about the care delivery process, particularly nurse to patient ratios, this is explained below and in the user guide. It is important therefore that you understand what to tool does and any potential difficulties with using it in your department. ECA members can contact the ECA for support prior to using the tool.

BEST is a workforce planning tool for use at local level in your Emergency Department (ED) to allow any disparity between nursing workload and staffing to be highlighted. The tool allows you to:

  • analyse the volume and pattern of nursing workload in your ED
  • track this against your rostered staffing level
  • calculate the whole time equivalent workforce and skill mix which would be required to provide the nursing care needed in the department during the audit period.

The tool does not produce recommended staffing levels but will allow EDs to work locally to reduce any disparity between workload and staffing. This can be achieved for example by improving patients pathways, departmental and hospital processes, roster designs and actual staffing.

What’s required

The BEST calculation requires data to be collected and input for a seven-day period on an hour-by-hour basis. A user guide is provided below, together with the various data collection appendices to explain how to gather your data, how to enter it and what the results portray.

It is important to pay particular attention to the definitions and instructions relating to:

  • how to measure patients dependency in adults and children
  • which staff to include and which to exclude.

Every ED is different and it is important that your results are used by the people who know most about your ED, you. BEST is not designed to define a minimum staffing number or to compare organisations to each other.

How it works

The calculations work by using nurse-to-patient ratios in the various dependency categories.

It is important that these ratios reflect how care is actually delivered in your department, if they do not then the outputs from the tool will not be accurate.

The ratios used by BEST are:

  • total dependency – 2 nurses to 1 patient
  • high dependency – 1 nurse to 1 patient
  • moderate dependency – 1 nurse to 2 patients
  • low dependency – 1 nurse to 3.5 patients

The hourly data sets used by BEST are:

  • patient dependency volume in the department using the Jones Dependency Tool
  • the total number of staff rostered to be clinical on shift in the department.
  • A calculation will also provide an indication of what skill mix breakdown is required in the whole time equivalent workforce in your ED using the FEN competency levels and supporting definitions which can be found at The Faculty of Emergency Nursing.

For help and advice or to offer feedback please email

Service Delivery and Workforce Toolkit 2013

Tools to help address service and workforce pressures

EDs across the UK are facing considerable service pressures relating to workforce and activity. The College has published a toolkit with the aim of providing assistance to Emergency Medicine clinicians and Departments by listing in one place existing resources together with a description of new developments that we hope will help to address these pressures. It also provides an update on College work to support Emergency Departments and focus attention on finding solutions to the workforce challenges.

This is not a complete resource – where there are blanks the College is working hard to identify or develop resources/guidance, and we are grateful for all the suggestions and good practice examples provided by Fellows and Members to date. If you are aware of existing resources or new initiatives that could appear in this document please contact Rosely Solomon ( The document will be updated and re-issued throughout the next year.

Download the Service Delivery and Workforce toolkit.

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