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.
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* Please note that the references to Consultant staffing in the remainder of the historic RCEM guidance has been superseded by the above publication. *
Find below the Royal College of Emergency Medicine’s workforce guidance tools and resources:
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.
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.
The following resources within this section are designed to assist with consultant working and job planning. Find below information on:
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 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 Sam.Mcintyre@rcem.ac.uk or contact the BMA CCSC EM subcommittee.
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.
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.
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:
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.
* 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.
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 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:
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.
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.
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:
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.
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:
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.
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:
The hourly data sets used by BEST are:
For help and advice or to offer feedback please email eca@rcn.org.uk
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 Sam McIntyre (sam.mcintyre@rcem.ac.uk). The document will be updated and re-issued throughout the next year.
Download the Service Delivery and Workforce toolkit.
Welcome to the Royal College of Emergency Medicine's Service Design & Delivery pages. Here you will find resources and documents on Emergency Department Design and Delivery, Informatics, ECDS, Research, Workforce and AAC.
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Information about delivering quality care and quality improvement, alongside the Royal College of Emergency Medicine's Clinical Audit resources and reports.
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The Royal College of Emergency Medicine (RCEM) has clinical guidelines available for professionals working in emergency medicine.
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