Written evidence submitted by the Royal College of Emergency Medicine (RTR0011)

About the Royal College of Emergency Medicine             
The Royal College of Emergency Medicine (RCEM) is the single authoritative body for Emergency Medicine in the UK. Emergency Medicine is the medical specialty which provides doctors and consultants to A&E departments (EDs) in the NHS in the UK and other healthcare systems across the world. If you have any questions, please contact policy@rcem.ac.uk

1. What are the main steps that must be taken to recruit the extra staff that are needed across the health and social care sectors in the short, medium, and long-term?
There is a significant mismatch between demand and capacity in Emergency Medicine and action must be taken immediately to secure the pipeline of doctors working in our Emergency Departments. At present, Emergency Departments are not safely staffed to meet current levels of demand. Despite the number of Emergency Medicine consultants increasing at a constant rate, the expansion in consultant numbers is not happening fast enough to cope with the level of demand growth. To staff Emergency Departments safely, the health system should aim for a ratio of 1 Whole Time Equivalent consultant per 4000 annual attendances. Currently, we are nowhere near achieving this. We estimate a shortfall of 2000-2500 Whole Time Equivalent consultants across the UK.

Expansion of the workforce is needed to ensure patients are treated by staff who are trained in Emergency Medicine as it must be emphasised that at present the majority of patients seen and assessed in EDs have their care and assessment delivered by clinicians undertaking training whilst working in EDs, as opposed to being assessed by staff who have completed training in Emergency Medicine. ED workforce expansion must also include an accompanying increase in the wider multi-disciplinary team (Allied Health Professionals, SAS Doctors, and Emergency Nurses) whilst also factoring in the need to provide the faculty to train the many members of the multi-disciplinary team as a separate to service element of trained ED staffing.

Additionally, less than 50% of trainees completing training are directly taking up Consultant posts and a significant proportion of those who do elect to work LTFT as a consultant. This gap must be factored into workforce planning. To secure the pipeline of doctors into Emergency Medicine, more action is required to ensure the specialty is a long term and sustainable job to work in.

1a. What is the best way to ensure that current plans for recruitment, training and retention are able to adapt as models for providing future care change?

At present there is no system in place to ensure that we are training enough clinicians to meet current and future demand. We have worked collaboratively with the medical royal college sector to amend the Health and Care Bill to require the Secretary of State to publish independent workforce projections on a regular basis. Although HEE’s Framework 15 will examine drivers of workforce demand and supply, the framework alone will not provide an assessment of the workforce required to meet present or future levels of demand. This data will help to provide a national view of staffing numbers and allow system leaders to make long term strategic decisions about funding, regional staff shortages, and specialty shortages. Strengthening workforce planning accountability would provide necessary central oversight and accountability but Integrated Care Boards must be able to operationalise workforce plans, to be truly responsive to population health needs, which can vary significantly across regions.

2. What is the correct balance between domestic and international recruitment of health and social care workers in the short, medium and long term?

The UK should aspire to produce enough health and care staff to meet patient demand and population health needs. International recruitment should not form any significant part of this and should aim to support training in an altruistic manner – and provide enhancement to the trainee’s country of origin – rather than be used for service delivery. On principle, if international recruits are required for service need, rather than service development, recruitment should take place from countries with comparative Emergency healthcare systems, standards, and training such as North America, Australia, New Zealand, South Africa and Canada. The Government could ensure there is free movement for healthcare staff between these countries to ensure it is easier for staff to be recruited,

3. What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors? In particular:

3a. To what extent is there an adequate system for determining how many doctors, nurses and allied health professionals should be trained to meet long-term need?

The present system for determining how many staff should be trained to meet long term need is not fit-for-purpose. Workforce planning should be based on population need, rather than a fixed financial envelope. The Emergency Medicine workforce model is predicated on insufficient numbers of appropriately trained Emergency Medicine clinicians who are expected to deliver safe care whilst quality assuring the actions of staff in training and simultaneously delivering said training. Staff in training form the majority of the ED workforce and they are expected to deliver quality assured care whilst undertaking training. Added to this is the high turnover of trainee staff through EDs, constantly reducing the skill mix and increasing the service delivery, supervision and teaching burden on those few appropriately trained clinicians. Expansion of the workforce is needed to ensure patients are treated by staff who are trained in Emergency Medicine. Funding for adequate and appropriately trained staff in EDs will improve job sustainability and improve quality of care. We recommend that all episodes of patient care delivered in UK EDs must be in a service that is led by Clinicians (EM Consultants) who are included on the GMC Specialist Register for EM and who personally deliver considerable patient care directly and who also ensure/deliver the training and supervision of the wider multi-disciplinary workforce. Additionally, all episodes of patient care delivered in UK EDs must be delivered by clinicians who have undertaken specific focussed training in EM and who can be evidenced to perform at the level of an ST4 UK EM trainee or above (ST4+) in circumstances where they are the most senior clinician reviewing the patient.

Furthermore, nursing staff play an essential role in maintaining patient flow in hospitals; the shortage of nursing staff in England must be urgently addressed. The flexibility that has been built into medical training must be made available to all staff delivering care in Emergency Departments, including Emergency Nurses. The skill mix of the Emergency Department Nursing workforce should comprise: 30% Emergency Charge Nurses, 40% Emergency Nurses, 10% Foundation Staff Nurses, and 20% Nursing Associates or Clinical Support Workers.

3b. Do the curriculums for training doctors, nurses, and allied health professionals need updating to ensure that staff have the right mix of skills?

The Emergency Medicine curriculum is regularly updated in order to reflect patient demand and changing population needs. The current curriculum has a clear purpose based on the scope of practice, service, and patient needs. The RCEM Curriculum is designed to train doctors to be EM Consultants, able to provide urgent and emergency care to all undifferentiated patients attending EDs nationwide, 24 hours a day, seven days a week, 365 days every year. EM Consultants are required to display a wide range of knowledge, skills, behaviours, and attributes, reflecting the broad nature of this specialty in practice. There is a need to review and adapt the curriculum on a regular basis in order to define the scope of Emergency Medicine practice.

3c. Could the training period for doctors be reduced?

This depends on the utility of the workforce. Emergency Medicine encompasses a broad scope of practice which involves significant experiential learning and is competency based, and there is a minimum set amount of time in which such a breadth of competencies could be achieved. Shortening the training period of doctors will narrow their scope of practice, and this would not be appropriate in Emergency Medicine training. Due to the nature of the specialty, there is a need to train for a sufficient period to accumulate the breadth of skills required whilst also ensuring patient safety. To shorten training, the scope of practice would need to be narrowed and defined as such.

Recent initiatives increasing flexibility in training have decreased rates of resignation from Emergency Medicine training but have also reduced the overall Whole Time Equivalent workforce. Less Than Full Time (LTFT) training and working is increasingly becoming the norm in Emergency Medicine. However, experience-based learning is based on full time working – this must be factored into LTFT training on a pro rata basis to ensure LTFT trainees are accessing the same amount of experiential exposure as full time trainees.

3d. Should the cap on the number of medical places offered to international and domestic students be removed?

The cap on number of medical places should be removed for domestic students. In the past, we have supported the Royal College of Physicians and the Medical Schools Council’s recommendations on increasing the number of medical students. International numbers should remain capped to prioritise the educational resources required on developing staff that will remain primarily within our domestic healthcare system.

4. What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them?

Staff choose to work in Emergency Medicine because it has previously been an exciting, rewarding, and varied specialty. Working in a high-stakes and high-pressured environment, means our workforce are exceptionally resilient and adaptable. However, escalating demand at all levels of clinical acuity coupled with the lack of investment into the NHS over the past decade has resulted in overcrowded Emergency Departments expected by default to provide a safety net for all other systems and services. This has compromised the standards of care Emergency Medicine clinicians are able to deliver to the increasing number of acutely ill and injured patients that they are specifically trained to provide care for, as well as a significant volume of non-emergency presentations now being directed to EDs. The demanding nature of this setting is a frequent cause of staff dissatisfaction, attrition, and career burnout. Not only has this resulted in unsustainable workloads for our staff but it is also inhumane and undignified for patients. In these conditions, staff are less able to provide safe, timely and efficient care to patients. Moral injury is a very real phenomenon for ED staff who are second impact victims in these circumstances.

In Retain, Recruit, Recover: Our Call for Action to Improve the Urgent and Emergency Care System we found that operational pressures, patient safety and staff retention are intrinsically linked. The acute pressures that have been building over the past decade have had detrimental consequences on our workforce and our patients. Three quarters of respondents to our workforce survey (74%) have considered changing their working patterns, with half (50%) indicating they are planning on reducing their working hours in the next two years.[1] We asked our members what could be done to improve their wellbeing and the most common recurring theme was addressing operational issues. Common themes included increasing the number of staffed beds, improving patient flow, and eliminating exit block. Many of these responses commented on the impact that operational issues have on patient care.

There is an important economic case to be made for investing in the Emergency Medicine workforce; it is more cost-effective to grow the workforce and tackle operational pressures to encourage good retention than to deal with the high economic costs of sickness, training new staff to replace the ones who have left early, litigation, and locum spending.

5. Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?

Many of the least resourced departments are in areas of high deprivation. Rural and coastal areas are particularly challenged by demographic factors, case mix, resources, and seasonal variation. These areas often struggle to recruit staff, many of whom are based in the urban areas. Patients and ambulances may have long distances to travel to the hospital and to the regional specialist centres. EDs in large towns often serve a very deprived population without the level of resources of a city department. They too may suffer from recruitment problems as staff choose to live and work near the metropolitan teaching hospitals where they were trained. These issues are further exacerbated by poor recruitment and retention in other aspects of the healthcare service, which then result in higher reliance on emergency care. Given the link between deprivation and ED demand, this should be factored into ED workforce planning. In such locations the need to provide sustainable working patterns and conditions is even more important.

6. What should be in the next iteration of the NHS People Plan, and a people plan for the social care sector, to address the recruitment, training and retention of staff?
Emergency Medicine as a specialty and the NHS more generally urgently require a fully funded, long term workforce plan that includes a commitment to growing the Emergency Medicine workforce and retaining existing staff that may be close to reaching career burnout. The first iteration of the NHS People Plan failed to outline long term plans for growing the Emergency Medicine workforce and committing to recruiting additional staff. It can take up to 10 years to train an Emergency Medicine consultant. Although there are no easy fixes to address the staffing crisis now, action can be taken to secure the pipeline of doctors working in our Emergency Departments.

A people plan for the social care sector is also urgently needed. We have long argued that Emergency Departments face the consequences of a failed social care system which does not allow for the timely discharge of vulnerable patients from hospitals nor prevent transfers from the community to EDs for no clinical benefit to the patient. This often results in old and vulnerable patients being cared for in corridors. Any discussion of capacity in the NHS must take into account the staffing challenges facing the social care system. Improving staffing in social care will go a long way in easing pressure on hospitals.

7. To what extent are the contractual and employment models used in the health and social care sectors fit for the purpose of attracting, training, and retaining the right numbers of staff with the right skills?

Terms and conditions of employment do not fall within RCEM’s remit, however job planning at all levels must highlight sustainability as being paramount to workforce retention by facilitating flexible working and the inclusion of all essential activities to an appropriate level within remunerated working. For example, education delivery and planning, clinical leadership, quality improvement, governance activity and participation in royal college activities. There must be recognition of high intensity working environments, especially for specialities involving significant amount of out of hours working. This is required for all levels of contractual and employment models. National ‘one size fts all’ models of employment are no longer fit for purpose for any professional groups.

8. What is the role of integrated care systems in ensuring that local health and care organisations attract and retain staff with the right mix of skills?
Integrated Care Systems should address the discrepancy between staff and system capacity, and patient need. At present, overspill in demand is routinely funnelled to EDs where patients will not currently be turned away. The UEC system is a spectrum of undifferentiated healthcare demand, of which only a segment is made up by emergency care. Other parts of the system, such as primary care, other secondary care services, and community care make up the remaining elements of the unscheduled care patient pathway. If population need is determined and provided for appropriately – as opposed to the current system whereby all undifferentiated demand is directed to a single place then this would help ease pressure on Emergency Departments with ensuing improved and more timely care for acutely ill and injured patients.

Integrated Care Boards will play an important role in operationalising workforce planning strategies. They must ensure the health systems are designed based on the needs of patients in their localities, rather than service availability. Assessing population need and operationalising workforce strategies must be dynamic not static, as workforce planning in healthcare should be able to respond to changes over time. Integrated Care Systems must ensure that patients have access to appropriate, well-resourced pathways that are able to deliver timely care.


January 2022

[1] RCEM (2021) Retain, Recruit Recover: Our action plan for the UEC system. Available here.