Written evidence submitted by Dr Daniel Darbyshire, Lancaster University Medical School (RTR0016)

About the author

I have several roles which have informed this response. I am a senior trainee in emergency medicine based in the northwest of England. I have previously been trainee representative to the Royal College of Emergency Medicine’s (RCEM) Sustainable Working Practices Committee, and I am currently chair of the Emergency Medicine Trainees’ Association and represent emergency medicine trainees at RCEM Council and on the Academy of Medical Royal Colleges Trainee Doctors Group. Each of these organisations have prepared a separate response to this inquiry.

This response is based on my currently research, which is currently being written up for submission for my doctoral thesis, on retention of doctors in emergency medicine. This research focuses on one particular group where the problems that this inquiry seeks to address are particularly acute, I believe the results may be of use to the enquiry in general.

About the research

The development of the research was funded by the BMA Foundation Kathleen Harper Award and the RCEM/NIHR Young Researcher Award. The study was funded through an NIHR Doctoral Fellowship.

The host institute in Lancaster University.

The study involved 3 months of workplace observation and interviews with emergency physicians, policy makers, and people who had left the practice of emergency medicine.

The aim of the study was to gain a deep understanding of retention in emergency medicine; to elucidate how retention is made possible. The objectives were to:

Workplace observations took place from January to March 2020 with interviews occurring from February 2020 to January 2021.

Greater detail on the methods of the study can be found in the open access protocol.

This empirical work supports the results of a scoping review on retention of doctors in emergency medicine also available open access.


The emergency department is a challenging working environment which is having an impact on staff retention.

Prioritising education is one way that emergency physicians try to make their careers sustainable, making them feel valued and supporting entrustment, autonomy, and competence.

Developing a community within the emergency department happens over time and through low-key interactions. This is important for building trust and patient safety as well as retention.

Less-than-full-time working, and portfolio careers are the two main retention strategies that emergency physicians employ.

Intelligent rotas administered with compassion are vital for those working in emergency medicine.

Role models demonstrating, and mentors supporting, sustainable careers are important.

1. Working Environment

The working environment experienced by those working in emergency departments is a threat to staff retention. In the context of a built environment that is, in many places, outdated and not fit for purpose is the experience of working in a crowded emergency department. The impact of crowding on patient outcomes and experience has rightly received significant attention, what this study adds is that it is having a detrimental impact on those who work in it, including clinicians who are reducing the number of hours they work in the emergency department with some leaving entirely.

Poor quality spaces for completing work that supports the delivery of emergency care also impacts the experience of working in the emergency department. Offices are neglected, lack windows, and have insufficient desks, chairs, and computers. They are not always clean. In essence they are neglected which has the effect of devaluing the workforce.

A similar neglect can be seen in the poor quality, or complete lack of, essential services for delivering health care 24/7 in modern Britain. Staff are given nowhere to park and encouraged to use public transport or cycle, but transport links are poor and facilities to shower, change, and store belongings are limited or absent entirely. Staff working night shifts do not have access to hot food, and in some places nowhere to buy food or drink or any description. Staff break rooms are too small, poorly furnished, and like other spaces, neglected.

Essential clinical equipment, including IT in clinical areas, is used constantly and as such not well maintained. Often equipment, such as desktop PCs, is not designed for such intense use. Therefore, broken equipment is a routine experience of working in an emergency department, this slows the pace at which emergency physicians are able to work which in turn erodes job satisfaction.

2. Education

Emergency physicians of all levels engage in educational activities during a clinical shift. This is vital for supervision, patient safety, and the development of a learning culture. It is also vital for staff retention. Prioritising education, whether in the clinical environment or classroom, makes learners feel valued. It also has the effect of adding variety to the workday for those providing the education. Education supports the development of entrustment and autonomy, both vital for developing clinical competence and increasing seniority and a sustainable career.

3. Community

Emergency physicians consistently rate working in the context of the team in the emergency department as vital for retention. This is a large team and may be helpfully considered as a community. Links between individuals that build this community are developed slowly, over time, and through low-key interactions such as brief conversations and humour. Such linkages build trust which in turn helps with the delivery of safe and effective care by facilitating communication and removing barriers to challenging error. Efforts to build community and develop teams need to be locally tailored to be successful, but all require time, effort, and resources. The benefit of building a community within an emergency department in terms of staff retention can be used as a convincing argument to advocate for resources.

4. Retention Strategies

Emergency physicians utilise a number of strategies to try and make their career sustainable. Of these less-than-full-time working and portfolio careers are the two most used. Both have the effect of limiting the number of hours an emergency physician spends in the emergency department in a working week, a clear response to the challenging working environment.

A fulltime working week for many emergency physicians can be up to 48 hours, with many doing additional administrative, research, or educational tasks on top on this. For many this is unsustainable and in part explains the increased prevalence of less-than-full-time working. As well as limiting the number of hours an emergency physician works this increases the time available for recovery and increases flexibility. For trainees this has been facilitated by the flexibility agenda of the statutory educational bodies, with the less-than-full-time pilot in England being a particular example. Previously trainees required approval based on a limited number of circumstances to work less-than-full-time, the pilot allowed trainees to choose to do so for any reason. The analysis of the pilot supports the benefits of less-than-full-time working for career sustainability, and the pilot has now been rolled out to several other specialties.

Some trainees work less-than-full-time to provide time for a portfolio career. Portfolio careers are particularly common, and important for, the consultant workforce. Additional roles in leadership, research, and education provide variety in the working week, allow for the development of additional skills, and are vital for career sustainability.

Well managed rotas, including self-rostering solutions, administered with compassion are important for those wishing to work less-than-full-time or have portfolio careers but they are also important for those who do not utile these strategies. Despite clear guidance on the importance of rest and rotas from the Emergency Medicine Trainees’ Association and on how to deliver them from RCEM’s Sustainable Working Practice Committee many departments still fail to provide rota which meet the needs of their doctors. This can lead to exhaustion and disillusionment which in turn impact retention.

Mentoring, both formal and informal, along with role models, are vital to support emergency physicians to develop and maintain sustainable careers utilising the strategies outlined above and to respond to the changing workplace and healthcare economy.


January 2022