• emergency care systems

Speak it loudly and speak it clearly: the specialty of Emergency Medicine (EM) in the UK has a medical staffing crisis. The problem has been high on the College's agenda for about 18 months, and it has done well in bringing it to the attention of the other medical colleges and to the civil servants in Whitehall. An Emergency Medicine Taskforce, set up at the end of 2011, released an interim report at the end of last year.1 It is wide ranging in its recommendations. Although we only highlight some key messages here, we believe that the report needs to be read carefully; it has some serious and game changing recommendations in it.

• Waiting for a natural solution to the problem is no longer an option; emergency departments (EDs), in partnership with the medical training and education system, will have to actively seek alternative staffing and training solutions

• Fundamental changes in training, support and supervision, working conditions and long-term career pathways are needed to ensure that EM is made attractive and sustainable to trainees in the future

• The present fragmented system across emergency and urgent care leads to duplication and poor use of its workforce; these services are commissioned and planned as individual components within the whole patient journey

• The year on year increase in ED attendances, combined with the expanding role of EM, has not been matched by increases in the ED workforce, particularly at a senior level. Current ED senior staffing compares unfavourably with international models in North America and Australasia

• A major contributory factor to the current workforce problem is the flawed assumption that emergency care demand can be managed downward

• The Centre for Workforce Intelligence predicts it will take until 2020 to secure sufficient consultant numbers (based on 10 whole time equivalent consultants per ED; the current average is 4.5). This is based on maintaining the number of training posts at current levels and ensuring 100% fill rates for such posts and programmes

• For core training, recruitment is to the Acute Care Common Stem, of which EM is a constituent specialty. In 2011, 96% of the 192 posts were filled—but retention in ED training is poor. For ST4 (first year of higher training) in 2011 there were 135 posts vacant in England but only 45 (41%) were filled. In 2012, there were 196 posts vacant in England and 86 (44%) were filled

• Recruiting doctors from overseas is a possible short-term solution; despite intensive recruitment efforts, this initiative has proved disappointing

• Maximising the potential of a wider workforce is important

• Commissioning needs to facilitate these changes and encourage whole system working. Commissioners will need to use expert advice from senates and networks and from other sources to determine the best approach to commissioning services

• Many patients and healthcare professionals currently find the existing nomenclature and arrangements for urgent and emergency care services confusing. The plan is for the NHS Commissioning Board to issue guidance on a simpler system

The report continues by commenting on the role that staff who are not emergency physicians can play.

• Staff and Associate Specialists (SAS) and Specialty Doctors: this group comprises doctors currently working under various titles including staff grade, trust doctors, associate specialists and specialty doctors, a group that been the backbone of many EDs. Unfortunately, this contribution to emergency care has not always been valued or supported. As a result, there has been an increasing trend for these highly experienced doctors to leave EM, particularly going into General Practice, leading to a vast expenditure on locums of variable quality and/or very junior doctors being largely unsupervised

• General Practitioner engagement is crucial but there are difficulties here too

• It is increasingly clear that there are many practitioners undertaking a role in the ED who are not doctors. They have the potential to provide a hugely important ‘ballast’ of professional continuity, reducing the turmoil resulting from the rapid turnover of junior doctors. If substantial numbers are employed, the continuity and quality of care will improve

• Most EDs now have an Emergency Nurse Practitioner service; it also tends to be the mainstay of Minor Injury Units, Urgent Care Centres and Walk in Centres. The Taskforce believes that there must be a consistent definition of what an Emergency Nurse Practitioner is as well as the scope of practice and training requirements

• The role and numbers of consultant nurses in EDs has increased, with in excess of 50 in the UK. While the role has four specific core functions there are widespread variations in role and scope

• There has been a proliferation of the Advanced Clinical Practitioner role in an unknown number of EDs across England

• Physician Associates is a workforce measure that can be introduced relatively quickly. The Taskforce recommends that Health Education England looks actively at promoting this new pluri-potential health professional discipline

The Taskforce has not shied away from its responsibilities; the proposals put forward are challenging, and to some readers, highly controversial. There is an old saying, namely, that if you keep doing the same thing in the same way, you will get the same outcome. Like sporting records, old shibboleths are there to be broken.

Let the debate continue, but do not procrastinate.