There are three proven ways to

Stop people coming

to A&E departments

Money……………

Waiting times………….

Distance………….

Current NHS theory:

Once you have

arrived at an A&E

department, then

prolonged hospital

admission is

almost inevitable!

Heard it all before?

Chris Moulton

Department of Emergency Medicine

Royal Bolton Hospital

Vice-President

College of Emergency Medicine

Royal Bolton Hospital

Royal Bolton Hospital

Nearly 20 years of problems in

A&E Departments: 1996 to date

Last big episode of trouble was

2001: beds and trolley waits

This time (2014)

it is medical

staffing and

lots of other

things!

Reasons for the problems?

An ageing population suffering from more

chronic illnesses (especially dementia) with

relative lack of social support and community

care (People over the age of 60 make up nearly a

quarter of Britain’s population; half of them have

at least one chronic illness)

A withdrawal from round-the-clock care or

arduous rotas by many health care professionals

(both in hospital and in the community)

More reasons……

Reduction of the NHS hospital bed stock with

inevitable consequences in the ability of the

system to respond to surges (The number of

acute hospital beds has decreased by a third in

the last 25 years whilst bed occupancy rates have

increased from around 80% in 1997 to nearly 88%

in 2012)

Hospital exit blocks due to cutbacks in

community and social care

And more......

More complex treatments with instructions to “go

to A&E” in the event of problems

Increased numbers of patients with mental

health and alcohol problems

Immigrant populations that have no previous

experience of UK general practice and may not be

registered with a practice

Complex systems of access to urgent care that

either do not deliver what they claim to or that

defy understanding by patients

And even more……

A 24-hour society (If you can shop at 2-00am, then

why can’t you go to an A&E department and have

an x-ray at 3-00am?)

Political tampering with healthcare systems

without any trials or evidence base for the costly

“improvements” that have been introduced

And many others………….

Consequences for EDs:

Poor experiences for patients

Failed targets

Financial losses for providing emergency

care

Dysfunctional A&E departments

Angry managers

Unhappy doctors and nurses

The Keogh Report:

Aspirational ideas;

rely on many things

changing to work

Not much until 2015

No mention of current

staffing crisis in EDs

Recommends ED and

UCC co-location

Not costed

Plans hospital

reconfiguration but

different from trauma

Major injuries,

strokes, STEMIs and

AAAs already move

Over 95% of patients

would not benefit by

transfer

Major Emergency Centres

MAJOR

Trauma and stroke but not PCI

Keogh Report plans:

NHS 111

Paramedics

Self-care

GP OOH

Community care

NHS provision of IT

Bed reservoir and

increased diagnostic

capacity

Correct staff to patient

ratio (Berwick Report)

Inadequate size and

poor facilities of EDs

Targets and quality

indicators

Educating the public………..

Self-care…………………….

NHS 111

Phone before you go =

10 million extra phone calls per year!

Who will answer them, will diversions

be safe and how much will it all cost?

NHS 111: Phone before you go!

Care in the community by paramedics

and community matrons………

24/7 working……………

So what is our College doing

about it?

CEM response: 10 priorities

Published in November, just before the

Keogh Report

On one side of A4 paper only

Five things that CEM are doing

Five things that we need others to do

Lots of media interest

Our 10 priorities………….

CEM priority number 1:

Clear provision of urgent care

Provide effective

alternatives to A&E for

patients without acute

severe illness or

injury seven days per

week and at least 16

hours per day

A&E cannot mean

'Anything and

Everything‘ anymore ;

no other healthcare

system works in this

way

The best known brand name:

If people keep walking across

the grass, then build a path…..

Co-location of EDs & UCCs

Problem!

Have you seen

all those

expensive but

empty Urgent

Care Centres?

Problem!

The A&E

paradigm!

Problem!

CEM priority number 2:

Ensure that exit block does not occur

Crowding has been

shown to increase

mortality

Even for patients who

are not admitted to

hospital

Over 12, 000 patients

spent 12 hours or

more on trolleys in

A&E departments last

year

Another 250 patients

waited for 24 hours

and one patient for

almost three days!

Problem!

How do you

make all those

independent

CCGs all do the

same thing?

Hospital bed numbers per

100,000 population:

The European Union average is 590.

Germany has 829 .

The United Kingdom average is 389 .

The Royal Bolton Hospital has 253.

CEM priority number 3:

Sort out the tariffs

Amend the tariffs so

acute trusts are not

penalised by each and

every non-elective

admission - Perverse

incentives produce

dysfunctional

systems

Up to 40% of patients

leave A&E

departments with no

treatment

This does not equate

to nothing being done

or not needing the

services of an ED!

CEM plan: Set up sentinel sites!

Problem! Minor injuries......

CEM priority number 4:

Although we are not a trade union……

Revise the current

employment

contracts to better

recognise evening,

night and weekend

work as well as the

intensity of A&E work

Conditions of service

should be equitable

not identical

For other specialties

too……

Not more money

CEM priority number 5:

Use the money carefully

Ensure that money is

spent wisely and

strategically

Last year, £120 million

was spent on

emergency medicine

locums

Over reliance on

locums is a feature of

fragile systems

Some use of locum

doctors is fine…..

CEM priority number 6:

Better care

Working with patients, regulators, employers

and government to improve emergency care

and patient experience

Problem!

So nobody

wants to be

an emergency

physician

anymore!

CEM priorities numbers 7 & 8:

Getting and keeping ED doctors

Promoting careers in Emergency Medicine

in partnership with the Health Education

England task force

Encouraging and advocating sustainable,

flexible and rewarding careers at every

level

They are leaving: 78 in 5 years!

3 2

19

13

15

21

0

5

10

15

20

25

2008 2009 2010 2011 2012 2013

Fellows (Consultants) who have moved overseas since 2008*

Their top five reasons:

High work intensity

Financial aspects

Feeling unappreciated

Lack of resources

Inadequate staffing

Other reasons:

Poor conditions of service

Unacceptable workloads

Lack of support from other hospital staff

Trolley waits

Inability to do their best for patients

Shabby small A&E departments

Constant criticism

Retention versus recruitment

The consultant job

The staff doctor job

The trainee job

Fair terms and conditions of service

The ED environment and working

conditions

CEM priorities numbers 9 & 10:

Getting and keeping more ED doctors

Establishing transferable competencies to

encourage and enable more doctors to join

Emergency Medicine

Implementing run through training -

allowing trainees to plan for six years and

not just three years

Predictions are always difficult

to make - especially when they

concern the future