In the past few months a series of bodies have been telling NHS workers what to do: the Care Quality Commission, The Francis Report, the Health Minister and so on. Now the College of Emergency Medicine and Accident and Emergency nurses have taken charge of their own workplaces, the emergency departments across Britain.
In April emergency department nurses at the Royal College of Nursing congress described how they were struggling to cope and what they thought should be done. The tone was set when East Dorset Branch proposed a motion on changes to emergency care, asserting in the briefing notes that “In all cases the consideration of A&E closures should be owned by those most knowledgeable in emergency care – health care professionals”.
Then in May the College of Emergency Medicine produced a detailed but concise document entitled “The drive for quality: how to achieve safe, sustainable care in our emergency departments.” The document describes why the government’s approach is unsafe and makes a total of 10 recommendations. As to be expected from those who prioritise to ensure survival, it even prioritises which should be done first while arguing that their total package of ten offers the best route out of the current crisis.
The demand for emergency care has risen significantly in recent years and, while there is a rise in older people using the service, the report points out that 58 per cent of people who attend Accident and Emergency are between 16-64 years of age. The rise in demand combines with the funding formula to produce the crisis. Under rules designed to encourage the system to reduce A&E admissions, hospitals are only paid 30 per cent of the normal fee when the numbers rise above the levels that were seen in 2008-9. Do the words “Alice” and “Wonderland” come to mind?
In response, hospitals have cut nursing posts. While there has been a small rise in the number of consultant posts, the medical posts to support the consultants have been difficult to fill as the workload is seen as unmanageable. So consultants in emergency medicine are providing significant direct “shop-floor” cover to help maintain safety in emergency departments, especially out of hours. This means their availability to support junior colleagues is stretched and the negative cycle deepens.
The College’s plan to break out of that cycle is radical and has four key elements: system redesign to manage workloads and decongest the emergency department; expansion and sustainable working practices for staff; a radical change to the way in which emergency care is funded; and a better system to measure the success of improvement rather than four-hour system performance alone. Its warning to government is stark: Do what we say or we hold you responsible for the deaths resulting. For more detail see www.collemergencymed.ac.uk. ■