EM challenges Actions to Address Beyond Keogh Dr Cliff Mann FRCP FRCEM President of the Royal College of Emergency Medicine
5 things CEM are doing: 5 things we need others to do: Establishing transferable competencies to encourage and enable more doctors to join Emergency Medicine Implementing run through training - allowing trainees to plan for 6 years not 3 Promoting careers in Emergency Medicine in partnership with the Health Education England task force Working with patients, regulators, employers and government to improve emergency care and patient experience Encouraging and advocating sustainable, flexible and rewarding careers at every level The College of Emergency Medicine www.collemergencymed.ac.uk Provide effective alternatives to A&E for patients without acute severe illness or injury 7 days per week and at least 16 hours per day - A&E cannot mean 'Anything and Everything', no other healthcare system works in this way Ensure 'exit block' does not occur - Crowding increases mortality Amend the tariffs so acute trusts are not penalised by each and every non-elective admission - Perverse incentives produce dysfunctional systems 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 Ensure money is spent wisely and strategically. Last year 120 million was spent on EM locums - Over reliance on locums is a feature of fragile systems
It s not a complex problem! Demand Capacity Output
Attendances (England) 371,864 increase rise last year 2.6% rise = 6 medium sized departments
2010/11 2010/11 2010/11 2010/11 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14 2013/14 2013/14 2014/15 2014/15 2014/15 2014/15 Demand Capacity Output Staff Beds Overnight Bed Availability EM trained/training doctors in UK Total 1850 146,000 144,000 142,000 140,000 Trainees Consultants 138,000 450 1350 136,000 134,000 132,000 Emigrated in last 5 years 510 110 130,000 128,000
Irrevocable loss of capacity 368 registrars 2000 patients each Working life of 35 years 736000 patients 12 DGH EDs 25 million patients There is one EM Consultant for every 11,500 attendances.
7,000,000 6,500,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 3,000,000 National Weekly ED locum spend Total Annual budget for average sized A&E 1,000,000 0
Demand Capacity Output
Overnight Bed Availability 146,000 144,000 142,000 140,000 138,000 136,000 134,000 132,000 130,000 128,000 89.00% 88.00% 87.00% 86.00% Percentage Bed Occupancy 85.00% 84.00% 83.00% 82.00% 81.00%
2,000,000 Elective Admissions 2010-2015 1,950,000 1,900,000 1,850,000 1,800,000 1,750,000 1,700,000 1,650,000 1,600,000 1,550,000
August October December February April June August October December February April June August October December February April June August October December February April June August October December February April 120,000 Numbers of Patients and Acute Days Lost 100,000 80,000 60,000 40,000 Total Number of Patients Acute Days Lost Linear (Acute Days Lost) 20,000 0 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
It s actually getting worse! Number of Patients in England Spending >4 from Decision to Admit to Admission 2014-15 304,276 2013-14 2012-13 167,941 152,414 2011-12 2010-11 2009-10 2008-09 2007-08 2006-07 2005-06 2004-05 108,191 93,905 61,969 73,519 79,300 57,841 54,187 92,663 0 50,000 100,000 150,000 200,000 250,000 300,000 350,000
and for some much worse Number of Patients in England Spending >12 hours from Decision to Admit to Admission 2014-15 1,239 2013-14 240 2012-13 170 2011-12 123 0 200 400 600 800 1,000 1,200 1,400
Agree and Publish solutions
Emergency departments (EDs) should be fully resourced to practice an advanced model of care where the focus is on safe & effective assessment, treatment and onward care. Whilst it is essential to manage demand on EDs, this should not detract from building capacity to deal with the demand faced, rather than the demand that is hoped-for. ED crowding adversely affects every measure of quality and safety for patients & staff. The main causes of ED crowding include surges in demand and lack of access to beds in the hospital system due to poor patient flow and high hospital occupancy rates Performance against the 4-hour standard is a useful proxy measure of crowding. EDs should be staffed so that capacity meets variation in demand NOT average demand
7 Day services?
EM A&E Commissioned Commissioned ED A&E Staffed Staffed
Emergency Department Acute OOH essential services A&E hub Minor Injuries GP/Mental health/ Community pharmacy/ District Nurse
with postoperative complications readmitted within a matter of hours already seen by a specialist hospital doctor in clinic already seen by a GP already seen by an optician already seen by a dentist
The Brand