Four out of five Emergency Medicine doctors believe emergency care is getting worse

4 December 2018

Over 80% of Emergency Medicine doctors believe that things within their profession are getting worse and cannot go on the way they are, according to a survey of members of the Royal College of Emergency Medicine.

As part of its anonymous annual membership survey, the College asked members ‘How do you feel about how things are in the emergency medicine profession at present?’ and ‘What are you most concerned about within the profession or wider NHS?’

With regards to emergency care, the questionnaire found that:

  • 43% of respondents believed that ‘things can’t go on like this’
  • 39% believed ‘things are getting worse’
  • 14% thought things were ‘the same as usual’
  • 4% were optimistic about the situation and believed ‘things are getting better’
  • Just 0.1% thought ‘things are the best they’ve ever been’.
They key issues that most concerned members were patient safety, staffing, sustainability, burnout, work load and increasing demand, recruitment and retention, and lack of funding.

The comments show a workforce struggling to cope in emergency care systems that are under pressure all year round. Many respondents were concerned about patient safety and the coming winter:
  • “Another winter like the one we had - I fear for the patients.”
  • “Patient safety is paramount. Without it, none of us can go home feeling proud, or even remotely satisfied with our day at work.”
Many pointed to a lack of system-wide ownership of Emergency Department performance:

  • “Increasingly expected to carry horrendous risk on every shift as the responsible senior, sometimes with little support from the rest of the hospital. Overcrowding is unsafe and when things go wrong ED continues to be held responsible and scapegoated.”
  • “Processes within the urgent and emergency systems... [there is an] unwillingness within the whole system to share risk.”
Staffing issues were important to numerous respondents. The workforce strategy in England is aimed at a five-year target and needs extending out to 10 years, during the growth and training of the additional doctors there is a need to increase reliance on locum doctors which is why the cap on locum spending is particularly difficult. Reflecting data from a recent RCEM factsheet, many admitted that they have thought about moving abroad, or even had, for better working conditions:

  • “With the stress levels, more doctors and nurses will leave for offshore opportunities. If I feel unsatisfied with my day job, I am unlikely to continue which is happening to a lot of us”.
  • “The risk that everyone is too busy to look out for others. Some systems appear slow to change to accommodate and encourage the typically varied natures of emergency medicine doctors. In Australia I may now work to live which is hugely important now that I have young children. I feel I would struggle to maintain such a family and work life balance in emergency medicine in the UK at this time.”
  • “Retention of staff, burnout in those that remain, recruitment of new staff all leading to under staffing and unsafe conditions for our patients.”
This is why the implementation of the workforce strategy in England and the creation of such a strategy in Wales, Scotland and Northern Ireland is so important.

Bed shortages and the impact of a lack of social care were a major concern:
  • “Access block due to lack of hospital beds.”
  • “Lack of acute beds/social care provision meaning that working conditions within ED are unbearable, which effectively dooms recruitment/retention.”
  • “Lack of support in terms of funding for staffing, beds, social care etc given the aging population and therefore the requirements now being pressed on NHS and ED in particular.”
  • “Lack of beds and forward movement for patients”
  • “Lack of social care and huge amounts of pressure in social care. This leaves an already stretched Emergency system as the only reasonable option for many people regardless of whether this is appropriate or not.”
The impact of the issues many raised had others questioning their ability to continue a highly pressured career long term, with burnout being at the forefront of minds:

  • “Burnout from continually accepting more and more risk with little acceptance of any risk from other parts of the hospital.”
  • “Burn out. I’ve seen excellent consultants look broken at times by the pressures they are under.”
  • “Burnout and doctors leaving because trusts think doctors are an inexhaustible commodity who don't need to be respected or protected. They seem to want to squeeze the maximum they can from doctors rather than go above and beyond what is required.”
A lot of respondents felt that the underlying issue to all the problems they faced was under-resourcing.

  • “The lack of funding and planning to provide an effective NHS for patients. An aging population and increasingly limited resources in both health and social care have proven to be a recipe for disaster with the situation likely to get worse.”
  • “People in strategic positions trying the same old things to decrease ED utilisation rather than investing and building capacity.”
  • “Ultimately, lack of funding which is causing every other problem”
President of the Royal College of Emergency Medicine, Dr Taj Hassan said: “These answers are deeply concerning and comes ahead of a winter that will likely test staff to their limits.

“While it is admirable that people continue to come into the specialty when circumstances are so difficult, this will be unsustainable without the workforce strategy delivering significant changes to working practices. We absolutely must address the staffing shortages in Emergency Departments in the short term and deliver well on the medium-term strategies. These comments bear that out.

“There is a genuine anger about the continued lack of resources hospitals and Trusts have had over the last few years, all the while having to deal with ever increasing demand, along with fear for the sustainability of both emergency medicine and the NHS.

“There are also legitimate worries about patient safety going into winter, and despite a welcome funding boost to address winter pressures, this was too little and too late to make a significant impact. Trusts and staff will once again have to work hard to ensure they maximise what they have. 

“The College has encouraged its members to continue to focus on safety as their first duty over the winter; ensuring that care is delivered in a timely manner, linked to acuity. We’ve also issued guidance to trust and board leaders that detail the actions they can take to mitigate the pressure to help keep them out of the ‘red zone’. 

“Finding ways to share the risk within the hospital and creating flow through their system must be the number one priority. Reports of ED staff being harassed to make hasty decisions and avoid 4hr breaches to make the ‘numbers look good’ is not the priority.  Emergency Departments must focus on adequate staffing levels and focus on safe, dignified and evidence based clinical care. 

“This should all be food for thought ahead of the forthcoming budget settlement. We know that the proposed increase for the NHS, while deeply welcome, is not what the sector said would be needed to simply maintain the current levels of service. 

“The College is working to help departments and providers find ways to collaborate and improve, but there will need to be a commitment from the NHS ten-year plan to help our struggling systems. We hope priority is given to those areas so evidently in need”.

Notes to Editors
The Royal College of Emergency Medicine Member and Fellow Satisfaction Survey ran during summer 2018. The survey was sent to the College’s 7,500 members and had 1,165 responses.