Election Manifesto 2019

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In reaction to the 2019 General Election we've set out what we believe should be done to fix and deliver safer, quality emergency care. Below is our guide for parliamentary candidates and their parties to the problems facing emergency medicine and what we need - and what they can help do - to solve them.

Emergency Medicine: stretched to the limit

NHS Emergency Departments across the four nations are operating at a dangerous capacity. Since 2010-11 attendances to Type 1 Emergency Departments in England have increased by 1,748,283 (12.5%) – equivalent to the workload of 22 medium-sized departments. Every year, millions of people turn to our Emergency Departments as increasing numbers are living longer with a complex range of medical needs. Primary and social care services have not been developed to address this need. Emergency Departments are now the first port of call for many patients. Alongside the rest of the health and social care system, Emergency Departments are inadequately supported and have not been resourced to meet demand. This means our Emergency Departments are stretched to the limit and staff are increasingly working in crowded departments, delivering care in corridors. 

RCEM CARES: our plan for better Emergency Medicine

Eliminating overcrowding in Emergency Departments must be the number one priority of any incoming Government. Emergency Departments are stretched to the limit, with staff increasingly working in crowded hospitals. As these challenges must be tackled on a whole system basis, all political parties must commit to addressing the following:

Crowding and corridor care       
With services not resourced to match demand placed on Emergency Departments, admitting patients into a hospital bed in a timely way has become frequently unachievable. As a result, patients are staying too long in Emergency Departments and end up being moved out of cubicles and into the corridor so departments can continue to function. Over 300,000 patients waited more than 12 hours in Emergency Departments in 2018-2019.1  This has been exacerbated by the loss of 15,000 staffed beds across England since 2011.

This October we witnessed the worst ever four-hour performance figures since records began. The Royal College of Emergency Medicine continues to take the view that the four-hour standard remains an important indicator of patient flow through a hospital.2  The ongoing Clinical Standards Review should only replace the four-hour standard with measures that evidently improve patient flow and crowding in Emergency Departments.  

Recommendations:

1. Increase the bed capacity in hospitals to maintain flow in Emergency Departments. We estimate that at least 4,000 extra staffed beds are needed in England alone this winter to achieve 85% bed occupancy.3  
2. Immediately publish a Social Care White Paper, with the view of expanding social care provision to improve patient flow and address delays in transfers of care in Acute Hospitals.  Additional funding must address the £2.3 billion shortfall in social care faced by councils, as advocated by the Local Government Association.4

Alternative access    
NHS Emergency Departments are crowded because we are increasingly providing care for patients who have tried to seek alternative care prior to their attendance. Access to care is variable across the health service, which is in part driving the presentations to Emergency Departments. The best and most cost-effective health care systems in the world are based on a strong primary care system and the College recognises that General Practitioners are frequently working under enormous pressure.

Recommendations:
1. Improve primary care provision through expanding the GP workforce advocated by the Royal College of General Practitioners and their hours of operation to ensure primary care is available into evenings and weekends. Round-the-clock support also needs to be developed to support frail elderly people in care homes.
2. Expand Same Day Emergency Care and co-locate primary care services with Emergency Departments to allow patients to be routed to the best place to obtain their care.

Recruitment and retention     
We know that NHS Emergency Departments provide the best care when they are adequately staffed. Currently our workforce suffers from burnout, attrition, and staff shortages. Emergency Departments have insufficient resources to meet the minimum number of consultants and senior decision makers required per 100,000 attendances. This is exacerbated by changes in pension taxation which is resulting in experienced consultants reducing their working hours, causing rota gaps and compromising patient safety. Nursing staff play a pivotal role in maintaining patient flow in hospitals, the shortage of nursing staff across the four nations must also be urgently addressed.

Recommendations:
1. Introduce investment in the workforce to meet RCEM guidelines6 for safe staffing levels for all staff working in Emergency Departments. This should be reviewed every five years in order to ensure staffing levels are keeping pace with changing demand.
2. Ensure the NHS People Plan provides a clear framework for addressing Emergency Medicine staff shortages for various staffing groups and introduce a clear strategy to recruit and retain staff, including nursing staff. As part of this, expand ‘returnship’ programmes that are currently available for allied health professionals to support Emergency Medicine staff returning to work after career breaks.
3.  Ensure patient safety is protected by reforming pension taxation legislation, to prevent further attrition of the Consultant workforce.

Experience
Patients are at the heart of our Emergency Medicine system, however crowding, long waits for treatment and admission to hospital wards means deterioration in care for patients, a loss of dignity, comfort, and delays in getting the correct timely treatment they need elsewhere in the hospital. This disproportionately affects children, elderly people, and the vulnerable. Crowded NHS Emergency Departments can be a frightening experience for people with dementia or those suffering from a mental health crisis. High demand, inadequate space, and poor departmental infrastructure create a volatile environment.

Recommendations:
1. Work with the College to develop an effective measure for patient experience in Emergency Departments.
2. Build on the commitments outlined in the Forward View for Mental Health and NHS Long-Term Plan and accelerate the expansion of mental health services.
3. Ensure sufficient capital funding is available for trusts to transform the emergency care system at pace to ensure it is fit for purpose.

Safety and Space    
The CQC estimates that over half of Emergency Departments in England are inadequate or require improvement for safety. There are similar concerns about Emergency Departments in the devolved nations. 13% of legal claims against the NHS in England originate in Emergency Medicine, the highest number of any specialty.

Recommendations:
1. CQC does not carry out any reviews of integrated primary and secondary care. The incoming Secretary of State for Health and Social Care should immediately commission CQC to carry out integrated health and social care system reviews.
2. Many of our departments are not adequately designed for the delivery of 21st century emergency medicine. Many departments need to be rebuilt.

Devolved Nations

In upcoming Scottish Parliament and Welsh Assembly elections and in the event that the Northern Ireland Executive resumes power-sharing, we would like all political parties to address the concerns highlighted by RCEM CARES. We will be producing detailed manifestos outlining our key policy recommendations for each devolved election.


Contact us    

The Royal College of Emergency Medicine’s Policy and Communications team works with politicians and policymakers in England, Scotland, Wales and Northern Ireland.
We are the first port of call for enquiries on all matters relating to health and Emergency Medicine policy.

Email: communications@rcem.ac.uk
Telephone: 020 7067 4814.

1 Actual Figure  329,961 see https://files.digital.nhs.uk/DB/1CED9F/AE1819_Summary_Report_Tables.xlsx  
RCEM (2018) Making the case for the four-hour standard. Available here https://www.rcem.ac.uk/docs/Policy/Making%20the%20Case%20for%20the%20Four%20Hour%20Standard.pdf
3 The calculation of 4,000 beds is based on the number of beds required to move to 85% bed occupancy across all bed categories rather than just General and Acute - which would give a higher 6,000 figure.  https://www.rcem.ac.uk/RCEM/News/News_2019/NHS_in_England_needs_over_4000_extra_beds_this_winter.aspx
4 https://www.local.gov.uk/about/news/lga-responds-latest-delayed-transfers-care-figures-1
5 https://www.nhsbenchmarking.nhs.uk/projects/emergency-care-type-1-2-and-type-3-services
6 https://www.rcem.ac.uk//docs/Workforce/RCEM_Consultant_Workforce_Document_(revised_Feb_2019).pdf