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Wales' Emergency Medicine Care 'Broken'

"Emergency Care in Wales is broken", according to the Royal College of Emergency Medicine (RCEM), which reported at the launch of a new survey today that most Welsh emergency departments (EDs) had to cover gaps in their rota at least once a week, and that the percentage of patients being admitted, transferred, or discharged within 4 hours stood at a record low of 55% in recent months, compared with the standard target of 95%.

Indeed, the 4-hour target has not been met by major EDs in Wales since 2010, with "unprecedented numbers" of patients waiting 8-12 hours in EDs from their time of arrival. During the first 6 months of 2022, on average 9906 patients waited 12 hours or more.

The "stark" figures derived from the RCEM Wales' emergency medicine workforce census, the first of its kind in Wales, which was launched at the Senedd (Welsh parliament) today. The census represented an in-depth analysis of the state of the emergency medicine workforce, which sought "to understand staffing numbers and the true extent of the workforce pressures present in EDs across the country". It also aimed to provide an insight into the working patterns of clinicians, and allow forecasts of future ED workforce needs.

'Too Few Clinicians to Cope with Demand'

The census results revealed "significant staffing shortages" and a health service that “remains in crisis”, the RCEM said. "There are far too few clinicians to cope with demand within the stricken health service."

Its landmark survey asked respondents about their departments' staffing position in the summer of 2021, and received responses from all 12 major EDs in Wales.

It found: 

  • There was one whole time equivalent (WTE) consultant per 7784 annual attendances, whereas the RCEM recommended figure is 1 per 4000
  • A fifth of the consultant workforce (19 of 101 consultants) planned to retire in the next 6 years
  • There were 90 gaps in the consultant rota, 33 in the middle grade rota and 8 in the junior rota
  • When asked about future staffing needs, departments across Wales reported that in the next 2 years they would need increases of:
    • 75% of consultants
    • 120% of the advanced clinical practitioner/ advanced nurse practitioner/physician associate workforce
    • 44% of the emergency nurse practitioner workforce
    • 30% of higher specialist trainees/ non-consultant senior decision makers
    • 50% of junior doctors

The primary reason for rota gaps was inability to recruit, the College’s report said. "This is leading to departments in Wales not meeting RCEM best practice recommendations of having an EM consultant presence for at least 16 hours a day in all medium and large systems."

Staff 'Exhausted, Burnt out, and Looking to Leave'

Dr Suresh Pillai, vice president of RCEM Wales, said: "The findings of this vital census are stark and [it] really shows why emergency care in Wales is broken; we simply have too few staff.

"We are way off the RCEM recommended ratio of one WTE Consultant per 4000 attendances. This means existing consultants are stretched extremely thinly in EDs. We need more consultants for the safe supervision of trainees and junior staff.

"It's no wonder that many are exhausted, burnt out, and looking to leave. Exhorting staff to work harder and 'find efficiencies' to improve care just won't wash – they are already at their limits, doing their very best. Any service that is not properly resourced will eventually collapse, and this survey makes it abundantly clear that the crisis  [in which] emergency care finds itself is down to having too few staff, attempting to deliver too much. That’s not the fault of patients or because there is 'too much demand', it's the result of a failure to plug the significant gaps in staffing and address retention issues.

"We need sustainable long-term workforce planning to ensure there is a pipeline of doctors coming through. We are way behind where we need to be in terms of staffing and things will only get worse in the years to come if this isn’t addressed. Nearly one fifth of the consultant workforce plan to retire in the next 6 years, but departments are saying they need at least 75% more right now.

Dr Pillai said that he was "keen" to work with the First Minister, Mark Drakeford, to "discuss the emergency care crisis and need for long-term workforce planning".

"The Welsh Government must provide the funding to increase the EM consultant workforce by an additional 100 consultants as a matter of urgency, and to facilitate this we must see an expansion to the number of EM training places offered," he said. 

Without Action the Future of Emergency Care in Wales 'Looks Bleak'

Dr Pillai added: "Junior doctors are being asked to do too much and we need to see an expansion in training places as soon as possible, to spread the load and help fewer feel the need to drop out of training.

"It's clear that current conditions are having an impact. Increasing numbers of trainees are choosing to work less than full time in an effort to achieve more sustainable careers. This is entirely understandable, but it has an impact on care; people choosing to leave or work less means an ever-greater burden is put on existing staff, resulting in compromised care and burnout, meaning they want to do the same. We have to address this urgently and make the specialty – and health care – more attractive to trainees.

Dr Pillai said that he would like to see a minimum of 225 consultants by 2027, but worried that current trainee numbers are not "substantial enough to reach this aspirational target following the training cycle, during which some will naturally drop out". In addition to the extra training places needed, he said the Government must look to launch an extensive recruitment campaign to attract trainees to train and work in Wales.

"Without these places and a concerted effort to increase staffing, the future of emergency care in Wales looks very bleak indeed," he said. "We hope the Welsh Government recognises this and we hope we can work together to improve conditions for staff and the quality of care for patients."