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Over the past five years there have been many changes in the way that emergency medicine departments work. This has been given recent prominence and encouragement by the recognition of the government—finally—that emergency medicine was in difficulty. There is also the recognition that the A&E department is the shop window of the NHS. A long trolley wait today is a newspaper headline tomorrow—particularly in London and the south east.
So why do we have a problem? Much is historical. Many A&E departments changed little for several decades after the birth of the NHS. A large, unattractive waiting room was the norm with all sorts of patients mixed in together. There was tacit acceptance that one would wait—sometimes for several hours. A&E had neither the glamour of surgery nor the academic backup of internal medicine. It was looked on as a necessary evil—a carbuncle on the side of the hospital. A&E consultants and SHOs worked hard and well, as did the A&E nursing staff, but opportunities to change practice were in short supply.
The past two decades have seen a gradually accelerating change in work, attitudes, and staffing. There has been an increasing number of consultant appointments with a new breed of energetic, committed individuals coming from a predominantly medical, rather than surgical, basic training background. Emergency medicine is now looked on as an attractive specialty without particular recruitment difficulties.
A breakthrough came recently with the publication of Reforming emergency care from the Department of Health—but with important input from Royal Colleges and Faculties. This pointed out that the long waiting commonly seen in A&E departments, first to be seen at all and second to obtain a bed if admission was deemed necessary, was totally unacceptable. The government introduced a target of four hours as the maximum time that a patient should spend from arrival to the department to being discharged or admitted. This above all has focused attention on A&E departments, although the point is increasingly made that emergency care is a whole system problem. It involves prehospital care and post-hospital capacity as well as the A&E department itself.
So where does skillmix fit in? It follows automatically from two facts. Firstly, there are too few doctors to deliver all the care that is required. This has been brought into sharp relief by the imminent introduction of the European Working Time Directive, which will cut drastically into the working time of junior doctors, as well as the demand, more and more, for consultant delivered care on the grounds of quality, speed, and safety. Secondly, and perhaps more important, is the result of putting patient needs first. Doing this one can work out a series of skills and competencies needed to achieve a timely, high quality outcome. The next move is to establish who has or could have these skills and competencies. Using this approach it is immediately apparent that much can be done well and competently without 10 to 15 years of medical training (and some perhaps better!).
The impact of these two factors—together with increasing skills of the nursing workforce—has been to cause radical rethinking by the A&E community of who should do what. There is still some resistance from those preferring to hide in their professional silos, but this is counterbalanced by management, politicians, and professional thinkers who have accepted that the status quo is not an option—and that patients deserve better than lengthy waits to be seen or to be admitted. The past two to three years have seen a dramatic rise in the number of emergency nurse practitioners undertaking a variety of tasks, generally involving minor injuries/illnesses, Walk in Centres, or triage. But more can be achieved. At present the position of the emergency nurse practitioner is hampered by the lack of clear definition of training needs and national criteria for training programmes. Emergency care practitioners are also being developed, so far on a pilot basis. Care facilitators are also appearing and having an important beneficial impact on patient flow, while physiotherapists are playing an increasing part with regard to the elderly population and orthopaedic problems. Many of the new developments in skillmix have come from emergency physicians and senior nurses working together in programmes such as IDEA, CWP, and the Emergency Collaboratives, all of which are accelerating change.
Obviously some control is needed to ensure that the quality of care matches the increase in quantity and speed of care. This is up to the emergency team as a whole. Equally someone has to lead and take responsibility for the work of the team. I would contend strongly that this should remain the domain of the consultant in emergency medicine, who has the breadth and depth of training to oversee all aspects of care.
The increased use of different people—that is, skillmix—is helping patient care. Even when we have sufficient consultants in post (six or seven for a 24 hour acute hospital) in 10 to 12 years time, the contribution made by non-medical clinicians will still be needed. Such clinicians have much to offer patients and complement doctors rather than replace them. Finally, we are moving to an emergency care system, which is both recognised as being of paramount importance to patient care and will be one of which we can be proud.
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