Indyplus: Letter from leading doctors to health bosses over A&E wards

FAO: CEOs of Acute Trusts and heads of Clinical Commissioning Groups in West Midlands region

Dear Colleague,

We write as a group of Service Leads for Emergency Medicine in the West Midlands, representing Emergency Medicine consultants in the region, with responsibility for eighteen of the region’s twenty one Emergency Departments (EDs). The EDs of the region manage in excess of 1.5 million patient attendances annually, in a region with a population of 5.36 million. This represents 8.5% of all ED attendances in England.

Following a winter and spring of sustained, extraordinary pressures throughout the EDs in the region, we now believe we are in a state of crisis which needs to be more widely acknowledged and moreover urgently addressed. This issue has in recent days and weeks been highlighted by NHS England, the Care Quality Commission, the Royal College of Nursing and the College of Emergency Medicine; we echo the sentiments of these organisations and highlight the fact that this crisis has been particularly and intensely felt throughout the West Midlands and surrounding region. It has come to a point where we must voice our most pressing concerns regarding the safety and quality of care currently being delivered in EDs across the region.

All of our EDs have been under immense pressure for the last few months. This pressure has been unprecedented and relentless, and felt by every ED in the region. All have shown inexorable rises in attendance rates, year on year, coupled with increasing intensity in workload, as we care for a rapidly aging population with complex needs. There is toxic ED overcrowding, the likes of which we have never seen before. Nurses and doctors are forced to deliver care in corridors and inappropriate areas within the ED, routinely sacrificing patient privacy and dignity and frequently operating at the absolute margins of clinical safety.

We regularly see our EDs overwhelmed with patients, with all cubicles occupied, and no egress into the hospital forthcoming, while patients continue to pour through the doors. Our departments are simply not equipped to safely care for such numbers of patients, an increasing proportion of whom are elderly and frail with complex medical, nursing and social needs. All of the available evidence demonstrates that in-hospital mortality is increased when the ED is overcrowded and patients have to wait excessively for beds. Such overcrowding is now the norm in our EDs. In addition, we are seeing an inevitable and unsurprising increase in serious clinical incidents and complaints, as well as delays and deficiencies in care. And for every incident reported, we know there are multiple examples of substandard care that go under the radar. We and our staff are carrying a huge burden of clinical risk which no other agency seems willing or able to share.

While matters have recently come to a head, this situation has been in the making for a number of years, as evidenced by the fact that the recruitment of doctors to Emergency Medicine is in a state of national crisis, and our region has not escaped the problem. The Herculean burden of work, responsibility and clinical risk is so obvious to junior doctors that they are unwilling to join us in the practice of what we once considered the most rewarding areas of clinical medicine, and instead opt for more attractive and sustainable careers. There is institutional exhaustion amongst ED staff, at all levels, across nursing, medical and clerical. We appear to be the only healthcare workers in our organisations who are expected to work under these conditions, and it is not sustainable. Recruitment is almost impossible, and retention is becoming hugely challenging. The relentless volume of work, coupled with a perceived lack of clinical support from outside the EDs is demoralising and destructive.

Recent developments such as the introduction of 111 and financial penalties for holding ambulance crews in ED are touted as solutions to the crisis: however we as ED physicians recognise that these measures will actually make the problem worse instead of better, and evidence is already emerging to support our opinions. Furthermore the unilateral and dictatorial manner in which these and other policies have recently been introduced have only served to compound the problems in our departments.

The position is such that we can no longer guarantee the provision of safe and high quality medical and nursing care in our EDs. It is not a case of standards slipping, but the inevitable consequence of being forced to work in sub-standard conditions. The aforementioned issues have led to us routinely substituting quality care with merely safe care; while this is not acceptable to us, what is entirely unacceptable is the delivery of unsafe care; but this is now the prospect we find ourselves facing on too frequent a basis.

As a group of committed clinicians, we have worked hard to improve safety, quality, efficiency and timeliness of care in our departments, but have now exhausted all of our own resources. The pressures in ED and the ambulance service reflect an overall emergency system failing to cope –a coordinated system -wide response is now urgently needed. We know there is no simple answer to this conundrum; however as things have continued to escalate in this unrelenting fashion with detrimental effects on patients and staff alike, it would be unethical of us not to highlight this to our Executive teams and Clinical Commissioning Groups. Furthermore, we firmly believe and strongly recommend that ED leads should be intimately involved with and consulted on the commissioning of Emergency services in the region, as well as other related emergency care changes-such as 111. He that wears the shoe knows where it pinches; it is imperative that the experts in delivering Emergency Care- i.e. ourselves and our colleagues, are an integral part of its development and reconfiguration.

We reiterate our profound distress with the state of EDs in the region; and, while not wishing to apportion blame or devolve ourselves of responsibility, we call urgently on behalf of our patients and our staff for a radical Health Economy-wide response to the urgent care needs of the population of the Midlands. We furthermore call for our EDs to be suitably staffed and supported whilst under such pressure and while longer term solutions are put in place.

Yours sincerely,

M Bernadette Garrihy, WM Regional Representative to College of Emergency Medicine,

Terri Bentley, Joint Clinical Lead for Emergency Medicine, Mid-Staffordshire Hospital,

Bob Coupe, Joint Clinical Lead for Emergency Medicine, Mid-Staffordshire Hospital,

James Crampton, Clinical Lead for Emergency Medicine, Burton NHS Foundation Trust,

James Davidson, Clinical Lead for Emergency Medicine, UHCW, Coventry,

Ola Erinfolami, Clinical Lead for Emergency Medicine, Solihull Hospital,

James France, Clinical Lead for Emergency Medicine, Worcester Royal Hospital,

Magnus Harrison, Clinical Lead for Emergency Medicine, University Hospital of North Staffordshire,

Christopher Hetherington, Clinical Director for Countywide Emergency Medicine Directorate, Worcestershire Acute Hospitals NHS Trust, Alexandra Hospital, Redditch,

Ruchi Joshi, Clinical Lead for Emergency Medicine, Walsall Healthcare NHS Trust,

Aidan MacNamara, Clinical Director of Emergency Medicine, Heart of England Foundation Trust,

Adrian Marsh, ED Lead at Shrewsbury and Telford NHS Trust

Rajan Paw, Service Head for Emergency Medicine, Dudley Group of Hospitals,

Mark Poulson, EM Lead for Sandwell and West Birmingham Hospitals,

Arne Rose, Lead Clinician for Good Hope Hospital Emergency Department, Sutton Coldfield,

Martin Smyth, Clinical Director for Emergency Medicine, South Warwickshire Foundation Trust,

Ben Stanhope, Clinical lead for ED, Birmingham Children’s Hospital,

Kumaran Subramanian, ED Lead at Shrewsbury and Telford NHS Trust,

Juliette Walton, Clinical Lead for Emergency Medicine, Wye Valley Trust Hereford.