interviews

Redesigning the acute workforce

Dr Chris Roseveare, president of the Society for Acute Medicine (SAM), sets out the workforce challenges for urgent care.

Urgent and emergency medicine has been at the forefront of warnings for the NHS in recent weeks, and many professional institutions have highlighted the critical need for change.

One of these reports came from a collaboration of the Royal College of Physicians (RCP), the NHS Confederation, the College of Emergency Medicine, and the Society for Acute Medicine (SAM).

It puts forward 10 priorities for “unsustainable” urgent care, including the need to move to a seven-day, consultant-led service, multidisciplinary teams and effectively aligned financial incentives.

‘Bulging at the seams’

NHE spoke to SAM president, Dr Chris Roseveare, about how working practices can be re-engineered to meet such huge challenges.

“The whole system is really bulging at the seams; hospitals at near-full capacity most of the time, with no slack whatsoever. Hospitals need to model capacity and design systems to enable each day to start with empty space.”

He welcomed the collaboration behind the new report, which was “something that hasn’t really been done before” – it was developed through multidisciplinary conferences of the four organisations.

It’s a step towards recognising that challenges in the NHS can’t be solved by groups in isolation: “We’re going to have to collaborate across traditional boundaries,” Dr Roseveare said.

With a political will

Aligning financial incentives to deliver a more preventative, patient-focused service has been talked about for a long time.

“He acknowledged “enormous barriers to getting the money in the right place”, but pointed to a “very significant change in political will to make this happen”.

“That’s very encouraging. It really does give the opportunity for some of the financial incentives which at the moment can actually stand in the way of making progress from improving things.”

Crossing the boundaries

Treating patients with multidisciplinary teams is becoming more and more critical, particularly for those with complex needs that “cross the boundaries between health and social care”.

The greater need requires a wider range of expertise to identify and treat accordingly. It is also essential that there is good communication and close liaison between teams both within hospital and in the community to provide the right professionals “close to the front door where they’re needed”.

Dr Roseveare said: “One of the things we’ve often done less well in hospital is recognising those needs quickly when a patient comes into hospital.”

He called for a focus on comprehensive geriatric assessment, recognising that treatment needs often go beyond the purely medical.

“It’s going to be a big challenge, and we need to look at how we deploy staff: where they work but also when they work. We haven’t always been very good at doing that in the past.”

Seven days a week

Managing such an approach across seven days will be extremely difficult, and involve reorganisation of working hours to avoid overstretching staff in intensive roles. There is also little in the way of reward that can be offered for working harder and longer; requiring a completely different approach to scheduling and incentives.

“We’re going to have to look at how those individuals are deployed at other times during the week, because many healthcare professionals are already working extremely hard.

“If we’re going to deliver more care at a weekend, that may mean we’re going to end up delivering less during weekdays. We don’t want to end up robbing Peter to pay Paul, providing a fantastic service at weekends, but sacrificing high quality during the weekday to provide that.”

Keeping up

The AMU has had difficulty recruiting recently, made more challenging by the intense nature of the work. This further complicates the need to move to a seven-day service, with provision of multidisciplinary professionals as standard.

Dr Roseveare explained: “Some of that has been because there has been a dramatic expansion in the number of posts, which has outstripped the supply of trained consultants in acute medicine. That’s clearly a good thing, but it’s going to be some time before we have enough trainees coming though to fill these posts.

“The work is quite intensive and to be sustainable we’ve got to make sure that we plan people’s job plans appropriately, so we don’t overburden them and recognise the intensity of work as well as the hours. That needs to be factored into the job-planning process.”

Meeting demand

There are significant challenges to creating a more sustainable and effective urgent care service – structural, cultural and financial issues all loom large, and must be taken into serious consideration to make this work.

Dr Roseveare said: “We’ve got to make sure we’ve got enough people working in the right specialties to deliver the care patients need; we’ve also got to ensure the right incentives are in place for people to work in these very demanding specialties.

“Unfortunately this is all occurring in a time of immense financial constraint and asking people to do more when they’re already working extremely hard, at a time when we can’t offer them more in compensation, is going to be enormously challenging.”

The 10 priorities set out a starting point to overcome these challenges: now it is up to the NHS to take these recommendations and turn them into action – before it is too late.