Associate Feature: A call to expand and retain the workforce of the NHS

Scotland’s Accident & Emergency Departments (EDs) have historically outperformed the rest of the UK. This is largely due higher spending on health than the other nations. However, the gap is closing. Spending on health per person in Scotland went from being 22% higher than in England in 1999–2000 to just 3% higher in 2019–20.1 What has followed is a consistent deterioration in performance; in 2021 so far, almost 15,000 patients have been delayed for eight hours of more in departments across Scotland and the latest data show that staff are now battling with winter-like demand in the summer months, which is taking its toll on staff wellbeing.

Without staff there is no NHS; yet this concept has not been taken seriously enough in recent years. To thoroughly understand the current state of the workforce, the Royal College of Emergency Medicine (RCEM) carried out a census of all major EDs across Scotland. Our report, published in July 2021, provides a breakdown of staff mix, working patterns, and workforce gaps, as well as a look towards the future.2

Safe staffing of EDs should be based on a ratio of one Whole Time Equivalent (WTE) consultant per 4000 annual attendances.  The census revealed that, at present, there is a shortfall of roughly 130 WTE consultants in Scotland.

But consultant numbers alone do not reveal the full picture. Non-consultant senior decision-makers are an integral part of ensuring EDs are staffed safely. However, EM workforce planning is generally modelled on forecasting only the number of consultants needed in six years’ time (the training cycle). This fails to acknowledge the crucial role that non-consultant senior decision-makers play.

EDs disclosed their ideal staffing numbers by the year 2026 and their responses revealed that an additional 113 consultants and 74 non-consultant senior decision makers (187 total) would be needed to cope with rising demand and address current understaffing.

While the increase in non-consultant senior decision-makers is not as sizeable as the consultant group, it represents a more complex issue. This is because there is often no predictable career pathway for becoming a non-consultant senior decision maker. As a result, it is difficult to estimate where these staff members will come from.

Current training numbers do not account for this gap. Furthermore, owing to intensity of working in the specialty, it is becoming increasingly common for trainees to work less than full time (LTFT). As rates of LTFT working rises, the number of training places in terms of headcount will have to accommodate. The issue is complicated further by planned retirals (of which there are 33 planned in the consultant group) as well as early retirals that may arise due to high rates of burnout further aggravated by the pandemic.  

There has been no respite or recuperation for our workforce. What ensues is a vicious cycle whereby operational pressures induce burnout, causing staff to leave the specialty or reduce their hours, and in turn the understaffing then leads to increased rates of burnout, and so on.

Retention of the staff we do have is just as important as recruitment and expansion. We know that poor staff wellbeing is linked to operational issues. We call on the Scottish Government to address these concerns. Only by tackling ED crowding, increasing bed and workforce numbers, and bolstering primary and social care can we ensure that Scottish EDs are there for everyone in their time of need.

This article is sponsored by the Royal College of Emergency Medicine.