Emergency Medicine by Numbers

“Patient dies on hospital trolley”…

…says the headline on page 13 of Saturday’s Herald.  This is a recurring story in the UK and we are all quite familiar with it.  The subheading is “Pensioner death after six-hour wait for treatment at new super-hospital”.  If you read the ensuing article, you will encounter the following:  a review has been instigated – check; the department in question was under extraordinary pressure at the time, due to patient numbers – check; the incident occurred after-hours – check; staff are working flat out – check; the health secretary has been informed – check; lessons will be learned from the review and the health board will take immediate steps as required – check; the shadow health spokesperson says the incident is symptomatic of serious underlying problems – check; our hard working NHS staff are undervalued and our government is applying a sticking-plaster quick fix – check; they have no strategic vision – check; the government must be held to account if they fail to give the public the care it deserves – check; this must be done before winter sets in properly – check.

What is also predictable about such a report is that which is absent from it.  There is no indication as to what might serve as a suitable “strategic vision”.  And there are no numbers.  The report is neither qualitative nor quantitative.

For this, I have to say some of the blame lies within my own profession.  As a body, we doctors have not provided coherent leadership for the benefit of managers and politicians.  How can they be expected to know what to do if we don’t tell them?  The trouble is, there is no coherent consensus within the medical profession as a whole as to what kind of “strategic vision” might work.  Even in the twenty first century, medicine remains profoundly tribal.  The more subspecialised and super-specialised it has become, the more its practitioners operate within “silos”, largely oblivious to what goes on elsewhere, unless the silo falls under threat.

Yet much of what needs to be done is predicated on the numbers.  How do you manage the front door of your hospital?  What is a reasonable work load for a doctor working in this environment?  You seldom hear this matter discussed – not in the public domain anyway.  In my experience, a doctor working in a busy and a high acuity emergency department offering a high standard of care can see, on average, about 12 patients during an 8 hour shift.  If he is not merely triaging the patients, but actually working them up and managing them in a comprehensive fashion, 12 is enough.

Let us now suppose an emergency department sees 100,000 patients per annum.  That is on average 274 patients per day.  That is busy.  For each emergency physician to see a dozen patients, we need 23 doctors “on the floor” – maybe 9 in the day, 9 in the evening, 5 overnight, depending on local demand.   Let’s give everybody a five day week with 6 weeks holiday and 2 weeks study leave.  Then a doctor will work 220 days in the year.  You only have 0.6 of your medical workforce available on a given day.  So the total medical workforce is 38 full time equivalent doctors.  Let’s make the skill mix top heavy – say 20 consultants, 12 registrars in training, and 6 junior doctors experiencing a “taster” under supervision.

If politicians want a “strategic vision”, there, at least, is one part of it.  Pie in the sky?  My old stomping ground, Middlemore Hospital Department of Emergency Medicine in Auckland, sees about 100,000 patients per annum, and its medical staffing is actually rather better than the above.  But then, emergency medicine in Australasia is in an entirely different league.  That’s why all our junior doctors want to go there.

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