­MR 15

Ymchwiliad i recriwtio meddygol

Inquiry into medical recruitment

Ymateb gan: Coleg Brenhinol y Meddyginiaeth Brys Cymru

Response from: Royal College of Emergency Medicine Wales


Welsh Assembly Health Social Care and Sport Committee


Inquiry into medical recruitment


Written evidence submitted on the behalf of the RCEM Wales (18 November 2016)


The Royal College of Emergency Medicine Wales (RCEM Wales) is the single authoritative body for Emergency Medicine in the Wales. RCEM Wales works to ensure high quality care by setting and monitoring standards of care, and providing expert guidance and advice on policy to relevant bodies on matters relating to Emergency Medicine.



Views on: The capacity of the medical workforce to meet future population needs, in the context of changes to the delivery of services and the development of new models of care.


1.  NHS Wales’ medical workforce faces a significant challenge to meet the health needs of a growing and aging population with increasingly complex needs.


2.  The number of people over 65 years of age is predicted to grow by 292,000 by 2039. This is an increase of 44%. Moreover, the total population of Wales has grown from 2,872,998 in 1991 to 3,099,086 in 2015. This is an increase of nearly 8% in the space of 24 years. By 2039, the population of Wales is forecasted to grow by at least 5%.[1]  


3.  This in turn is reflected in an increasing propensity to access health services. Demand from people over 65 years of age, for instance, continues to grow considerably and has resulted in rising numbers of GP appointments both in person and over the phone. This increase in demand in primary care services inevitably leads to increasing pressures in secondary care services, including A&E departments.


4.  The latest results from the GP Patient Survey, for example, show that one in three patients (32.9%) who were unable to get an appointment at their GP surgery out of hours went to Emergency Departments instead.[2] Furthermore, between 2014-15 and 2015-16 attendances at major A&Es in Wales has increased by 11,125 or 1.41%, and this figure is set to grow.


5.  This increase in pressure on emergency services is also evidenced by the declining performance of the four hour standard in Wales. According to Stats Wales, the percentage of patients spending less than the 4 hour target has been in decline since 2013 and this downward cycle has continued into 2016/17.[3]


6.  In order to address this increase in demand, Welsh Emergency Departments require a workforce of sufficient size and with the necessary number of senior decision makers to treat patients effectively and in a timely fashion.


7.  However, although there were considerable increases in the A&E workforce between 2010 and 2013, since then that progress has stalled. Between 2013 and 2015 the workforce expanded by no more than 0.28%, despite the growing and ageing population.


8.  Moreover from 2013-14 the number of consultants per attendance has deteriorated. This has gone from one to every 11,575 attendance in 2013-14 to one to every 12,230 in 2014-15. This echoes our wider concerns about on-going difficulty recruiting staff to support the speciality in Wales. (See the figures below.)[4]


Staff Category







% Change since 2010

% Change since 2013

All Grades


















Specialty Doctor









Staff Grade









Associate Specialist









Foundation House Officer 2









Foundation House Officer 1










9.  There are plans in all Welsh Emergency Departments to increase the number of Consultants and future models estimate that a minimum of 100 Emergency Medicine Consultants will be required within the next six years.


10.     However, around 15-20 of the current 65 substantive Emergency Medicine Consultants working in the 13 Welsh A&E’s are planning to retire within the next few years. This means that Health Boards will be required to at least double current consultant numbers to meet demand.


11.     Furthermore, many junior doctors working within emergency medicine are not necessarily training to qualify in that speciality. Indeed, out of the current 91 junior grade training posts in Wales, 41 places are occupied by F2 doctors, 39 by GP trainees and only 11 places are taken up by doctors who wish to train in emergency medicine.


12.     In short, supply is not keeping pace with demand. If decisions about the recruitment and retention of A&E staff do not accurately reflect the nature of demand then performance cannot reasonably be expected to improve, the morale of staff will inevitably decline and the health and wellbeing of Wales’ population could be compromised.


Views on: The implications of Brexit for the medical workforce.


13.     The decision to leave the EU could have a significant impact on health and social care in Wales.


14.     According to the Nuffield Trust, 10% of doctors and 4% of nurses are from the EU and are working in the UK. Data also shows that around 6% of doctors working in Wales were trained in another EU country.[5]


15.     The huge contribution made of staff trained outside the UK who now work in the health and social care sectors in Wales is beyond doubt. Without more non-UK nationals joining the NHS, the health and social care systems will struggle to function as our current workforce, as evidenced above, is insufficient to meet increasing demand.


16.     Moreover, the volatile Pound Stirling could make competitive salaries more unattractive in the UK compared to other EU nations, especially given the UK’s average salary only ranked 10th out of the 28 EU countries.[6] Since the Brexit vote, the value of the Pound has dropped by c.16% compared to the Dollar and c.6% compared to the Euro. The uncertainty of when the Pound might recover might also play a part in dissuading healthcare professionals from immigrating to the UK.


17.     Therefore, we strongly agree with the message Vaughan Gething AM and many others have sent in stressing how much we value all of our staff who have moved from other countries to work in the NHS. RCEM Wales believes that EU staff need to be further reassured of their value. We must also continue to attract vital medical professionals from the EU and around the world as the current system cannot be sustained if workforce and trainee numbers do not increase.


Views on: The factors that influence the recruitment and retention of doctors.


18.     Whilst emergency medicine training posts at year one (ST1) have a 100% fill rate in Wales, only 61% of higher specialist training posts in Emergency Medicine are being filled.[7] This, coupled with existing vacancies, means that the current emergency medicine workforce remains significantly short at 44% of the baseline recommendations advocated by the College.


19.     Paradoxically, there are not enough ST1 training posts available for the increasing demand.


20.     There is also a real and current issue that more of our NHS staff are emigrating to work abroad. This is due to dissatisfaction caused by working in understaffed and under-resourced A&E departments and the attraction of more lucrative work outside the UK.


21.     The figures shown below, for instance, give a snapshot of the varying workloads of A&E consultants around the globe by estimating the average number of patients one emergency medicine specialist treats on one day.   


1 A&E Consultant

Estimated number of patients 1 Consultant treats per day









New Zealand[10]



22.     There were around 768,000 patient attendances to major A&Es in 2015.[11] These cases were dealt with by 63 A&E Consultants. Therefore, each doctor would see an average of 33 patients per day with varying levels of need, as shown above.


23.     By comparison, in Australia in 2014–15, there were almost 7.4 million emergency department attendances in public hospitals: around 20,000 presentations per day. There are an estimated 1132 emergency specialists in the Country.[12] This equates to around 18 cases per doctor each day. Therefore, A&E consultants in Wales have a 46% higher workload than their Australian counterparts.


24.     Inexorably rising workloads increasingly mean that NHS staff on the front-line of services are more likely to suffer from burn-out and stress. Indeed, across the UK health system, over 60% of the current consultant workforce reported that their job was not sustainable in its current form.[13]


25.     Furthermore, the average basic salary of an emergency medicine specialist also varies considerably between English speaking countries.


26.     NHS Consultants can earn a basic salary of between £75,249 and £101,453 per year. This is similar to emergency medicine specialists in Canada who earn on average £111,200.[14] However, salaries can be more attractive elsewhere. For consultants in New Zealand, average salaries will range from approximately £118,550 to £177,830 which is around 43% greater that the UK’s highest basic salary for A&E Consultants.[15]















27.     In addition, ‘Out of Hours’ working is currently recognised by paying doctors the same sum for working 1am to 4am on a Sunday night as they receive for working 1pm to 5pm on a weekday afternoon.[16] In Australia, basic salary assumes a working week of 38 hours. After this, staff are paid approximately 15-25% higher than their basic salaries for all overtime and on call work.[17]


28.     When considering the factors that influence the recruitment and retention of doctors, the location of departments can also be crucial in determining their popularity, especially with younger trainees.


29.     As a primarily rural country, some emergency departments experience recruitment challenges due to its remote location. This is seen in Mid Wales where public transport systems are less robust and travel times to major Cities are longer. Therefore, these departments need to offer other incentives, for example, competitive salaries, to lure staff.


30.     However, it is important to note that A&E medical staff who train in Wales tend to choose Wales to live and work – around two thirds of current substantive ED Consultants were trained in Wales. This is in part due to the relative affordability of Wales and also because, according to the GMC National Training Survey 2016, Wales’ emergency medicine training services scored three “above outliers”, or examples of excellence. On this basis, if more training places were made available, retention rates should rise.


Views on: The development and delivery of medical recruitment campaigns, including the extent to which relevant stakeholders are involved, and learning from previous campaigns and good practice elsewhere.


31.     RCEM Wales supports new initiatives that will entice people into the emergency medicine speciality in Wales.


32.     One such new initiative is the Emergency Medical Retrieval & Transfer Service (EMRTS Cymru) which has the potential to support recruitment into Wales if sessions with the Service were offered as a supplementary part of training.  


33.     Cardiff University will also be hosting an intercalated BSC in Emergency Medicine to help attract undergraduate trainees into a future career in Emergency Medicine.


34.     Furthermore, emergency medicine consultants are looking at other staffing models which strengthen the workforce and help with resilience and retention of staff. Advanced Nurse Practitioners (ANPs), for example, have recently been introduced in some areas and work as non-medical practitioners to support emergency medicine staff.


35.     Recently, a developmental programme has also been introduced in Wales to train more Emergency Nurse Practitioners (ENPs). However, the scope of ENP Minor Injury practice is limited and whilst the regional programme is welcomed, the numbers on the programme are very small. Currently there are only 13 ENPs in the programme.


Conclusions and Recommendations


36.     There are too few senior and Middle Grade medical staff in A&E departments to deliver effective and efficient care alongside too little training places.


37.     Government and NHS Wales providers need to ensure that more trainee places are made available to fill the current workforce spaces and to also keep up with demand. To achieve seven day coverage of EM consultants between 8am and midnight, the College believes that a minimum of 10 whole time equivalent consultants in each ED is required, rising to 16 or more in larger units.[18]


38.     Both current staff and future trainees, from the UK, EU and beyond, need to be valued and supported. Without their support, we will not be able to staff the consultant posts for the future or continue to deliver the invaluable services that are already under significant pressure.


39.     The College continues to call for safe and sustainable staffing of all Welsh emergency departments. We must ensure that the working environment, shift patterns, competitive salaries and work-life balance promote rather than discourage recruitment and retention. This would mitigate the attraction of more lucrative work offered by other countries, decrease staff burn-out rates and would also improve patient satisfaction.




RCEM Wales has been campaigning for some time for the reform of emergency medicine around the elements of our STEP campaign. If acted upon this would ensure that A&E were properly staffed and resourced and improve services for patients in need. Details of that campaign can be found here.

[1] Stats Wales National level population estimates by year, age and UK country

[2] GP Patient Survey, July 2016

[3] Stats Wales Performance against 4 hour waiting times target by major hospital and NHS Wales Informatics Service Monthly Accident and Emergency Report - After April 2013

[4] Stats Wales Medical and dental staff by grade and year

[5] Nuffield Trust Fact Check: migration and NHS staff and Stock of doctors by country of first qualification

[6] Average Salary in European Union 2016

[7] RCEM Essential facts regarding A&E Services in Wales

[8] Canadian Institute for Health Information Emergency Department Visits in 2014-2015 and Canadian Medical Association Emergency Medicine Profile

[9] NCIB Paediatric emergency room activities in Italy: a national survey and Eurostat Physicians by medical speciality

[10] ACEM Specialist Emergency Medicine Workforce and Ministry of Health Emergency department use 2014/15

[11] Stats Wales, Performance against 4 hour waiting times target by major hospital

[12] Australian Government, Medical workforce 2012 and Australia’s hospitals 2014-15

[13] RCEM Stretched to the limit

[14] Physician / Doctor, Emergency Room (ER) Salary (Canada)

[15] NZ Doctors’ Guide

[16] NHS Consultant Contract Terms and Conditions

[17] Salaries In Australia

[18] RCEM Wales STEP Campaign