#66: Define “whole”.

County Councillor’s Report

First appeared in the February edition of the Highley Forum.

Back in September 2014 I wrote…

Perhaps democracy is increasingly irrelevant to people’s daily lives.

I was talking then about the way changes at Shropshire Council were impacting on the way the council engaged with the people of Shropshire, although more accurately I should say increasingly disengaged with the people of Shropshire, a process that, if anything, has increased since then.

There are still a lot of people who persist in thinking that “the council” is still what they’ve always thought of as “the council” – it ain’t!

When, in 2009, the old district councils and county council became a single unitary council, changing from a committee system to one known as (and I kid you not) ‘Strong Leader Plus Cabinet’, Shropshire Council has increasingly become what I would call a “Service Director led administration”, where the directors of service departments, in close partnership with consultants, no longer just advise the elected councillors in the Cabinet but determine policy which is rubber-stamped by Cabinet portfolio holders and presented to ‘Full Council’ (which no longer meets monthly) where it is voted through by the majority of votes of the ruling group from which Cabinet is drawn.

Directors of Service and consultants are not answerable – and certainly not accountable – to the electorate whose lives they influence and who have to drive over the roads they have allowed to deteriorate to the point of absolute misery, adding insult to injury by forcing the electorate who pay the taxes that pay their salaries and consultancy fees to then pay for the resulting damage caused by their failure to do the job they’re employed to do.

For years the North Shropshire MPs and North Shropshire councillors who are nine of the ten members of the Cabinet have campaigned for the North West Relief Road around Shrewsbury. (Those of an uncertain disposition who have paid for new tyres and/or wheels try to contain yourselves.)

The Department of Transport has agreed to give £54m towards the construction of Shrewsbury’s north-west relief road, with work expected to start in 2022.’

The full cost of the road is estimated at £71m, with the council to provide any remaining funds.’

[My note: Do the sums: £71m – £54m = £17m of OUR money.]

Steve Davenport, cabinet member for highways and transport, said: “The North West Relief Road will benefit not just Shrewsbury but the whole of Shropshire…”’

Define “whole”. There is an argument for the NWRR, but there is an over-riding argument for the roads in the rest of Shropshire to be addressed with more than a passing sympathetic remark and an explanation of how cash-strapped the Authority is and therefore, “sorry, (forced smile, slight tilt of the head to one side and a shrug of the shoulders) you’ll have to wait a bit longer”.

Our MP (Philip Dunne, a nice chap) has just stepped up to the mark on behalf of South Shropshire. A little late, but welcome aboard Philip. Let’s see if anything changes on the B4555.

Dave Tremellen

16 January 2020

#65: Consultants, eh? Who’d have ’em?

Article first appeared in the Highley Forum, March 2020 edition.

County Councillor’s Report

£130,000 + £380,000 = £510,000

Nice work if you can get it. Bit late for me to scramble onto the consultancy bandwagon, though, even with an Upper Second Honours degree in Business Studies I’ve spent too long in the real world to convince potential clients that I’m the right person to tell them what they want to hear rather than the truth.

A lifetime ago, after graduating, I looked into going into business consultancy with an ex-copper friend, Ron, who I’d been at college with and the name we decided on was ‘NBS Consultancy’, the first initial standing for ‘No’ . But Ron’s circumstances changed and the idea was dropped, although I did do two and a half years freelance work for various local and central government agencies, but soon tired of finding myself sitting on the opposite side of some executive’s desk, dying to tell him (women execs were usually more switched on) that he was actually the problem he’d called me in to try and find!

As far as the recent furore over Shropshire Council’s employing consultants at the £510,000 cost given at the head of this article (£130K to advise on “solutions” to our highways issues and £380K to advise on the refurbishment of Shirehall), what angered me was that within the Council we had people who were more than able to tell anyone who asked what the problems were and what needed to be done to put them right.

In response to the Chief Executive’s email to all Elected Members telling us of his unilateral decision to appoint a highways consultant, I wrote back…

This is some kind of joke, right?

Everything’s falling apart so “we” employ another consultant when we’ve got all the expertise we need in-house and have done since the district and county councils were operating prior to going unitary, expertise that has the detailed LOCAL knowledge that informs the work programme of the efficient highways department we WOULD have had if only officers had been allowed to do the job they’ve trained to do, if only they were given the resources they so desperately need to do the job they’re professionally qualified to do!

Let the people we’ve got do their job and give them the resources they need to do it. It really is that simple.

Angry? Me? It’s gone beyond angry, especially given that five years ago, in February 2014 – yes 2014 – I asked this question of the highways portfolio holder at Full Council…

Will the Portfolio Holder for Highways admit that they have lost the battle with potholes in South East Shropshire? In the event that they still cling to the delusion that they are in fact still in control of roads in my part of the county, would they point to the evidence to support that claim.

Claire Wild, Portfolio Holder for Highways and Transport, replied: Shropshire Council has not lost the battle with potholes in South East Shropshire.

She went on to list a number of major jobs that were programmed for Highley (including the complete resurfacing of High Street), NONE of which were ever started, so if her argument was open to challenge back then, her successor has even more of a challenge to contend with because we’ve had five years of a crumbling highways network getting even further beyond hope of being salvaged by anyone, let alone a consultant at the going rate of £1,000 a day for six months.

Too much and too late anyway.

Dave Tremellen

(The very) Independent Member for Highley Ward of Shropshire Council.

#64: The first thing elected Members knew about the highways consultant employed by Shropshire Council was via an email sent to all councillors and some service directors.

It was not marked Confidential nor did it come with a notice that circulation was in any way restricted, hence…

On 29 Jan 2020, at 14:44, Clive Wright wrote:

Dear Member

I want to inform you of changes I am making, with the support of the Portfolio Holder, Steve Davenport, in Highways with immediate effect. As you are all aware, we need to improve performance and delivery at pace. To achieve this the following actions have been taken:

1) We have appointed a consultant, Tom Blackburn-Maze, who will be with us until the end of June. Tom is providing advice on how to make crucial improvements based on his experience of running very successful Highways operations elsewhere. Tom will be providing advice to myself, Mark Barrow and the Highways team.

2) ******** has been asked to take on a different role.  He will continue to deal with front facing issues and add vital management capacity to the work of highways which is so critical to members, town and parish councils and the public.

3) ******** will continue as Interim Head of Highways and will manage the day to day operation of Highway repairs and maintenance.

4) Alun and Steve will act on the advice of Tom but will report to Mark Barrow or me in Mark’s absence (on leave for 2 weeks).

5) We are moving the Highways front of house into the Customer Service Centre. This will coincide with reconfiguring CONFIRM (the Highways computerised management system) to provide Members with up to date information on line. The Customer Contact Centre already successfully handles complex referrals such as, for example, children and/or adults requiring social care.

6) Robust conversations have taken place with Kier at the highest levels. We have agreed an up scaling of Kier mobilisation and I expect to see a change over the next few weeks.

7) We will be working at faster pace focusing on areas of highest need over coming months. We will work to eliminate unproductive behaviour such as, for example, fixing one pothole whilst leaving the one next to it. Concentrating on areas will enable more work to be done faster and make it easier for us to supervise and ensure quality.

8) We will experiment with using local contractors as an alternative to using Kier. We can do this within the terms of our contract with Kier. This will provide evidence of the best way to proceed going forwards.

9) I expect highways repair costs to increase and these costs are being projected. We also anticipate that the Government will again make available additional ‘Pothole Funding’, though this is not yet confirmed.

10) We will reduce the rate of temporary repairs with an initial target of less than 5%.

11) We will hold a Members workshop at the end of February to update all Members.

12) The Portfolio Holder has requested that Scrutiny take a look at Highways improvement to provide a forum for all Members to be as involved as they wish. This is, of course, a decision to be made by Scrutiny as to whether they wish to include Highways in their programme.

As it stands there is currently 3500 reported highway defects on our systems. Clearing this backlog is our priority. We would ask Members to please use the on line portal to report further defects as this is the fastest way to ensure that issues are logged and acted upon. We understand that some Members prefer to call the engineers or email officers directly. Where this occurs the response will be for those staff to refer these enquiries in to the Customer Service Centre and let Members know. Having multiple channels of reporting is causing defects to be missed or double logging of the same defect. We can review this as we move forward and once we are on top of outstanding work.

I hope this keeps you informed.

Best wishes

Clive Wright

Chief Executive

Shropshire Council


My furious response was…

Dave Tremellen 30 Jan 2020, 09:43 (4 days ago)

to Clive, Members, Directors, Tom, Alun, Steven

This is some kind of joke, right?

Everything’s falling apart so “we” employ another consultant when we’ve got all the expertise we need in-house and have done since the district and county councils were operating prior to going unitary and, moreover, expertise that has the intimate, detailed LOCAL knowledge that informs the work programme of the efficient highways department that we WOULD have if only the officers we’ve ALWAYS had had been allowed to do the job they’ve trained to do – if only they were given the resources they so desperately need to do the job they’re professionally qualified to do!

What you’ve done is an insult to every one of those highways professionals and a poke in the eye for David Evans with his arms-length list of highways problems across Craven Arms; David Turner with his catalogue of highways problems across Much Wenlock; Kevin Pardy and a lethal roundabout he’s been trying to get made less lethal for years; Me, with collapsing carriageways and an army of residents with damaged cars (one phoned me yesterday to report her EIGHTH smashed wheel) not to mention a GP practice who can’t get a locum to attend because they refuse to travel the B4555; so what do “we” do, we employ another highways consultant on top of the department full of consultants we’ve already got in WSP, all of whom, presumably, were taken on because they come with “…experience of running very successful Highways operations elsewhere”.

No way a consultant will sort that lot out, let alone the rest of the county, but now he’s here, whilst he’s at it perhaps he’ll explain to the rest of us how the hell the North West Relief Road is going to benefit the rest of Shropshire, as Steve so confidently assured those us concerned about where the £17 million difference in the predicted cost of the scheme of £71 million and the grant of £54 million is going to come from, because we KNOW where it’s going to come from – US!

Let the people we’ve got do their job and give them the resources they need to do it. It really is that simple.

Angry? Me? It’s gone beyond angry, Clive.


Dave Tremellen

Independent Member for Highley Ward

Shropshire Council

Which got me this response…

From: Clive Wright
Sent: 31 January 2020 08:41
To: Dave Tremellen <Dave.Tremellen@shropshire.gov.uk>
Cc: Members; Directors; Tom Blackburne-Maze; Alun Morgan.Highways
Subject: Re: Highways Management Changes

Dear Dave

Thank you for your comments. I appreciate that there has been a number of false starts and ongoing problems in the Highways service. This is why I have now stepped in directly and personally as other management action has failed.

I agree with the thrust of what you are saying. My first port of call in initiating action was to approach and work with front line staff. The time had come to roll up sleeves etc. I have listened to what they consider is needed and I hope and believe we are winning their support. I offered to make immediately available budgets of £2.5m, their response was that this alone would not fix the problems and might make things worse. We must fix the the budget (and we have, albeit in times where resources are limited); our working processes (we are engaging our staff on this, not serving it up to them); incentivise our contractor to mobilise (we are doing this) or find alternative arrangements for small works (we are also doing this with local contractors); and provide different leadership (and I have made swift changes). We are continuing to engage the Highways staff and I met them all for an open conversation earlier this week and to feedback how we are acting on their input, what specific actions are being taken and today how we can only be successful through them.

Solutions are often seem simple from the outside and are more complicated in reality. My approach has been to understand the problem before we come up with the solution. Having said that, what we have to do in this case is not rocket science. There are four components: leadership and motivation; right process; contractor will and capability; resources – money and right skills in the right place. We have to fix all four. The goal is high quality and efficient delivery.

I agree that we should have been able to fix this ourselves without consultant input but we are way past that point and with the support of the Portfolio Holder we agreed it was time to bring things to a head. The consultant is here to bring experience, but his remit is to work with our staff and design solutions with them, not for them. The solutions for Shropshire are likely to be different to those in other places, though there are some fundamental things that we are currently getting wrong. Experience is a massive lift in this respect. I am not blaming our staff but an example is where we have been temporary fixing 74% of potholes, this should be closer to zero or no more than 5%. This change alone implemented quickly will likely pay for the cost of the consultant.

Some of the problems we have, such as parts of the network not being designed for heavy agricultural vehicles won’t be solved anytime soon (though we are lobbying and applying for funding). However, I do intend to dramatically improve our performance on the issues you raise, particularly small works and maintenance. The proof of the pudding, as they say, will be in the eating and I hope you will afford me the chance to demonstrate the change.

Finally, as you know, I too live in South Shropshire, and I’m not proud of our performance or with our contractor.  All services are stretched but overall staff motivation and optimism is good and we will continue to perform beyond what might be reasonable with the resources we have. We can and must do better with the resources we have in Highways, we will need to add funding and ensure this is well spent. I hope that Members will continue to support and work with us towards this goal. Challenge is always welcome, it provides opportunity to see things from a different perspective and this is a great strength in our Council. I am always open to finding better solutions. Right now, confidence is low in all quarters (Members, the Public, staff and our contractor), but we can and will rebuild this by getting things done on the ground.

I hope this provides you with some assurance.

Best wishes

Clive Wright

Chief Executive

Shropshire Council

Assurance it did not provide. Well, not entirely, although as a statement of intent it doesn’t leave much to challenge.

My fear is that circumstances will overtake the good intentions listed there for the simple reason that Shropshire Council’s priorities do not have to do with the concerns of ALL its citizens, as witness an economic growth policy predicated entirely on HS2 and the development of the north west of the county, everywhere else can “do one”.

There is not even any support for anywhere in the other three-quarters of the county to even think about doing something for themselves because all those of us representing that rest of the county can get is advice because it comes cheap – unless it comes via a consultant at £1,000 a day!

As I said in my response to Clive Wright’s announcement, we already had all the expertise we ever needed, it was just ignored, by-passed, marginalised, take your pick.

In the case of my own electoral ward, significant programmes of work had been planned over the last several years by our existing highways engineers, designed and costed and all of them subsequently pulled in favour of works elsewhere by people who “knew better where to allocate resources”.


#63. Essential reading for ANYONE who thinks they know enough to express an opinion on Future Fit!

Will this be read in its entirety? Probably not because it challenges too many of the fondly clung-to misapprehensions that have bedevilled the “debate” (and there’s a laugh) over the future of Emergency Medicine in Shropshire.

The original pdf can be found if you google for… Emergency Medicine Taskforce Interim Report.

Because the report is a pdf document it was necessary to convert it to a Word document and re-format the text which results in the corruption of some formatting which it’s then necessary to put through a spell-check. I apologise for any typos, they’re mine not the original authors!

You will also note the absence of the graphs and figures referred to in the text, they were not translatable from pdf to document format.

Emergency Medicine Taskforce Interim Report.

Executive Summary


In recent years, the poor recruitment at ST4 in Emergency Medicine (EM) has raised concerns within the specialty and the medical profession. The specialty in 2011 and 2012 has achieved a lower than 50% fill rate into higher training. Fewer trainees are opting to choose EM for higher specialty training due to concerns over the intensity and nature of the work, unsociable hours, working conditions and the sustainability of such a career to the age of 68.

The Emergency Medicine Taskforce was established by the Department of Health in September 2011. This is its interim report. The Taskforce in fulfilling its Terms of Reference has explored many aspects of medical education and training, which may be contributing to the problems that the specialty is currently facing.

Fill rates, trainee numbers and deanery data has been collected, expert evidence and opinion has been sought to establish the key factors effecting Emergency Medicine. Using this data and evidence the Taskforce has developed a number of recommendations focusing on medical education, training and service provision in order to improve the recruitment and retention in the specialty.


It is essential that commissioners seek advice from those who understand the urgent and emergency care landscape and the population served.


Poor fill rates have lead to a decline in the number of higher trainees and thus the supply of future Consultants. The Taskforce group have looked at ways in which to increase fill rates for Emergency Medicine posts at ST4, whilst simultaneously identifying ways to enhance the desirability of the specialty.

The College of Emergency Medicine (CEM) has recommended a minimum of 10 whole time equivalent EM Consultants for each Emergency Department. This number is designed to provide up to 16 hours a day EM Consultant presence 7 days a week. Increased EM Consultant numbers will ensure improved work/life balance prospects for the trainees, enhanced protected training time and better supervision.

In recent years, there has been an increase of non-medical practitioners undertaking a role in the ED. These practitioners work with and compliment the senior medical workforce, interacting closely with Emergency Medicine Consultants. Many of these roles have been developed in UK hospitals.

Innovative developments in skill mix and roles will continue to play a major part in the delivery of urgent and emergency care. The Taskforce will look to highlight best practice and encourage dissemination to the wider health economy.

The Training Programme

To improve recruitment rates in Emergency Medicine more flexibility is needed in the way core training is configured and delivered. The specialty is currently considering the entry requirements for core training and recognising transferable competences of trainees currently in other specialties.

CEM also wishes to explore the parallel running of a run-through training programme.


Reconfiguration is a complex agenda and involves an understanding of professional views, patient safety, public access and the political dynamic. Given the pressures on primary care and EM services to meet unscheduled demand this may be a consideration for the future.

Market facing pay / terms and conditions

It is impracticable to pursue market facing pay and changes to terms and conditions at this current time as this would simply drive up current costs without fundamentally addressing the problem. In the longer term this area may well need to be reconsidered to make the specialty a more popular career choice.


The report should be used by Health Education England (HEE) as a basis for further discussions as to how best to address the workforce issues that the report highlights at a national and LETB level; recognising that each LETB area may need different aspects of the solutions that the Taskforce have identified.

However, there is an urgency to this and the Taskforce believes that measures will need implementing in the next months if we are to avoid increasing problems. The Taskforce would also wish to emphasise that urgent work is needed across the spectrum of emergency and acute care specialties (so not just EM) to address the service pressures. Developing an attractive and sustainable career in Emergency Medicine and those other specialties that have a large emergency component is the major and urgent challenge.

Department of Health (DH) officials and members of the College of Emergency Medicine (CEM) established the Emergency Medicine Taskforce in September 2011 to address workforce issues in Emergency Medicine. The group has considered

these issues and made recommendations on the future clinician staffing of Emergency Departments (ED) with the aim of ensuring patients within EDs receive high quality care that is consistent, responsive, safe and effective as well as being value for money. Regular updates of these recommendations were provided to the Medical Programme Board.

Introduction and principles

The specialty of Emergency Medicine is currently facing critical workforce shortages at ST4 and Consultant level in many areas in England. This problem is sufficient enough to potentially threaten the reliable delivery of urgent and emergency care services.

Waiting for a natural solution to the problem is no longer an option and EDs in partnership with the medical training and education system will have to actively seek alternative staffing and training solutions in order to meet service delivery and public expectation.

Fundamental changes in training support and supervision, working conditions and long-term career pathways are needed to ensure that Emergency Medicine is made attractive and sustainable to trainees in the future.

Additional pressures on acute medicine departments and General Practice could result in increasing pressures on the ED and the wider service in some trusts.

This is an interim report from the Emergency Medicine Taskforce Group.

The principle underpinning the work of the group is that patient safety is paramount and the current situation in which much of the care within the ED setting is invariably delivered by relatively junior doctors in training is no longer tenable or acceptable. All patients attending the Emergency Department should be reviewed by a suitably trained and experiencedclinician1.

The issues that prompted this initiative were:

    • Concerns over patient safety.

    • Desire to optimise quality and effectiveness of care in Emergency Departments (EDs).

    • Inadequate Emergency Medicine Consultant numbers.

    • Trainee recruitment difficulties and attrition.

    • Difficulty in staffing ED rotas at higher specialty trainee, SAS rota and senior level particularly overnight.

    • F2 and other junior doctors inadequately supervised in EDs.

    • Staff grade doctor recruitment difficulties and attrition.

    • Overnight closure of EDs.

    • Significant and increasing expenditure on locums and agency staff.

    • Emerging roles for non-medical staff that appear to lack national standardisation around preparation.

1CEM Operational Handbook, The Way Ahead, Version 2, Dec 2011

    • An opportunity to develop a collegiate response to meet the increasing demands placed on EDs.

Urgent and Emergency Care describes the provision of all unscheduled care, whether, in primary care or hospital based. The future model of care will determine the workforce needs. Workforce planning aims to create the capacity required for the known or predicted demand. This is the main aim of this document. It does however mention policy and service design issues, which may be able to influence demand, either by decreasing it or redirecting it. The present fragmented system across emergency and urgent care leads to duplication and poor use of its workforce. If every patient could see the appropriate clinician first; then the quality of care would be improved. An emergency and urgent care system that is truly designed around patients and the staff delivering the care, will address demand and capacity issues, variability and sustainability problems because it would become an attractive specialist area to in which to work. In addition, whilst it is undesirable for staff to be overstretched it is equally undesirable for staff to be underutilised and thus the model by which care is provided is highly relevant but is not addressed in this predominantly workforce-focused paper. The group recognises the era of tight financial constraints and thus the limitations for any additional investment in workforce. However, this must be balanced against the wider healthcare system’s commitment to patient safety, public expectation and the negative publicity surrounding the consequences of inadequate ED staffing. A permanent, fully trained and experienced senior ED clinical workforce will deliver the care that the public expect and deserve.

ED clinical staffing needs to reflect the high risk profile of many ED patients, of all age groups, presenting in large numbers with undifferentiated conditions with the consequent potential for significant mortality and morbidity. This care needs to be provided 24 hours/day, 7 days/week.

In England the year on year increase in ED attendances, both in terms of number and complexity, combined with the expanding role of EM in both diagnosis and treatment, has not been matched by increases in the ED workforce, particularly at a senior level. As a result, there is frequently a mismatch between demand and ED expertise, particularly overnight and at weekends.

Current ED senior staffing compares unfavourably with international models in North America and Australasia. The risks associated with inadequate senior EM staffing have been dramatically demonstrated in Mid-Staffordshire NHS Trust, and elsewhere.

A major contributory factor to the current workforce landscape has been the flawed assumption that emergency care demand can be managed downward. Although initiatives such as long-term condition surveillance, 111, NHS Pathways, Urgent Care centres and the Directory of Services are welcome and have been shown to have local impact on patient flows, this has not resulted in an overall reduction of unscheduled care ED attendance (for example, the Urgent Care Centres for Birmingham and Solihull area had 250,000 attendances per year, only 4% of which result in referral to secondary care, N Chauhan, personal communication). It should, therefore, be reasonable to anticipate a continuing rise in ED demand, as the population ages and public awareness of the importance of chest pain, stroke and infection initiatives, for example,increases.

The present urgent and emergency care system is inconsistent and is often commissioned and planned as individual components within the whole patient journey.

There is an enormous amount of variation in how this care is delivered, which often results in patients being confused with regard to which part of the system is most appropriate to meet their need. As a consequence, patient outcomes are not optimised, care is fragmented and staff are left feeling demoralised. More recently, ‘whole system’ and ‘team’ working are being encouraged which have benefits for workforce planning and for the quality of care being delivered, but the implementation of such arrangements is inconsistent, and is dependent upon individuals rather than systems.

Current financial challenges mandate an evidence based approach to the delivery of emergency care. The evidence suggests that care delivered by more experienced clinicians is safer, has better outcomes and is highly cost effective.


  1. The model of care recommended by the College of Emergency Medicine (CEM) is for Consultant presence 16 hours per day, seven days per week. This requires 10 Whole Time Equivalent (WTE) Consultants per ED, compared to the current average of 4.5 WTEs.

  1. The Centre for Workforce Intelligence (CfWI) predicts it will take until 2020 to secure sufficient numbers of consultants. This is based on maintaining the number of training posts at current levels and ensuring 100% fill rates for such posts and programmes. However, this is unlikely to occur given current attrition rates which will inevitably lead to a significant revision towards2030.

  1. For core training, recruitment is to the Acute Care Common Stem (ACCS), of which EM is one constituent specialty. In 2011, 96% of the 192 posts were filled– but retention in ED training is poor. For example, many ACCS trainees migrate to another specialty rather than progressing to ST4 (EM). In 2012, 94% of posts we refilled.

  1. For ST4 (first year of higher training) in 2011 there were 135 posts vacant in England but only 45 (41%) were filled. In 2012, there were196posts vacant in England and 86 (44%) we refilled.

  1. Based on the GMC Trainee Survey there were 169 CT3 trainees in post on the 30 April 2012. Of these trainees, only 84 applied to the national EM recruitment ST4 recruitment round. 92% (77) were considered appointable and were offered a post, with 85% (71) accepting a post.

  1. Recruiting doctors from overseas represents a possible short-term solution but will not provide longer-term recruitment and retention solutions given there were significant immigration obstacles to this recruitment option during 2011-12. This route is now open and there is still significant scope for the UK to recruit non-UK/EEA doctors into EM posts in 2012. In practice, despite intensive recruitment efforts, this initiative has proved disappointing. It may be that the issues of quality of support and supervision of trainees are impacting on overseas recruitment.

Consensus views of the Taskforce group.

The benefits of an EM Consultant present service are well described.

Sub-optimal recruitment and retention and poor progression though training in EM may be related to:

  1. The difficult conditions under which Emergency Medicine is currently practised with its high decision density, relentless target pressures, overcrowding and with junior doctors competence stretched by the challenging caseload.

  2. Perception of poor work/life balance in comparison with other specialisms and peers.

  3. Deficiencies in training and supervision, in part related to inadequate consultant and senior clinician numbers.

  4. The training assessment burden and sequencing of training.

  5. Uncertainty as to how a future career in EM will develop and be sustainable.

    1. Maximising the potential of the wider workforce is important

  1. General Practitioners have a crucial role in delivering urgent care, but the number of GPs who take on this role is less than was anticipated.

  2. Development of Advanced Clinical Practitioners (ACP) and Physician Assistants/Associates2as an increasingly important part of the future ED team would be valuable in providing a stable, consistent, ‘mid-level practitioner’ workforce.

  3. Roles and career development of SASG and specialty doctors working in Emergency Departments need addressing. This group need the opportunity to develop and maximise their potential.

    1. Commissioning needs to facilitate these changes and encourage whole system working

  1. In principle the reconfiguration agenda for EDs is supported. This will demand careful triangulation between the expectations of the public, the responsibility of the profession to ensure safe care and the political dimension.

  2. Reconfiguration of ED services overlaps considerably with other aspects of commissioning and wider configuration and provision of urgent/emergency care.

  1. Commissioning of services

Clinical commissioning groups (CCGs) will work under a statutory duty to seek advice in commissioning services from a broad range of professionals, including those who are well placed to understand the urgent and emergency care needs of local populations. They will also be able to access advice from clinical senates and networks.

The clinical senates will bring together doctors, nurses and other professionals to give expert advice, which we anticipate that clinical commissioning groups will follow, on how to make patient care fit together seamlessly in each area of the country. Clinical senates will provide advice and support on a range of issues, and from a variety of health care perspectives, including public health and adult and child social care experts, as well as allied health professionals. Health and wellbeing boards will provide an opportunity to ensure join up between health, social care and services that have an impact on health.

The framework in the Act for ensuring the competence of commissioners, in securing continuous improvement and ensuring the promotion of integration, apply particularly to emergency and urgent care services. Commissioners will need to use expert advice from senates and networks and from other sources to determine the best approach to commissioning.

CCGs must (under 14V of the NHS Act 2006, as inserted by Clause 25), obtain advice appropriate for enabling them effectively to discharge their functions from persons who (taken together) have a broad range of professional expertise in:

  1. the prevention, diagnosis or treatment of illness; and

  2. the protection or improvement of public health.

CCGs can include emergency care or unscheduled care specialists in their governing bodies or committees. The Department of Health does not want to require this specifically, but there is nothing to prevent it. CCGs should ensure EM Consultant input occurs to provide an informed contribution to this crucial area of commissioning.

For CCGs to make the best informed decisions the involvement of those central to the delivery of urgent and emergency care should be integral to commissioning. The local lead for Emergency care is such a person.

    1. Definitions of service

The delivery of a coherent 24/7 urgent and emergency care service aims to provide the highest quality of patient care. This will be facilitated by developing a system in which people can easily identify the right place for their care. The evidence indicates that many patients and healthcare professionals currently find the existing nomenclature and arrangements for urgent and emergency care services confusing. They struggle to understand which services are provided at which facilities at what time and where they should go to access the most appropriate service for them. Over the years, the picture has become more confused, and more layers of complexity have been added, and so work is under way to simplify this and make the system more consistent and more intuitive to navigate.

The new NHS 111 system should support the development of a simpler system and people will be encouraged to use this before attending a face-to-face facility, unless they have a life threatening condition in which case they will use 999. Following engagement with the public and the NHS, as well as various other stakeholders, the plan is for the NHS Commissioning Board to issue guidance on a simpler system. The ultimate aim is to produce an evidence-based categorisation of services that will improve patients’ ability to access the right service first time. To this end, discussions with external stakeholders and NHS colleagues continue and we expect further progress to be made in the second half of this year.

  1. Workforce

The future core ED workforce will, therefore, be a hybrid team of suitably trained and experienced decision-making clinicians including:

  • Em Consultants

  • EM Higher Specialty Trainees – ST4 and above

  • Consultants and higher trainees in acute medicine and other acute specialties including trauma and orthopaedics, paediatrics and psychiatry. This group can make an important contribution to patient care by their earlier involvement in the patient journey.

  • EM Specialty Doctors (SAS grade)

  • General Practitioners

  • Advanced Clinical Practitioners (from various nursing and AHP backgrounds)

  • Physicians Associates

  • Emergency Nurse Practitioners

  1. EM Consultants

The role of the EM Consultant is multi faceted and involves:

  • Direct patient care, particularly the most ill and complex cases

  • Supervision and teaching of other clinicians at all levels, and supervision of others in their supervision and teaching roles

  • Leadership including interacting with management, senior clinicians of other departments and the public

The demands on an EM Consultant are unrelenting, with a constant stream of decision making for high-risk patients presenting with critical illness, serious injury or with the potential for high morbidity and mortality, generally overlaid with additional Departmental management responsibilities.

In order to ensure patient safety, this decision dense activity is only safely sustainable for a limited number of hours. This is important when considering the total number of Emergency Medicine Consultants required in an ED, accepting that these Consultants will be working a shift pattern.

The College of Emergency Medicine has recommended a minimum of 10 whole time equivalent EM Consultants for each ED. This number is designed to provide up to 16 hours a day EM Consultant presence 7 days a week. Increased EM Consultant numbers will ensure improved work/life balance prospects for the trainees, enhanced protected training time and better supervision as well as an improvement in mortality and morbidity rates in and out of hours (OOHs).

Work is also being done to identify how ED Consultants may continue to work with a greater age given the likelihood that changes to NHS pensions. This may necessitate ED Consultants working in this high-pressured and relentless environment well beyondtheageof60.In the interest of patient safety,the intensity and unsocial

nature of EM mean that there should be the option to reduce the proportion of unsocial working as clinicians get older and this needs to be reflected in workforce planning.

  1. EM Trainees

Emergency Medicine is a highly attractive specialty for junior doctors throughout the world. Internationally, EM residencies rank amongst the top few specialties attracting junior doctors of the highest calibre in large numbers.

While EM is still viewed in the UK as an interesting specialty, trainees experiencing the current workload in ED, and witnessing the unsocial hours of their consultants, are leaving the specialty to pursue careers other specialties; usually anaesthetics or general practice. There are also significant problems with EM trainee recruitment at the more senior levels, and with progression from core to higher training.

The Emergency Medicine Trainees’ Association (EMTA) of the College of Emergency Medicine organised a survey of EM trainees in 2011 (reference).

The main points arising from this survey were:

  • A desire for greater Consultant supervision.

  • Greater emphasis on education and training compared to service provision.

  • Concerns over the current work/life balance in Emergency Medicine.

The trainees’ perception of their future in the specialty is judged problematic, as are the issues with the existing training programme.

Currently there are vacancies at ST4 in EM with fewer applicants applying than there are posts to fill. As well as the reasons described above, some of the difficulties in filling these posts have arisen from the current entry requirements being rigid. Currently applicants eligible for entry into ST4 need to have all the competences and experience that they would have acquired within an EM core training programme. They must also have passed the Membership examination of the CEM (MCEM). Doctors with some experience of the specialties comprising core training in EM often find it difficult to gain the additional experience needed for ST4 entry from outside a designated EM training programme. Doctors from other specialties are not encouraged to change specialty into EM since there is currently no agreement in place for transferable competences that might reduce the duration of the training programme to CCT. This means that all trainees applying for core EM training from another training programme must apply at CT1level.

The consequence of these factors is that approximately 30% of core trainees are opting to go into alternative specialties, such as Anaesthetics.

  1. The Training Programme

To improve recruitment in Emergency Medicine more flexibility is needed in the way core training in EM is configured and in the entry requirements for higher specialty training. This is most easily addressed by reverting to, or running a parallel, Run- through training programme (see Fig 1.)

CEM also wishes to explore ways of recognising transferable competences of trainees currently in other specialities in order to increase the pool of trainees eligible to apply for HST posts.

A trainee with some previous experience in the specialties comprising core EM training will be allowed to enter at a level higher than CT1 and, through targeted training, will gain missing competences later in the programme. Unlike the current core training programme, the actual length of time spent in each specialty area and the order in which the experience is gained, will be flexible, depending on the previous experience of the trainee. A review of the curriculum, person specifications, funding and assessment matrix will be required.

Progression through training needs to be improved: in particular, trainees in core training are failing to pass the MCEM within the three year ACCS programme. One of the reasons for this arises out of the current sequence in which experience is gained during the ACCS programme. Current trainees complete only 6 months of EM in the first two years of the programme. One part of the solution could be a reorganisation of the EM Core Training programme. A proposal to alter the current sequence of training has been considered in which the third year of EM training, (Paediatric EM and Musculo-skeletal competences) is moved to Year 1, with ACCS (EM, AM, Anaesthetics and ICM) being completed in years2-3.

Fig 1. Emergency Medicine Run through Programme

  1. SAS and Specialty Doctors

This group comprises doctors currently working under various titles including staff grade, Trust doctors, associate specialists and specialty doctors.

In the past, this group of doctors has been the backbone of many EDs providing high quality safe care throughout the 24-hour period 7 days a week.

Unfortunately, this contribution to emergency care has not always been valued or supported. Many of these doctors report working predominantly unsocial hours, have job plans with little or no provision for CPD and feel unsupported both within their department and in their organisation. As a result, there has been an increasing trend for these highly experienced doctors to leave EM, particularly into General Practice where there are opportunities for an increased salary and little unsocial hours working.

In turn, this has led to a great difficulty in populating SAS rotas, particularly overnight and at weekends. This has led to a vast expenditure on locum doctors of variable quality and/or very junior doctors being largely unsupervised in EDs, particularly overnight and for extended periods at weekends.

A recent survey of the College of Emergency Medicine FASSGEM group identified the following factors leading to attrition:

  • Non-sustainable rotas with high frequency of out of hours work

  • Poor morale within the department or perceived lack of respect

  • Poor working environment with high stress levels

  • Poor pay and conditions

  • A perceived inequality with higher specialty trainees

This group need the opportunity to maximise their potential. As well as CPD, the option for further training and development is important, so that these doctors have a sense of continued development and are able to make greater contributions to clinical care. A clear sense of career pathway and the opportunity to pursue the CESR route would enhance the working lives of this important group.

  1. General Practitioners

General Practitioners could have a crucial role in delivering urgent and emergency care. In principle, GPs could be invited to consider the following options:

  • Ensuring prompt access to community Urgent Care for as much of the seven- day period each week as possible, including some limited access available in the evenings and at weekends. There is evidence that improved access both in hours and out of hours is linked to decreased ED attendances.

  • High quality chronic disease management including individualised plans for acute episodes can prevent hospital attendance and admission.

  • GPs should provide Primary Care expertise in a facility co-located with the Emergency Department or fully integrated in to ED.

  • In the ED, facilitating discharge of patients back to community facilities.

  • Encourage those GPs who wish to develop Emergency Care skills as a special interest, with skills and competences as agreed by the RCGP and College of Emergency Medicine.

General Practitioner engagement is crucial. However, many locations are having difficulties in recruiting because of an increasing tendency for individuals to limit out of hours work and significant pressures on the GP workforce.

  1. Emergency Department Nursing

It was not considered to be within the remit of this group to consider emergency nursing, except where those with a nursing qualification take on an autonomous enhanced role as outlined below. However, the group did identify the relatively high turnover of staff in this general group and an increasing dependence on agency staff in many EDs.

  1. Mid-level non-doctor clinicians

It is increasingly clear that there are many practitioners undertaking a role in the ED but who are not themselves doctors. Such roles have been developed in many UK hospitals and of course also world-wide. They have the potential to provide a hugely important ‘ballast’ of professional continuity within the ED, reducing the turmoil resulting from the rapid turnover of junior doctors in training. If substantial numbers are employed, the continuity and quality of care would be improved. In addition, the quality of education for juniors could enhance, allowing them to focus on their learning needs (‘deliberate learning by doing’) rather than only the needs of the service (‘serendipitous learning while doing’). Such clinicians also bring a great deal of experience to their role since they tend to stay in place for some years (e.g. UK Advanced Clinical Practitioners (ACPs) and US Physician Associates typically stay in a single specialty for over 8 years3). Such mid-level clinicians may be drawn from nurses (e.g. ENPs), other practitioners (e.g. ACPs) or could be new to the clinical world (e.g.PAs).

Fig 2. shows the ‘flow’ of junior doctors at various stages of training as they ‘pass through’ the core ‘medical’ workforce: most direct care is delivered by junior doctors, SASG and Specialty doctors and, increasingly, non-medical clinicians and the diagram demonstrates the delivery of care as well as the role of the junior doctors, and the supervision delivered for those in training by the permanent members of the workforce, including senior specialty trainees, SAS doctors and consultants.

3American Academy of Physician Assistants. National physician assistant census report: results from AAPA’s 2009 census. Alexandria:AAP,2010.www.aapa.org/uploadedFiles/content/Common/Files/National_Final_with_Graphics.pdf[Accessed 5 January 2012]. 

  1. Emergency Nurse Practitioners

During the past 10-15 years, the role of Emergency Nurse Practitioners in emergency

/urgent care has developed and matured. Most EDs now have an ENP service and ENPs tend to be the mainstay work force in Minor Injury Units, Urgent Care Centres and Walk in Centres. In many EDs this contribution has been predominantly in providing high quality safe care for patients presenting with less serious injury or illness. There is a good evidence base that those with appropriate training do provide a very safe and effective minor injuries service. Unfortunately, training and degree of autonomy have been variable. However, the move to an all graduate nursing profession in 2013 has been an impetus for nurses particularly ENPs to achieve graduate status particularly in the sphere of emergency nurse practitioning.

The Taskforce feels there needs to be a consistent definition of what an ENP is as well as their scope of practice and training requirements. There need to be mechanisms developed so skills are transferable between NHS organisations.

    1. Consultant Nurses

The role and numbers of Consultant Nurses in EDs has increased, there are now in excess of 50 nurses employed in this role throughout the UK. While the role has 4 specific core functions including clinical practice, there are variations in role and scope of these posts in terms of advanced clinical practice. Future Consultant Nurses are likely to be drawn from current ACPs who possess an advanced clinical focus that will enable them to work at an intermediate tier and beyond. This group of staff are well placed to manage the increasing body of ACPs and ENPs within many EDs. They will obviously work closely with Emergency Medical Consultants who will have overall responsibility for the service and will contribute to greater consistency in terms of clinician workforce planning.

    1. Advanced Clinical Practitioners

In recent years, Advanced Clinical Practitioners (ACPs) have developed skills and competencies in providing care for more seriously ill and injured ED patients. They come from a variety of backgrounds. The most effective schemes train them to see the whole range of patients presenting to the ED. There has been a proliferation of this type of role in an unknown number of EDs across England. The high volume high- risk nature of undifferentiated patients presenting to the ED mandates absolute certainty with regard to the skills and competences of any clinicians working in all areas of the ED as it does for doctors.

It is crucial that development of the ACP model is underpinned by the following:

      • An emergency care workforce profile

      • A national curriculum

      • Nationally agreed standardised assessments

      • Standardised assessments and competence across disciplines working at this level of practice

      • Defined role and scope of role and lines of accountability

      • Nationally agreed indemnity for the role

      • Nationally agreed remuneration for the role

Representatives of RCN, FEN, Emergency Consultant Nurse Association (ENCA), College of Emergency Medicine and Department of Health are currently exploring these issues. The curriculum and assessments developed by the College of Emergency Medicine provide a proven template with some transferable commonality to the ACP agenda.

It is crucial, however, the group developing the ACP model explore the role and scope of such practitioners, which will be applicable to the generality of EDs.

The general principle should be that ACPs work with and complement the senior medical workforce, interacting closely with the Emergency Medicine Consultant.

Where individuals have greater experience or wish to enhance their core ACP skills, then specific additional training maybe arranged. This would ensure that those ACPs who so wish are allowed to fulfil their potential, whilst ensuring that the greater body of ACPs provide high quality safe care within their scope of practice.

ACPs should therefore be regarded as a crucial part of the ED clinical team of the future.

Further work should be undertaken to develop the ACP role, this includes:

  • Develop a nationally applicable curriculum, competences and assessment framework.

  • Achieve consistency with regard to the clinical role.

  • Describe the boundaries of such practice in the generality of Emergency Departments.

  • Define the likely timescale for a widespread implementation.

  • Undertake piloting to define the evidence base for this initiative.

  • Develop an evidence base for the role.

To develop an effective ECP will take three years of training and then a period of two years of mentorship, building on a previous background of specialist skills in nursing or an AHP.

  1. Physician Associates(PAs)

The situation regarding Physician Associates (PAs) is analogous to that of ACPs described above.

The role of PAs in the ED has been impressively developed in North America, for example a typical ED staffing, such as at Johns Hopkins, involves approximately 12 PAs, 3 FY1/2s equivalents, 5 specialty trainees and 8-9 consultants. (Personal communication, T Ritsema, PA-C, Assistant Professor, George Washington University.)

The optimal contribution of PAs to the ED is by working under the supervision of a senior EM doctor undertaking a range of activities contributing directly to patient care. This model provides a defined scope of practice with an invaluable contribution to the overall provision of patient care. The senior EM doctor benefits from being able to allow the PA to practice within their skills and competences, thus freeing up the EM doctor to care for other patients.

PAs are currently working in a number of UK EDs (City Hospital, Birmingham; Dudley Group of hospitals; Northwick Park; Leicester Royal Infirmary; Kingston Hospital; Mid Staffordshire; Hairmyres Hospital (Lanarkshire); Derby Royal Infirmary will advertise posts shortly.

PA training programmes last 2 years and the Taskforce identified that University- based programmes can be established and a new cohort of students recruited within a very tight time frame of less than a year. Programmes follow a national curriculum and graduates have to pass a national assessment. PAs are expected to join a managed voluntary register, and to undertake re-accreditation every 6 years (as per the US model for PAs and indeed doctors). Thus, PAs development is one of the workforce measures that could be introduced most quickly.

The Taskforce identified that there is no current defined responsibility within DH, or elsewhere, to support the further development of PA training programmes within England despite increasing evidence that PAs can provide a high quality contribution to patient care, and mounting support from doctors working in a number of specialties including EM, physician specialties, mental health, family medicine and surgery. The Taskforce recommends that Health Education England looks actively at promoting this new pluri-potential health professional discipline.

EM Professional

Implementation Time


Immediate if they can be recruited.


Approx. 3 years


Approx. 3 years


3-5 years, dependent on level of experience


5-12 years

  1. Reconfiguration

It is recognised that having an increased number of specialists in one location allows more patients to be seen by senior clinicians earlier in their care. It also gives those clinicians more exposure to serious illness and hence improves their competences and abilities; this underlies the rationale for hospital reconfiguration.

Given the ED workforce shortages and the current era of tight financial constraints, the potential opportunities provided by reconfiguration demand consideration.

There is a view, given the pressures on both primary care and EM services to meet unscheduled demand, that the system should consider reconfiguration in the form of integrated emergency or unscheduled care services working across primary and secondary care, for which doctors (from EM and GP backgrounds) and other clinicians would be trained to the same standard and accredited. The key to this model would not just be the accredited clinicians, but even more crucially the development of community and social resources, which would provide alternative options for care other than acute hospital admission, access to rapid specialist assessment when necessary.

Decisions regarding the reconfiguration agenda are complex and involve triangulation of the views of the profession regarding safety, of the public regarding access and the political dynamic but there is a clear urgency if services for patients are to be maintained.

  1. Market-Facing-Pay/Terms-and-Condition

Market facing pay and adjustments to terms and conditions can, in certain circumstances, improve recruitment and retention in unpopular working environments (specialty and/or geography). However, market facing pay in the current circumstances, of significant and sustained workforce undersupply, will simply drive up costs without fundamentally addressing the problem of maintaining comprehensive service provision.

In the longer term, this area may well need to re-considered as it could be part of a package that would make EM a more popular career choice for a number of professional groups, and in particular doctors. There is some experience of the positive impact this can have from Australia.

  1. Summary of Recommendations of group

  1. An increase in Emergency Medicine Consultant numbers to ensure a consultant presence for 16 hours a day, 7 days/week in all Emergency Departments and 24 hours a day, 7 days/week in larger departments or Major Trauma Centres.

  1. Work with the CfWI to explore workforce modelling in EM.

  1. EM trainee numbers should be carefully calibrated to support continued Consultant expansion.

  1. Early exposure to the EM component within ACCS core training to improve early experience and improve MCEM pass rates.

  1. Develop alternative routes into EM training for trainees currently in other specialty programmes.

  1. Explore the recognition of transferable competences of trainees currently in other specialities to increase the pool of trainees eligible to apply for EM training at a level higher thanCT1.

  1. Support Associate Specialist and Staff Grade Doctors (Specialty Doctors) in their roles to ensure retention and increase work satisfaction. Measures to achieve this should include:

    • Job planning to avoid unsocial hours’ predominance and enhance support for CPD.

    • The College of Emergency Medicine will look to ways of supporting the development of this group using the College curriculum and assessment systems.

  1. GPs could be invited to consider the following options:

    • Ensuring prompt access to community Urgent Care for as much of the 24 hour period each day as possible, improving access available in the evenings and at weekends.

    • GPs could provide Primary Care expertise in a facility co-located with the ED.

    • GPs could work with the ED team to facilitate discharge of patients back to community facilities.

    • Those GPs who wish to develop Emergency Care skills as a special interest should be encouraged to acquire skills and competences as agreed by the RCGP and CEM.

  1. Expand training of clinical nurse specialists and PAs, and define their roles. It is clear that the day-to-day delivery of ED care will require significant expansion of the non-medical clinical workforce. No formal estimates have been performed but given current issues re: delivering care, the Taskforce recommends that there is a need for at least 10 such higher specialty trainee and SAS rota clinicians per ED. To ensure consistency, development of the roles of each of these groups should be underpinned by:

    • A national curriculum for ED-specific competencies

    • National Standards for skills and competencies

    • National Assessment framework

And the working group also recommends that the College supports such developments.

  1. There is a real urgency about the ED workforce crisis, and these recommendations need to be enacted urgently. For PAs, core generalist training takes two years, and universities need up to a year to initiate programmes. Thus, a recommendation to use PAs within ED needs to be made quickly so that new graduates will be available from summer 2014, and can then undertake post-graduate training and provide a significant impact on the ED workforce by say mid-2015. In addition, many PAs taking a generalist PA course will not enter ED, thus significant numbers of PA courses need to be instituted as soon as possible. Lastly, PAs are not statutorily registered and thus cannot prescribe not order x-rays, both of which are clearly significant barriers to their effective implementation. Registration with HPC would solve this problem quickly.

18. Actions underway:

  1. CEM and GMC are working together to develop a Run-through training programme and facilitated entry into EM training.

  1. Work with ACCS colleagues in anaesthesia and acute medicine to consider-ordering the training programme to provide earlier experience in the main specialty.

  1. Training and assessment review and development of alternative training and assessment system that is now ready for consideration by the GMC.

  1. CEM and DH colleagues working with colleagues in advanced nursing and PAs to support development of curricula and assessment systems.

  1. Research and piloting to demonstrate effectiveness and provide the evidence base for clinical and cost considerations of recommendations.

  1. East Midlands Deanery/LETB held a half-day symposium in July 2012 to look into the issues faced by the specialty in the area. The symposium brought together stakeholders to share information and solutions that were being implemented to address recruitment, retention and progression of a multi- professional workforce in speciality.

  1. The issue of provision of a workforce to deliver Urgent and Emergency Care is the focus of the Academy (7/7 working group) and the RCP (Future Hospital Commission).

  1. DH survey of the Emergency Department workforce.

  1. CEM Dashboard exercise which includes staffing, training and commissioning.


  1. Guidance for commissioning integrated Urgent and Emergency Care: Royal College of General Practitioners August2011.

  1. Guidance and competencies for the provision of services using practitioners with special interests – Urgent and Emergency Care RCGP2008.

  1. The Benefits of Consultant Delivered Care: Academy of Medical Royal Colleges January2012.

  1. Developing and Emergency Care Workforce for the Future: The Nursing Contribution – discussion paper Royal College of Nursing January2012.

  1. Reorganisation of ACCS Emergency Medicine Elements – EMTFG Subgroup.

  1. Emergency Medicine Operational Handbook – The Way Ahead. College of Emergency Medicine December2011.

  1. College of Emergency Medicine and Department of Health Taskforce Group National Survey of Emergency Medicine Trainees 2011 – Trivedy and Jenkinson January2012.

  1. Emergency Medicine Competencies Subgroup Report – EMTFG January2012.

  1. Reconfiguration of Emergency Care System Services – College of Emergency Medicine Position Statement January2012.

  1. The development and potential of mid-grade non-doctor clinicians to deliver safe ED care in the context of a Consultant Led Service – Peter Chessum and Gary Swann, Jim Parle February 2011, modified July2012.

Appendix 1

Emergency Medicine Taskforce Membership:

Prof. David Sowden – (Chair) Director of Medical Education (England), METP, DH John Heyworth – Immediate Past President, CEM

Patrick Mitchell – Director of National Programmes, METP, DH Joanne Marvell – Specialty Recruitment Manager, METP, DH Alison Carr – Senior Clinical Advisor, METP, DH

Mike Clancy – President, CEM

Helen Cugnoni – ACCS lead for Emergency Medicine

Andrew Fraser – Policy Support Officer, Urgent and Emergency Care, DH

Prof. Matthew Cooke – National Clinical Director, Urgent and Emergency Care, DH Colin Holburn – Consultant in Emergency Medicine, fellow of CEM

Prof. Robert Crouch, Consultant Nurse, University Hospital Southampton NHS Foundation Trust Jim Parle – Professor of Primary Care, Physician Assistant Course Director, University of Birmingham

Gary Swann – Consultant Nurse, Emergency Care Directorate (HEFT) Tim Yates – JDC Representative, BMA Junior Doctors Committee

Peter Chessum – Advanced Clinical Practitioner, Heart of England NHS Foundation Trust Agnelo Fernandes- Representative, RCGP

Alison Graham – Chair, Scottish Association of Medical Directors Mike Jones – Vice President, RCP, Edinburgh

Prof. Moira Livingston – Commissioning Director, CfWI Barry Lewis – Chair, COGPED

Don MacKechnie – Representative, CEM

Bill McMillan – Head of Medical Pay and Workforce, NHS Employers Prof. Gillian Needham – Postgraduate Dean, NES

Trish O’Conner – Emergency Medicine Consultant, Hairmyres Hospital Emma O’Donnell – Senior Policy Manager, DH

Sarah Parsons – Medical Workforce Manager, NHS Employers Chris Roseveare – President, Society for Acute Medicine Caroline Shaw – Chair, FASSGEM (EM)

Garry Swann – Consultant Nurse, RCN Stephen Timmons – Lay Representative, CEM Chet Trivedy – Representative, CEM

India Peach – Project Support Officer, METP, DH

Previous chair

Patricia Hamilton – Former Director of Medical Education England, Department of Health

#62. Snowflakes, please read the writing on the wall…

…the writing that’s been there, in plain sight, for YEARS!

So many people with so much to say and all saying it through their backsides, especially the intensely irritating ‘Save Our NHS’ who have so much to say, all of it selectively picked from articles that support the arguments of its “spokeperson” and which she uses to reinforce the prejudices of her unquestioning supporters.

Well, to balance the argument – insofar as there is any room for argument in the face of the facts – I present two articles taken from the Shropshire Star of three years ago.


PUBLISHED: May 14, 2016 07:59

Future Fit: Doctors defend plans for having one A&E in Shropshire

Having one A&E department in Shropshire will mean patients are cared for in the “right place at the right time”, according to senior county doctors.

Consultants from the Shrewsbury and Telford Hospital NHS Trust have said plans for how hospital services will work in the county in future will provide the best care for patients.

It comes after the county’s two clinical commissioning groups threw plans for the future for the region’s two main hospitals into chaos when they failed to agree on whether to back the strategic outline case for Future Fit – the programme in charge of the review into hospitals in Shropshire.

The outline plans suggest one single A&E unit supported by a network of urgent care centres, one diagnostic and treatment centre and local planned care on both the Royal Shrewsbury Hospital and Princess Royal Hospital sites.

No decisions have been made and several options are suggested in the strategic outline case, which is effectively the first stage of the project.

Mark Cheetham, consultant general and colorectal surgeon and scheduled care group medical director, said: “One emergency department doesn’t mean worse access to healthcare. In fact, it would mean greater access to the right people in the right place at the right time. This is better for our patients.

We need to be brave and we need to look at ways of providing the best care for our patients in a sustainable way in the long-term. This isn’t about what is right or easy for us. And it’s not only about what is good for our communities today.

This is a long-term plan which is about providing the best care for our children and our children’s children.

The SOC is a further step forwards towards the development of better health services for Shropshire, Telford & Wrekin and mid Wales.

I have seen at first-hand the benefits that consolidating services can bring. In emergency surgery – which was consolidated on the Royal Shrewsbury Hospital site in 2012 – for instance we now have a team of 11 surgeons who specialise in abdominal surgery.

There is always one consultant free from all other activities to provide emergency care for our patients. The result has been a thriving large department of surgery with improved outcomes.

“I believe that by co-locating key services in an emergency centre, we will be able to provide safer, better care for patients who are seriously ill or injured. “Developing a separate diagnostic and treatment centre will allow us to provide better care for patients having planned surgery with an improved patient experience and a reduced chance of cancellations.

There is much more work to do as we refine our thinking and further develop these plans; I feel it is a positive start that will help to provide the best care possible for our patients whilst resolving some of the issues we face.

The easiest thing in the world would be to do nothing. That would be dangerous.”

“These plans are about ensuring patients now and in the future have the best access to the best medical staff in the best place when they need it, and I fully support that move.”

Dr Kevin Eardley, consultant renal physician and unscheduled care group medical director, added: “The strategic outline case describes options that will improve current hospital services ensuring that the sickest of our patients have access to better emergency, urgent and critical care services.

The reconfiguration of health services between hospitals has been observed locally already for the benefit of patients.

Patients from our region who have sustained major traumatic injuries currently travel to major trauma centres in Stoke or Birmingham. Patients who have serious or life-threatening heart attacks already go directly to Stoke or Wolverhampton.

In recent years at SaTH we have already made successful changes – children with severe illnesses are cared for at the Princess Royal Hospital and patients with major surgical illnesses are cared for at the Royal Shrewsbury.

The driver for these changes has been to improve access to the very best possible care and therefore improve the chances of a full and quick recovery.

Improving access to specialist services requires clinical pathways that direct patients to the most appropriate service where they will be cared for by specialist teams made up of a workforce who have come together, grown their expertise, and are therefore better able to deliver the very best possible care for generations to come.


Friday 20 May 2016

We, the undersigned Emergency Medicine Consultants, would like to take this opportunity to clarify our views on NHS Future Fit, The Shrewsbury and Telford Hospital NHS Trust’s (SaTH) Strategic Outline Case (SOC) for its Sustainable Services Programme, and the portrayal of “Accident and Emergency” in the media. NHS Future Fit and the SOC are an attempt to redefine high level medical care to the population that we serve.

We know that having all the services a patient requires on the same site improves the care delivered to that patient and the clinical outcome. We already send patients with major injuries or who have had heart attacks to Royal Stoke University Hospital. These patients have a lower risk of dying and an increased quality of life after being discharged. Within SaTH we have already concentrated emergency surgery onto one site in Shrewsbury and this has led to better outcomes. We now have a death rate below the national average. Acute stroke services are on one site in Telford and again this has improved the care and quality of life for patients who have suffered a stroke. Concentrating the paediatric inpatients at one site in Telford has increased our ability to recruit and retain high quality medical staff, which is better for our patients.

We acknowledge concerns about the increased transport time for patients. However, whilst getting a patient to hospital quickly is important, it’s more important that patients are seen in the right place, by the right person as soon as possible. A bigger more specialist site will mean more high quality staff, meaning patients can be seen by the right person much more quickly.

It’s all very well saying that we should employ more people at our sites, but the fact is our Emergency Departments are not attractive because they are small, with staff preferring to work in bigger state-of-the-art units. A single but larger Emergency Centre will help us to recruit.

At present the majority of patients who present to our A&E do not actually need to be seen there and would be equally well treated in an Urgent Care Centre/Minor injury Centre (e.g. cuts, fractures, stitches etc), which would remain at both sites if the SOC moves forward to Outline and then Full Business Case, as we hope. People would be seen, diagnosed and treated with local follow-up arranged, if required. The proposals would ensure that a high quality service is provided on both sites for the majority of patients who don’t need treatment in an A&E and the remaining patients would be cared for in an Emergency Centre. The Emergency Centre would be able to deliver high quality, life-saving care through a dedicated Emergency Team well supported by other relevant specialities.

Having one Emergency Centre would allow the Trust to ensure there is always one of our own senior doctors present 24-hours-a-day, seven-days-a-week to deliver care compared to the current situation of locum doctors more frequently delivering the care.

This model would also help to keep services in the area rather than moved to the bigger centres in Stoke or Wolverhampton. In addition, it would allow the Trust to be at the forefront of medical research, which it cannot currently do with the present configuration.

Following consultation with colleges from across the region, the ability to recruit and retain experienced, highly skilled staff would be increased – ensuring our patients receive the safest and kindest care possible in the county, rather than having to travel outside of Shropshire and Telford & Wrekin.

Doing nothing is not an option. The current model is not sustainable and change is needed. We must ensure patients now and in generations to come have the best services possible.


Mr Subramanian Kumaran FRCS, FRCEM, Consultant and Clinical Director for Emergency Medicine

Dr Adrian Marsh FRCEM

Consultant and Clinical Lead for Emergency Medicine, The Shrewsbury and Telford Hospital NHS Trust, Royal Shrewsbury Hospital, Mytton Oak Road, Shrewsbury, SY3 8XQ


Princess Royal Hospital, Apley Castle, Telford, TF1 6TF




See also #53; #54; #56

The direct impact of the promotion of the ‘preferred sites’ on Highley.

The realisation of the potential impact of the ‘review’ of Shropshire’s Local Plans (supposedly reflecting the aspirations of local communities within parameters established by national and county policy) started with this email, received Friday, June 15, 2018.

The consultation exercise was part of the Local Plan Review and was promoted by planners as an information gathering exercise, at no time during the meeting that followed was preference for any site considered because, we were told, that would form part of the later “consultation” process.

What we didn’t fully appreciate at that time was that to planners “consultation” means something entirely different to what most people understand to be consultation. [See: #53: How Do Planners Get Away With It?]

The letter Highley parish council received said:

Meeting to discuss Shropshire Local Plan Review – Preferred Options for Site Allocations in Highley

As you are aware, Shropshire Council recently consulted on the Preferred Scale and Distribution of Development as part of its review of the Local Plan. The next stage of work involves the identification of preferred site allocations for Shrewsbury, the market towns and the key centres, [Highley is classified as a Key Centre in planning terms] together with the preferred scale of growth, development boundaries and potential allocations for Community Hubs. We hope to publish these preferred options for consultation in October 2018.

To inform this stage of work, we are assembling relevant information for all settlements which we are proposing will be identified as locations for development in the new Plan (this includes Shrewsbury & the market towns) so that we can arrange a focussed discussion on the key issues. The growth guidelines which we have identified for housing and employment land for Highley within the Preferred Scale and Distribution of Development consultation, will require approximately 4 hectares of additional housing land and 1 hectare of additional employment land to be allocated.

Shropshire Council has undertaken an initial strategic screening of development sites around Highley in order to discount those sites which are unavailable and/or wholly unsuitable. I have attached a map and accompanying table showing the remaining sites which have been promoted to us by landowners (only a small proportion of which will actually be required). This information is currently confidential and should not be shared more widely at this stage. More detailed assessments, including analysis of landscape and visual impacts, are currently being undertaken and these will help to identify constraints and opportunities associated with the remaining sites, which, alongside views from the local community as expressed through the Town Council will inform the site allocation process.

The irony of the planner’s use of the term “preferred site” seemed to have passed them by, because that last sentence clearly implies that whilst the identified “preferred” site is identified as the preferred option, the planners go on to say that the word “preferred” should not be taken to mean what everyone else thinks it means – that using the word does not indicate a preference.

Question a planner on this and you’ll get a blank look because they simply will not see what they’re doing here, and they certainly won’t get your confusion at being told that the word “preferred” doesn’t actually mean exactly what you’ve always taken it to mean – that something is favoured over any alternatives on offer.

It’s necessary to explain all that because the planning department’s take on the English language is unique and, together with “preferred”, their understanding of what constitutes “consultation” will also require a fair bit of effort to get your head around. It’s as well to be prepared and that earlier reference to an earlier blog article will help. [See: #53: How Do Planners Get Away With It?]

In the following article, the question I’m posing is: how does the way Shropshire Council planning department’s approach to “local engagement” relate to principles laid down as far back as 1969.

The Skeffington Report, ‘People and Planning. Report of the Committee on Public Participation in Planning’, prepared by Arthur Skeffington MP was published in 1969 so planners have had plenty of time to get their heads around it.

Until the Skeffington Report, planning had been a largely ‘top down’ system, consultation had been a gesture only, involving those already familiar with the planning process and how to participate, resulting in poor community involvement.

The Skeffington Report proposed that local development plans should be subject to full public scrutiny and debate. Planners were supposed to become more pro-active and ‘hard to reach’ parts of communities become better engaged as part of a “genuinely democratic process”, working towards consensus between a wide range of competing interests.

Those lessons appear to have been forgotten, at least by that part of Shropshire Council’s planning department responsible for the current Local Plan Review.

Shropshire Council’s approach to consultation gives rise to concerns about effective community engagement with the planning system, which can be complex, remote, and generally difficult to engage with, negative factors planners often do nothing to mitigate because the status quo works to their advantage!

As the Rt Hon Nick Raynsford MP said following the recent review of the planning system he undertook in 2018:

“We ignore at our peril the anger and disaffection felt by so many communities at the failure of current planning policies and procedures to listen to their concerns and respond to their needs”.

Well, someone doesn’t mind a bit of peril because very little has changed in the interim and it’s arguable that things have actually got worse!

How much worse for Highley?

The map accompanying the letter we got from Shropshire Council setting out Shropshire Council planning department’s intentions identified seven sites, two of which had been the subject of earlier applications for Outline Planning Permission, one had been withdrawn for unspecified reasons – the agent acting for the landowner in that case had been Helen Howie (see blog #56: Planning: The Failed Process or The Curse of the NPPF, a community nightmare) – the other (HNN014, see map below) had been refused, the details of which I set out later in this text.

[Taking advantage of the newly-acquired ‘preferred site’ status, HNN014 subsequently reappeared as an application for 20 ‘affordable’ houses, a development that was refused as ‘over-development’ See Appendix.]

The earlier history of the preferred site.



Look closely at that location map above, in the centre at the top you’ll see “Hazelwells”, a Grade 2 Listed building, the preferred site falls within the curtilage of that historic local asset Hazelwells Hall!

You will also notice that the left hand (western) boundary of the preferred site is indented because 20 years ago, householders on Yew Tree Grove, whose properties overlook the field, bought a 25 yard strip to extend their gardens.



The householders on Yew Tree Grove applied to get the strip of land changed from Grade 3 Agricultural land to Residential but Bridgnorth District Council (BDC) placed an order called an Article 4 Direction on the whole of this site…

An article 4 direction is made by the local planning authority. It restricts the scope of permitted development rights either in relation to a particular area or site, or a particular type of development anywhere in the authority’s area. Where an article 4 direction is in effect, a planning application may be required for development that would otherwise have been permitted development. Article 4 directions are used to control works that could threaten the character of an area of acknowledged importance, such as a conservation area.

Article 4 directions can increase the public protection of designated and non-designated heritage assets and their settings. They are not necessary for works to listed buildings and scheduled monuments as listed building consent and scheduled monument consent would cover all potentially harmful works that would otherwise be permitted development under the planning regime. However, article 4 directions might assist in the protection of all other heritage assets (particularly conservation areas) and help the protection of the setting of all heritage assets, including listed buildings.

[Historic England: Restricting Permitted Development: Article 4 Directions and Heritage]

ANY development by those householders, regardless whether that “development” took the form of a greenhouse or raised vegetable beds, was forestalled by Bridgnorth District Council planning department’s Article 4 Direction placed on the WHOLE FIELD.

Not to be outdone, the house owners on Yew Tree Grove did eventually go to the expense of getting the Article 4 Direction overturned on the strip they’d purchased, had they not then every household would have had to apply for separate planning permissions to erect any “structure” (however loosely defined) on their individual plot.

Crucially, that Article 4 Direction remains in force on the rest of the field to this day.

The senior planning officer for Bridgnorth District Council at the time issued additional guidelines that precluded any further development on the WHOLE of the eastern ridge of the ‘plateau’ that Highley sits on, to preserve the skyline as viewed across the Severn Valley. That senior planning officer was Ian Kilby, current head of planning at Shropshire Council who said…

The view of the Bridgnorth Office is that we would prefer not to see more development on the eastern side of the village – i.e to not add to existing development on the western ridge of the Severn Valley or the upper slopes to the western side of the village. We consider therefore that any allocations should be on land to the south/southwest on the basis of landscape impact.”

The blighted alternatives.

There are a number of realistic alternatives to Shropshire Council planning department’s preferred site, but one in particular offers a solution to a long-standing problem on the main road through the village – the rat run down the Hazelwells estate road to avoid being stuck behind the 125 bus in either direction as it travels along Clee View Terrace, the terrace of houses shown in the centre of the Google Earth image below.

There is a bus stop opposite the middle house in the row (under the large tree in the image). With cars parked on the road immediately outside the houses the road becomes a single carriageway, so if there is a bus there you have to wait until it clears Clee View.

Clee View bus stop and rat run via Hazelwells Road…


Coming from the northern Bridgnorth direction, in anticipation of that hold up vehicles choose to turn left off the B4555 and travel down Hazelwells Road to its southern junction with the B4555, the route shown shaded running vertically down the middle of the image below.


This site offers the solution…

… Woodhill, obscured by the ‘HNNO19’ label, to the left of Clee View terrace.

The schematic drawing below shows one design for the site. The block shown away from the separate dwellings (bungalows) is a residential block for nursing the elderly and infirm.


The design is an indicative illustrations only and subject to change following detailed discussions with the landowners, their architect, and the planners, but it’s an idea of what COULD be done.

The bus stop is to the right of the word “Shelter” and the area roughly drawn in outline is the area where off-road parking for Clee View residents could be sited, together with an off road pull in for the 125 bus.

The bonus offered by this alternative site is the employment opportunity offered by the sheltered retirement housing, a significant economic benefit to Highley.


The following Appendix is particularly useful in demonstrating how advisory comments can be ignored by both developers and by the planning officers that make them.

A planning application for the smallest of the preferred sites (HNN014) for TWENTY two-storey ‘affordable houses’ has recently been submitted. An earlier application had sought to build NINE bungalows.

The earlier application for bungalows was refused planning permission in 2016 and was taken to appeal on the grounds of non-determination because of delays by Shropshire Council in processing the application. The application was then refused for the following reasons:

1. Insufficient information has been provided to enable the Local Planning Authority able to conclude that the proposal will not cause an offence under the Conservation of Habitats and Species Regulations (2010), the scheme as such is contrary to National Planning Policy Framework and Shropshire Council Local Development Framework Core Strategy CS17.

2. In the absence of the agreement to make a contribution towards affordable housing provision, the proposed dwellings would be contrary to Policy CS11 of the Shropshire Council Local Development Framework Core Strategy and to the Council’s Supplementary Planning Document on the Type and Affordability of Housing.

(Officer’s report to the South Planning Committee.)

My own view as the Local Member was that whilst the application for nine bungalows was a reasonable use of the plot (because relatively low profile in terms of its visual impact), I shared both the parish council’s concerns about the site falling outside the established development boundary and the serious concerns about access to the site off the busy B4555, otherwise it would have met a local need for such housing.

On notice of the appeal, Shropshire Council’s report (subsequent to the earlier officer’s report to the South Planning Committee) was submitted because…

2.1 An appeal has been lodged against non-determination of this application and the decision now rests with the Planning Inspectorate. However the Council is required in the appeal process to indicate what its decision would have been if it still had authority to determine the application.

2.2 The application is presented to committee as the Parish Council has submitted a view contrary to officers and the application has been requested to be referred by the Local Member.

That report went into considerable detail to explain how the development of nine bungalows would have a moderate-to-low impact, both aesthetically and in terms of its impact on the local infrastructure, Shropshire Council’s own planners were of the opinion that whilst…

Highley is identified as one of the key centres in Policy CS3 of the Core Strategy. This establishes the principle of Highley as a sustainable location for new development. The application site in particular is located within walking distance of town centre services and facilities (the town centre around 500m from the site boundary) and is within close proximity to the Severn Centre. It is considered that in these respects there are clear sustainability credentials to the site which must be weighed up when determining the application.

…it should be noted that…

Sustainable development’ isn’t solely about accessibility and proximity to essential services. The NPPF states that it is ‘about positive growth – making economic, environmental and social progress for this and future generations’. In paragraph 7 of the NPPF it states that these three dimensions give rise to the need for the planning system to perform a number of roles:

an economic role – contributing to building a strong, responsive and competitive economy, by ensuring that sufficient land of the right type is available in the right places and at the right time to support growth and innovation; and by identifying and coordinating development requirements, including the provision of infrastructure;

a social role – supporting strong, vibrant and healthy communities, by providing the supply of housing required to meet the needs of present and future generations; and by creating a high quality built environment, with accessible local services that reflect the community’s needs and support its health, social and cultural well-being; and

an environmental role – contributing to protecting and enhancing our natural, built and historic environment; and, as part of this, helping to improve biodiversity, use natural resources prudently, minimise waste and pollution, and mitigate and adapt to climate change including moving to a low carbon economy.[6.1.15]

Significantly, the original committee officer report referenced the contextual factors that are supposed to be at the heart of a “plan-led planning system”.

It is not considered necessary or appropriate to [seek] additional sites outside of the Highley development boundary in an area of open countryside, and this would be contrary to the development strategy for the area. A core planning principle in the NPPF is that development should be genuinely plan-led, empowering local people to shape their surroundings, and this is what the recently adopted SAMDev Plan [Shropshire Council’s long term development plan] has achieved, providing a practical framework within which decisions on planning applications can be made. The use of this land for residential development would undermine the NPPF’s objective of a Plan-led approach to development.

The presumption in favour of sustainable development that runs through the NPPF is a relevant material consideration, but it is not considered that this ‘presumption in favour’ should outweigh the significance and primacy of the up-to-date development plan policies in making decisions. On balance, it is considered that the proposal would not be acceptable, being contrary to Policies CS3, CS4 and CS5 of the Core Strategy, and SAMDev Policies MD1, MD3, MD7a and S9.

The promotion of Shropshire Council planning department’s preferred sites blows a hole through all those clearly expressed reservations about the earlier application for the development of the site HHN014, the smaller of the two sites comprising the preferred development area identified by Shropshire Council.

According to Shropshire Council’s figures, the two sites HHN016 and HHN014, are scheduled to take a development of 122 dwellings, despite the reservations expressed over the earlier 2016 application for “just” nine bungalows.

The more cynical among us saw the recent application for 20 affordable two-storey houses as an ill-disguised attempt to sneak in a larger development on the back of the clearly expressed Shropshire Council preference for this, a suspicion that was confirmed in the albeit brief conversation I had with the developers of those 20 two-storey houses at their ‘public exhibition’, the preferred status actually being cited to confirm the “local need” for “such a development”.

It was also clearly inferred that their decision to apply for planning permission was AFTER discussion with Shropshire Council and so I was doubly gobsmacked that, given the history of the site, they still went ahead with an application that was subsequently refused as “over development”!

And Shropshire Council are giving the go-ahead for 122 dwellings regardless of the consequences. Why? Because they can point with one finger to a site that meets in one go what Shropshire Council planning department has determined to be Highley’s contribution to meeting the county’s housing quota until 2036.

That’s why.