From Casualty to Emergency medicine:

The history of Training in Emergency Medicine UK

“You have to understand the past to know

the present” Carl Sagan

50th Anniversary RCEM

Chris Maimaris
MB ChB, FRCS, FFAEM, FRCEM
 1950s: 800 casualty areas -OPD
• Hospitals dominate
• Medicine and Surgery
• Inpatients and OPDs
• Surgery: GS, trauma+Ortho
• Medicine : Ditto

• General practice infancy

• College GP 1952
• RCS, RCP, RCO&G
• Faculty Anaesthetists RCSEng
Platt Report 1962
 Platt Report 1962
• 800 hospitals with “casualty” departments
• Difficult provide adequate experienced staff
• Large number pts who should be Rx by GPs
• Need a service for seriously injured +RTAs
• New name: “Accident Emergency”
• Reduce number departments
• Consultant surgeons to supervise
 1970s
• 1967: CSA- Casualty Surgeons association

• 1970-75 pilot 30+ A&E Consultants

• Specialist Advisory Cmt in A&E at RCP: 1st SR 1978
• 1977: 109 consultants – 60% higher qual.- FRCS
• BMA concerns: moratorium new appointment
• BMA Lewin Report 1979
 BMA Lewin Report 1979
• Pilot is successful
• Well organised A&E care
where consultants present
• A&E cons work better if
surgeon and physician
• Establish and expand SR
training
 1970’s New Addenbrookes 1972
Birmingham

Accident Hospital
 PG Training Structure 1980-1995

HO, SHO, Registrar, Senior Registrar grades

Parent college issues certificate

Higher Specialist training

1+5+5= 10+ years
Approved A&E SR post
SAC A&E advice re: 3yr
Senior Reg posts (+A&E Registrar =2yr)

postgraduate diploma General Professional

Colleges: FRCS, MRCP, Training: Med, Surg,
other SHO/Reg - 5 years

Pre-registration year
My Training 1980-91
• 5 yrs HO+SHO
• 2.5 yrs Registrar
• 3.5 yrs SR
• 12 hospitals
• FRCS Ed
 1980s:
• 1983 First diet of FRCSEd (A & E) - became MRCSEd (A&E)
subsequently. Final diet in 2009.
• 1984 Australasian College of Emergency Medicine established
• 1986 1st International Conference Emergency Medicine London
• 1988 BAEM British Association A&E Medicine: Journal A&E M
PLUS Archives of Emergency Medicine journals.
• ATLS at RCS and ACLS
Archives of Emergency Medicine, 1988
Adequacy of senior registrar training in accident and emergency
medicine over the last 5 years
P. DRISCOLL, A. COPE & S. A. D. MILES
SUMMARY
This study investigated the limitations of the present Senior Registrar training
programmes in A&E Medicine. A completed questionnaire was returned from 46 of
the 48 Consultants who had taken up post in the last 5 years and had themselves
studied on one of the established training programmes.
The positive views of the clinical training contrast sharply with the administrative
and managerial components. Around 80% of the new Consultants had no training in
clinical budgeting or ordering equipment and only half had experience of
appointing staff and organizing locums. This is worrying as over 63% had or are
currently facing staffing problems and 69% have financial or equipment difficulties.
A more active training programme in A&E administration and management is
recommended.
 1990s
• Consultants make a difference
• Limited training capacity, budgets, output
• 250 A&E Depts to have at least 1 cons, Big EDs 2+
• Old Buildings, crowded A&Es, long waits
 1995
European Council Directive
93/16/EEC of 5 April 1993 to
facilitate the free movement of doctors and
the mutual recognition of their diplomas,
certificates and other evidence of formal
qualifications:
4 Freedoms: capital, people, goods,
services.
2nd August 1993: UK ratifies EU Treaty

Re-organisation of Specialist Training

The roles of the Specialist Training Authority,
the CCST and the GMC's Specialist Register
ORANGE GUIDE - RITAs
 PG A&E Training Structure 1996-2007

‘Calman’ system: 1995-2007

1+5+5 = 10+ years CCT

Higher FFAEM
Specialist
RITA: Orange guide to training (SpR) Training
5 years
Regional Recruitment

General
Professional MRCP, MRCS and
Local Recruitment (SHO) Training MCEM
3-5 years

Pre-registration year
 EoE 1995-97

• Curriculums and PGMDT Deans (EoE J Biggs)

• Regional Committees for HST A&E Medicine
• Chair Howard Sherriff, F/B S Shankar
• PD- Program Director -CM
 1990s:

• 1993 Inauguration Faculty A&E Medicine 6 “parent” colleges

• 1996 First specialty exam Faculty A&E Medicine (FFAEM)
• Faculty is granted coat of arms by the College of Arms
• 1998 SAC A&E Medicine under auspices of FAEM.
– Chairman Jonathan Marrow
 Audit Commission 1995: “By Accident
or Design”
• A&E care delivered
mainly by SHOs
• More Cons/Middle
Grades
• Better organisation
• ENPs
• Better SHO training
 Better care for severely injured - RCSEng 2000

Retrospective study of 1000 deaths from injury in

England and Wales BMJ 1988: I D Anderson, M
Woodford, F T de Dombal, and Miles Irving

• 24 hr CT/Image
transfer
• All ventilated pts
transferred NCCU
• Evacuation
Heamatomas <4hrs
 BAEM: ‘Way Ahead’ Reports
• Medical staffing
• Workloads
• Interfaces : GP, specialties
• Recommended minimum
staffing levels
• Consultant JP
• Training
• CDU/Observation wards
Modernisation of A&E Depts 2000
• New Government 1997: Same spending plans
• Winters 1998 +1999 critical: Long A&E waits
• Modernisation Public Services: NHS Plan: 2000
• Increase NHS Budget GDP 6% to 8%
• Modernisation Agency: NSFs, NICE, Networks
• MMC-Modernisation of Medical Careers 2007
UK medical graduates 50 years
New Consultant and GP contracts 2003
2005-07 MMC

• Abolition of SHO grade

• Foundation year FY1+2
• Run-Through training
• 7 Core Stems + ACCS
• Regional recruitment
• Implementation 2007
UK MMC Career Framework Proposal MMC 2005-07
Continuing Professional Development

Senior
Senior Medical
Medical Appointments
Appointments

Specialist and GP Registers

CCT route Article 14/11 route

Specialty training in Postgraduate Medical Training Continuing Professional Development

Specialty/GP training “schools”

Career
Specialist and GP training programmes posts
(Run-through training)

Fixed term specialist

training

Foundation training in
foundation schools

F2
F1
Undergraduate medical training
in medical school
Arrows indicate competitive entry
Medical school – 4-6 years

School of Emergency Medicine

Run-through training in Emergency Medicine 2007

CCT in Emergency Medicine

+/- sub-specialty/certification

FCEM

ST4,
ST5,
ST6
ST6
Emergency Medicine
ST5
ST4
MCEM
ST3
ST3 EM trauma & musculoskeletal or T&O
ST2
EM Paediatrics + Paediatric EM
ST1
ACCS
ST2 1 year Anaesthetic + ICU
ST1 1 year EM + AM

Competitive Entry by Interview

FY2 2+6 = 8
FY1
 Un-coupled EM CCT training 2008

CCT EM +/- Sub-specialist –

Independent specialist practitioner Post-CCT

CCT route FCEM Article 14 -CESR route

Sub-specialisation: ST4,
dual accreditation ST5,
PEM, ICM; Acute Med;
ST6 30/12 in EM
HST 3-yrs
Pre-hospital EM
up-to 6/12 relevant other

Competitive Entry ST4: Some/All CT competences

CT3 EM Musculoskeletal or T&O MCEM

2+3+3=8 EM Paediatrics

ACCS
CT2 1 year Anaesthetics + ICU 6/12 each or 9/3 Core Training 3 yrs
CT1 1 year EM + AM 6/12 each

Competitive Entry: CT1 ACCS (EM) +CT3

FY2
Foundation Training
FY1

School of Emergency Medicine

 ACCS EoE without Essex/Beds/Herts Anaesthetics/ICM
80
Emergency Med
48 48 56 62 POSTS

70 Acute Med

Other
60

50
Percentage

40

30

20

10

0
2007 2008 2009 2010
EoE: ST4 Recruitment 2010

School of Emergency Medicine

National initiative
Recruitment Initiatives 2012-17
Regional
• Expand ACCS from 14 to 43 posts
• Aim full recruited+ reduce attrition
• Re-introduce RT option 85+% of STs
• DRE-EM: 30+ posts
• Regional activities
– monthly teaching programs
– SAS TPD+ Night Safe training program
– Exam preparation MCEM and FCEM, MCEM A
– ARCPs, Workshops and Faculty Days
– School manager, website, promotional material
 Good training practice-Local level?

• Well staffed EDs in all grades

• Balanced Rotas, Training environment, WpBAs
• Consultant 08-24, MGs 24/7, clinical supervision
• Good weekly teaching programs
• Attendance at regional days and SL
• Regular feedback and support for progression
• Faculty STRs: timely, fair, reflecting ST abilities
• Support for slow learners
Australian EM training
What Next?

• ‘Addenbrookes’ model: Common front-

door with Acute medicine 2006-
• Multi-professional workforce
– ENPs, ACPs, PAs, Physios, SW, MH,
Pharmacists, Discharge planners
• Expansion of EM and AM- ACCS
• Co-location OOH Primary care
• Work-Life balance: EM/AM attractive
 EM Training 50 yrs Perspective
• EM development driven by its patients All times
• Casualty ---A&E 1960s
• CSA at BMA: new specialty 100 Consultant 1970s
• Lewin Report –SR training programmes 1980s
• ‘Calman’ Reforms and MMC changes 1990s-00s
• NHS modernisation and re-organisation 2000-
• The future in your hands
 My advice to a young FY2 doctor asking about a career
in Emergency Medicine…

• “Ithaka” by CP Cavafy
• As you set out for Ithaka
hope the voyage is a long one,
full of adventure, full of discovery.
Laistrygonians and Cyclops,
angry Poseidon—don’t be afraid of them:
you’ll never find things like that on your way….