Re: President’s Newsletter No. 4 – June 2010
I have previously provided periodic updates on issues of importance to Emergency Medicine (EM) and the Association and it is now timely that I do so again. The period since my last update could certainly not be described as being boring and there are a number of issues of importance to the specialty which I wish to bring to your attention.
The Association has previously expressed its support for reconfiguration. This support has been predicated on the process being done properly with appropriate infrastructure put in place to deal with patients whose Emergency Department (ED) facilities are being replaced. While we continue to support reconfiguration on this basis, it has become apparent that “reconfiguration” is likely to be foisted on certain regions because of severe recruitment difficulties. This has meant that the normal contingency planning and lead-in periods have not been observed and this is likely to result in predictably poor outcomes rather than the better outcomes that we would normally associate with properly executed reconfiguration. While many in the HSE and DoHC see the current recruitment difficulties as an opportunity, we have repeatedly made the point that unstructured chaotic “reconfiguration” is not going to be a positive development and is not one which we could support.
Currently EM is particularly affected by the shortage of doctors to take NCHD posts in the Irish Healthcare system. We are not alone in this and a shortage of Anaesthetic and Surgical doctors may well force significant service changes and restrictions around the country. Indeed these deficiencies and shortages of EM NCHDs may bring around unstructured reconfiguration which is a very worrying development.
In the specialty’s attempts to try and navigate through the recruitment difficulties the issue of the lack of a right of audience with bodies such as the Medical Council has been thrown into sharp relief. We, EM, have written to the Medical Council on two occasions with a view to meeting them so that ACEMT can become the body recognised under the 2007 Medical Practitioners Act as being responsible for EM training. Currently that statutory function falls to the ISPTC which in turn is a committee of RCSI. Although ISPTC delegates the day to day management of EM training at HST level to ACEMT, that has not equated with an automatic right of audience. We are continuing to try to get the Medical Council to respond positively to our overtures.
A second area of concern has been the lack of a Basic Specialist Training scheme in EM. Each of the more traditional mainstream specialties has a BST programme although these use different terms to describe themselves. We have plans in place to launch a BST Programme from July 2011 and have had a positive response to these proposals from RCSI and HSE METR. While this will certainly not solve the current recruitment difficulties it will move us to a situation where our trainees have a comprehensive training programme at BST level which will mean that those entering HST will be trained to a predictable level and some of the current secondment arrangements will not longer need to be part of the HST programme. This will make it significantly easier to administer the programme.
It is intended that ACEMT will appoint a BST Programme Director who will work hand in hand with the HST Programme Director currently in place.
Emergency Medicine Project
Since Dr Barry White has taken up the role of HSE National Director for Clinical Care, he has developed a number of projects. His stated intention is to ensure that clinicians make decisions in these projects which are to be implementation strategies rather than aimless reports. This is in contrast to the historical model where managers try to “interpret” what clinicians have told them and set about implementing these strategies themselves, without necessarily having any knowledge of the subject matter.
The current projects include management of various chronic medical conditions which account for the vast majority of hospitalisations as well as Acute Medicine and Critical Care projects. Initially, it was intended that there would be an EM project at some point in the future as either part of the second or third wave of such projects. However, it quickly became very clear in the projects that were underway that there was a necessity to engage with EM and feed its input and expertise into their deliberations. The Acute Medicine project is intended to guide the national implementation of Acute Medical Units which HSE have accepted are a good thing. Their operation and their interface with EM are issues into which the specialty has an opportunity to contribute. The specialty (through IAEM and ACEMT) nominated Dr Una Geary to be the EM representative on the Acute Medicine group and Una is doing sterling work in ensuring that what is proposed is EM-proofed. Key in her input has been the acceptance that EDs cannot be asset stripped to facilitate acute medicine; that there is much in EM such as observation medicine and the use of CDUs which will need to be built upon rather than scaled back and the necessity for parallel investment in EM. On foot of the better understanding of the EM perspective, Dr White has recently agreed that there should be an EM project as part of the first wave of these projects. A delegation from IAEM, ACEMT and CEM National Board for Ireland has met Dr White and we have agreed to develop this. This will inevitably involve some painful decisions for the specialty including issues such as closure of suboptimal EDs, changes in service delivery and more nationally agreed ways of doing things but the alternative scenario of having such changes foisted on us without our involvement is clearly a far inferior option. It is logical to us that Dr Geary should Chair this project and ACEMT and IAEM have jointly recommended this approach. The project will involve a small working group but with a bigger Advisory Group with regional representation to ensure that anything that is being proposed is not just one region specific. I fully acknowledge the justifiable scepticism that legitimately exists in the EM community, however we are better seeking to influence the processes from within than have them foisted on us as has been the norm previously. Clearly we intend to try and maximise the resultant benefit to EM. In particular, additional Consultant appointments, redevelopment of deficient EDs and the absolute necessity to definitively deal with the curse of ED overcrowding are bottom line issues for us.
Changing of the Guard
As many of you are aware Mr James Binchy will step down as Honorary Secretary of the Association at the AGM in Waterford in October. This will be a year before his current (2nd) term was due to end but there is logic in not having key office holders demit office simultaneously. James has served the Association extremely well over his 5 years in the role and it is appropriate that we recognise the hard work he has put in. I, for one, am only too aware of the efforts he has made on behalf of the specialty. Over the next couple of months we need to ensure that James is replaced by somebody who is going to take on the mantle effectively and help lead the specialty through what will undoubtedly be turbulent times.
At the same meeting there is a requirement to select a President elect who will take over from me in October 2011. While the roles of the Secretary and President are different, they are clearly complimentary and it is important that the Association functions as a coherent team. We have enough difficulties with outside agencies without having internal tensions or differences exposed.
Over the next few months you may well be approached to see how you might be able to contribute to the development of the specialty and ensure that IAEM, ACEMT and the Irish National Board of CEM continue to provide a coherent unified leadership for the specialty albeit within the complicated structures that our history has forced upon us.
Over the next few years the Association will need to further our agreed mandate to create a single unitary body, probably an intercollegiate faculty, to ensure that EM is represented by one body based in Ireland which can control all aspects of the specialty and make us self sufficient.
Now that the ICEM 2010 is behind us, the focus shifts to the 2012 ICEM which we are hosting in Dublin in June 2012. We will be by far and away the smallest body to host an ICEM and it is therefore incumbent on all colleagues, be they full or associate members, to contribute positively to the success of this meeting which is undoubtedly a huge undertaking. The implications of us failing from a financial perspective are truly frightening yet we have a track record of hosting successful meetings both national and international and we need to bring this enthusiasm and expertise to bear. Within the next few weeks we will be setting up various groups to oversee different elements of the organisation of the meeting e.g. Financial, Academic, Social programme etc. Some of these will build on existing structures within the Association but will need to be expanded. When you are approached to 4 assist, I would be grateful if you would give this project your full commitment and enthusiasm. ICEM 2012 is a challenge but there are enormous opportunities for the specialty to project itself in a positive light, both nationally and internationally, which we shouldn’t lose sight of. Given that our specialty is associated in many peoples’ minds with the “trolley problem” and overcrowding it would be nice to see a different aspect of the specialty projected.
Over recent weeks we have begun the exercise of producing publicity flyers and a website for ICEM 2012 which I would encourage you to have a look at. The URL is www.icem2012.org
The process of moving the membership from the previous mix of standing orders and cash / cheque payment by Direct Debit has been far more difficult than was anticipated. This was complicated by a conflict in the information given to us by our new Bank of Ireland branch in College Green. They made it clear to Niall and I that standing orders would not be transferred from our old account in Raheny to College Green and on this basis we didn’t advise members to formally cancel any standing order they may have had. Unfortunately because of recent arrangements made nationally, banks are obliged to make the process of transferring branches and banks much more straightforward and they now automatically transfer standing orders, direct debits etc. This has produced a situation where some colleagues have paid both by direct debit and standing order. This has been a considerable administrative burden for Niall who has had to make refund cheque payments to those who have made duplicate payments. If you have not already cancelled your standing order please do so immediately as otherwise you are just adding to the unnecessary administrative burden.
It has also become apparent in attempts to regularise subscription payments that a number of IAEM Associate members have continued to enjoy the benefits of membership without paying their subscriptions. As in any professional organisation there clearly have to be benefits to membership that do not apply to those who are not members. Our intention therefore is that following this newsletter those who are not in good standing will cease to receive communication from the Association and will pay the (higher) non member rate for conferences or other IAEM provided services.
On a more positive note it has been decided to more closely integrate the functions of IEMTA and IAEM. From the 2011 subscription year, Associate membership of IAEM will automatically include membership of IEMTA. It will no longer be possible to be a member of IEMTA without having Associate membership of IAEM. It is planned that, at current levels, the single subscription would be less than the combined subscriptions that currently apply. However, Associate members who currently do not pay an IEMTA subscription (€50) will pay a higher subscription. To simplify administrative arrangements, it is proposed that a subscription process will use the IAEM direct debit process and IEMTA’s contribution be remitted to them.
Continued ED Overcrowding
Although ED overcrowding seems to have been with us forever, there have been some positive straws in the wind which are worth acknowledging. There has been some progress with a Full Capacity Protocol implementation in Limerick and a 5 parallel process using a different name in Beaumont. In addition, we have finally managed to interest the Health and Safety Authority in the overcrowding issue which has been a long time coming. They have already issued a mandatory improvement notice on AMNCH, Tallaght and we hope that letters that have been sent from other EDs will invoke a similar response. It is only when it is no longer acceptable for there to be ED overcrowding that real change will happen. It is also apparent that the Acute Medicine group has been told bluntly by HSE and the Minister that they must contribute to the resolution of the “trolley problem”. While the provision of AMUs is unlikely to contribute to resolving ED overcrowding the forced engagement of medicine with the acute element of their current workload will certainly be helpful.
I suspect that some colleagues may not have looked at the IAEM website for some time. I would draw your attention again to www.emergencymedicine.ie and ask you to note that over recent months a considerable amount of detail has been uploaded to it, covering various aspects of the generality of EM. This includes new sections on Academic and Research matters as well as significant additions to the Training section as well as further additions to the more traditional IAEM portions of the site. If you haven’t already registered with the site please do so as that will give you access to other members only service which we will be progressively adding to over time.
In all, my message at this stage is a mixture of ongoing frustrations about overcrowding, recruitment and implosion of hospital services but some positive opportunities which may allow us move Emergency Medicine forward.
With best wishes to you and your families for the upcoming summer season.
FRCS FRCS Ed DA(UK) FCEM
President, Irish Association for Emergency Medicine
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