Restructuring our workforce.

P roviding high quality emergency care to acutely ill and injured patients has become more challenging than ever. There are increasing pressures from all sorts of different directions. Patients quite rightly expect better treatment, delivered with better communication. At the same time, emergency treatments have become increasingly sophisticated. As a result, it might be expected that it would take longer for staff to provide high quality care. Indeed, there is already some evidence (presented in this journal) that this is the case. All of these pressures are occurring in the context of overcrowded accident and emergency (A&E) departments and the government having set ‘‘performance targets’’ that focus heavily upon the rate of processing patients. The pyramidal medical staffing structure of A&E departments in the UK has meant that it has traditionally fallen upon junior doctors (especially senior house officers) to provide most of the emergency care. The European Working Time Directive and other restrictions on junior doctors’ hours have already begun to have an impact on the way that the A&E service is delivered. Further changes are inevitable. The most obvious changes will result from the implementation of the proposals set out in ‘‘Unfinished Business’’ and ‘‘Modernising Medical Careers’’. 4 The introduction of foundation programmes will undoubtedly change the role of the senior house officer in a significant way in the next few years. For these junior doctors, the balance between service and training will shift more towards training. A&E departments will have to seek out alternative ways of delivering the service. Changing the roles of existing staff and developing the roles of new staff may help to achieve this. Some developments (such as emergency nurse practitioners) are so widespread that they may be reasonably considered to be the norm, while other innovations (such as paramedic emergency care practitioners and physician assistants) are largely untested in the UK. 6 The paper by Mitchell et al in this issue of the journal shows that a significant proportion of the time of a junior doctor in A&E is spent performing administrative and technical tasks that might be easily undertaken by other suitably trained people. Mitchell et al suggest that physician assistants would be ideally placed to fulfil some of these roles. The concept of physician assistants may appear to be comparatively new in the UK, but they are already well established in the USA. 9 The US physician assistants have developed their own professional identity. They typically follow a background of study of a medically related subject at college by a further period of university study. Physician assistants are inherently dependent practitioners, working alongside a designated physician. They seem to be most effective when the relationship between the physician assistant and the physician is harmonious and well established. In this respect, it would seem more sensible for the physician assistant to work directly with a more senior and experienced doctor, rather than an inexperienced junior doctor who only works for a short period in A&E. Given the nature and rate of change facing UK A&E departments, decisions about developing new roles may have to be taken in the very near future if the service is to be maintained.