You’re missing the point, Jeremy

I haven’t said much about Mr. Hunt’s address to the King’s Fund, or the uprising and furore it has caused amongst medical professionals. This will come as a surprise to most of you.

When I say I haven’t said much, I have barely shut up about it to my friends and family, firmly and repeatedly ranting and reiterating all the notions and arguments you will have read the internet over. The reason I have not written about it to date, is that there were people far more qualified and eloquent than myself taking up the battle, and it was enjoyable to sit back and read some excellent, incredibly worded letters and diatribes that were emerging from varying areas of clinical medicine.

The reason I am writing now is because I feel a little as if we are missing the point. It doesn’t matter how many Facebook rants, twitter campaigns, signatures on letters we have, this is not going to change the final outcome.

Jeremy Hunt and David Cameron do not read social media; they have people for that. And right now they definitely aren’t reading it because they are on a nice long, comfortable summer break. It is hugely ironic that Mr. Hunt’s speech criticised doctors for not working hard enough, criticised our union and told it to “get real” about the challenges facing the NHS, whilst he prepared to sun himself for 2 months. No, the jobs aren’t the same, and no, I am not criticising him for his inbuilt holiday. I am just pointing out the incredible timing.

As the media bubble is dying down, and attention is shifting away from the implications of his words, this is the time to take action.

No one in the NHS wants you to be more likely to die on weekends. As a junior doctor who has worked 3 out of the previous 4 weekends, with one still to come, I know how stressful and challenging working weekends can be. I know the devastation of someone dying unnecessarily on your watch. I know the heartache when you leave work at 11pm on a Saturday, a broken human being, and have to return again at 8am the next day. But the issues we face do not stem from inadequate Consultant cover.

Take a typical 400-bed district general hospital; maybe 12 medical wards. During the week, there will be anywhere up to 4 doctors per ward, with consultant or registrar input most days. There will be an entire team of radiographers, radiologists, biochemists, microbiologists, outreach nurses, clinical nurse specialists, not to mention highly trained and experienced ward sisters who know their patients inside out. There will be specialist teams working and receiving referrals, psychiatry, rheumatology, neurology to name but a few. Getting advice about a patient is easy.

Come the weekend, there is one on call radiographer for the entire hospital, potentially 2 biochemists running all the samples sent to the lab, and a team of 4 doctors covering all the wards and running an acute medical take. Usually you will take between 20-30 patients per day, and as such the registrar and one SHO is entirely focused on the take. This leaves an FY1 (with anywhere between zero days and 12 months of experience) and one SHO (a doctor 2-4 years into training) covering all the potentially unwell ward patients.

It is impossible to do a ward round on 400 patients. It is impossible to assess each and every person for signs of deterioration. The only way we know about you is if your day team has handed you over as likely to need review, or if your observations are so horrendous that they trigger a hospital wide emergency call. As I’m sure you can imagine, catching things when they are already an emergency dramatically decreases our chances of turning things around. Now, say someone needs an urgent CT, or urgent blood transfusion, or, god forbid, out of hours surgery or blue light transfer to another hospital. Being the weekend, this takes so much longer, purely due to demand outstripping supply, and the fact that people have to come in from home to perform tests.

You run like idiots from one ward to the next, assessing and managing people who are sometimes on the brink of death. The sense of relief that floods through you on a Monday morning when the normal teams turn up is indescribable. I often compare it to firefighting, only you are fighting so many fires at once you don’t know where to start.

Now, if someone can point out how getting consultants to work longer at weekends will solve this, I’m all ears. The government know that this isn’t the crux of the issue. They are not idiots, and that makes these proposals all the more terrifying. They have identified an issue, which is that the NHS as a whole does not operate the same on a Sunday as it does on a Tuesday. They have created mass hysteria by implying that if you are in hospital over a weekend you will probably die. (As an aside, if you read the literature properly, there is no such obvious link between weekend admission and death, which honestly is a miracle considering how unsafe the working conditions are).

The government has alluded that workers in the NHS don’t want 7 day working. This is a lie. I have lost count of how many times I have said I would happily work twice the number of on calls if it meant twice the number of doctors present. But then they would have to pay us all a fair wage and where would that money come from? To implement 7 day working, you either have to employ more people, or work the current employees harder. There is no money for increased recruitment, let alone the dwindling supply of people actually willing to work in the NHS.

It was the changeover for junior doctors last week. The time for new FY1s, fresh from medical school and enthusiastic about their future careers, to come out into the harsh reality of the NHS. One of these fresh eyed and enthusiastic doctors was working with me on the weekend. He was struggling against a new computer system, no log ons, no patience from nursing staff and discharge coordinators and a demanding consultant. All the while trying to learn how to document properly and order the correct tests. This young doctor worked close to a 12-hour shift (4 hours over his contracted hours) on his birthday. He missed a surprise party thrown by his friends, and finally left the hospital late at night, only to come back bright and early and do it all again the next day. All without a word of complaint and a smile on his face. These are the people keeping the NHS alive in the face of ridiculous proposals and underhand attempts at privatisation. New FY1s, I admire you, and it is for you that we must fight these proposals. Join the BMA, go to meetings, have your voice heard. It might be cynical, but there is a very real possibility that this is a long term plan to privatisation –  they raise an issue, try and fail to fix it, and then legitimise the idea that the NHS is no longer viable.

The proposals try to highlight areas of weakness with no legitimate offer of solution, all the while alienating people who willingly give up their time off, their social lives and any semblance of normality and go above and beyond to keep people alive against horrendous odds.

I am not trying to be arrogant, but doctors are the people you want on your side. We are the people who have endured 5 or 6 years of grueling exams, long hours trailing around after consultants in hospitals, and actually celebrated the day when we graduated and were able to work like dogs from 8am to 7pm and beyond for pityingly little compensation and very little thanks. I am not looking for sympathy. We do this job because the rewards are immense. People come into hospital close to death and by our input (and that of many other hospital professionals) go home healthy. We get to see people at their worst, and help them recover. It is a hugely satisfying and rewarding job, and the only reason you still have people doing it is that you never get over the joy of giving someone back their mother/father/sister/child when they thought they had lost them.

And David Cameron and his health secretary have that, and that alone, to thank for doctors and healthcare professionals in general still getting up and going to work in the morning (or middle of the night for that matter).

It is naïve and unrealistic to expect people to work harder, longer, and for less money, which is essentially what the new proposals boil down to. And we are medical professionals, we do not strike, we do not make waves, we accept multiple reforms, none of which have been an improvement on the last, all the while quietly assessing and treating your family, without complaint at 2am, without complaint when we should have left work 3 hours ago, because we know we are privileged to be able to provide this type of care, we know how important it is. But the NHS is running on our goodwill now, and I don’t know how much more we can take.

I trained as a doctor, not a discharge coordinator.

My current medical placement is on an Endocrine ward. This basically means that as a firm, we should get all the acute diabetes cases; complications including renal disease, ulcers, hypoglycaemia etc. We also get people who have deranged electrolytes such as a low sodium, which in some cases is an indication of an underlying cancer or other disease. If I was in a tertiary centre (big teaching hospital) then I would be seeing exciting, rare endocrine cases such as Cushing’s, Addisonian crises and the like. As it is, in a district general hospital, there are not enough endocrine cases to fill the ward and as such we become the dumping ground for various other cases.

We take the social care cases, the patients who are awaiting placement, the long stayers, people with no discharge destination, the waifs and strays of the hospital. Whilst this feels like it should be a varied job, it is actually the dullest thing in the world. Within a very short space of time these patients are medically stable and they are in need of physiotherapy, OT input and social services for packages of care. Or they are awaiting transfer to a rehabilitation ward, or to another hospital for dialysis, or amputation. A typical ward round for us consists of maybe three or four patients who are medically unwell, and then about 20 medically fit long stayers.

This makes you incredibly lazy as a physician. It is so easy to write “obs stable, afebrile, no new issues” in the notes several times over and then go get a coffee and spend the day surfing the net. It is incredibly easy to miss a hospital acquired infection because you haven’t listened to someone’s lungs for a day or two, or noticed that their catheter is draining more concentrated urine. These guys go off quickly too, they go from months of medical stability to dead in a day or two.

It is a well known fact that increased time in hospital increases your risk of getting an infection and dying. It drives me crazy the amount of time it takes to get these guys out of hospital. I understand that there is a complicated assessment process involved in setting up placements, for example. The patient has to be needs assessed, placed in the right type of care facility, means tested for funding and then the individual home has to be seen and agreed by either the patient or their family. This can take weeks. What worsens this process is the total inability of any professional inside or outside of hospital to communicate with someone else. Social services will require a checklist. They will not communicate which checklist to the nursing staff. The nurses will fill in an inappropriate checklist, fax it off and it will be declined. The decision will not be communicated back to the ward. The doctors will go on the ward round and write “medically fit for discharge, awaiting placement” for weeks on end without knowing where in the process they are. Inappropriate people will be asked about updates – OTs get asked when the placement will be approved even though it is driven by social services, but social services are never on the ward and frustration leads to apportioning blame for delay to the wrong people.

Every time that someone is discharged from hospital with an existing package of care that needs restarting, a section 5 is necessary 48 hours prior to discharge to give the carers time to set up the package again. Everyone knows this is necessary, we know who comes in with a POC and therefore they will certainly need the same or increased POC on discharge, yet inevitably we will get to the morning of departure and it is news to everyone that the section 5 has not been sent. It is apparently impossible for the different teams on the ward to communicate directly with each other. People write their interactions in the notes and other teams don’t read them and then plans are made on incorrect information.

In order to attempt to coordinate all these things, there is a multidisciplinary team meeting on a weekly basis. This is my least favourite activity of the week. At face value, it is an excellent plan. You can get updates from therapy, nurses, discharge teams and doctors and then everyone is on the same page and we can expedite someone’s discharge. In reality, however, most weeks social services don’t turn up, totally negating the point of the meeting for at least half of the patients, or the sister in charge will have out of date information, or the doctors will spend half the meeting discussing someone entirely medical, thereby wasting the time of every other professional in the room. In complete defiance of their job title, the discharge liaison team neither discharge, nor liaise. The social worker never has an up to date ward list and is always at least 3 weeks behind with information. It would make a brilliant sketch show, it would be hilarious if it was exaggerated. As it is, people sit in acute hospital beds costing the NHS £500 per night doing nothing other than eat shit hospital food, go delirious from a hospital acquired infection, or become thoroughly institutionalised because it takes four months to communicate the need for placement, fill in the correct forms and get approval.

I don’t know what the answer is, obviously people should be in a place of safety until they can be appropriately discharged, but should that place be an acute ward in a hospital? Arguably not. In addition, most of the patients have come in with relatively minor complaints such as a UTI or chest infection, and got stuck after recovery due to worsened mobility or inappropriate houses for discharge. This job has definitely highlighted to me the importance of trying everything possible in A&E to get these patients safely out of the door. No one wants to take responsibility for discharging a 92 year old with a UTI in case she goes home and falls. But the other option is a 6 month hospital stay, loss of independence and eventual placement. Obviously, if people are unsafe at home I am not suggesting emergency care physicians chuck them out into the cold at 3AM, however, all most people need is a course of antibiotics, or some IV fluids, or plugging in to community services and they will be fine. Alternatively, we saturate our medical wards with people who have no medical problems, and the doctors become deskilled and lazy, and wonder why they bothered going to medical school in the first place.

This is a red NEWS call to AMU

Yesterday I collapsed in the treatment room in A&E.

I was working my third consecutive 13-hour shift over a bank holiday weekend. I was running a fever of 39 degrees and had the most horrendous head cold. I was probably sicker than at least 20% of the patients I was being asked to admit to hospital. I was the only SHO on shift for medicine, and when I had awoken with blocked sinuses, the inability to stand upright without staggering, and the full knowledge that realistically I should spend the day horizontal, slipping in and out of sleep and having hot ribenas, it did not even cross my mind to call in sick.

I am not writing this for sympathy. I know an overwhelming amount of people who have done the same thing. As medical professionals, we consistently prioritise other people’s needs above our own. It is part of the job. However, yesterday I was unsafe. I could barely walk, let alone be expected to make a legitimate management decision for a patient. I drugged myself up on a combination of co-codamol and nurofen, and wandered the hospital with a box of tissues and a litre of ribena.  In my mind, there was no other option. Bank holidays and weekends run on skeleton staff – the number of doctors to patients is dangerous even when everyone is on top of their game. You have to be legitimately dying to justify staying home.

Bank holidays in particular also tend to run on locum staff, particularly locum registrars. Now, whilst some of these are amazing doctors, most aren’t. Even if they are good clinically, they usually don’t know the hospital layout, don’t have access to the reporting systems, don’t know how to request imaging. It makes an already stressful shift unbearable when they don’t even have good clinical skills. My registrar on Friday did not recognize when a patient went into ventricular tachycardia on a monitor, and it was only because I happened to walk behind her that we managed to check if the patient had a pulse, start him on the correct medication and take him to CCU. How could I call in sick when I knew what state I was leaving the on call team in?

Things like updating families about patient’s conditions go by the wayside. Urgent blood tests get handed over from day team to night team and back again. Once you have been clerked in on an acute take you are lucky if you see a doctor at all until the next normal working day – if you are unlucky enough to be admitted on Good Friday then you can usually expect to sit idle, with no further medical assessment until 4 days later.

The only thing that alerts us to a patient’s deterioration is the NEWS call – a call put out when a combination of a patient’s blood pressure, heart rate, temperature and oxygenation reaches dangerous levels. These calls mean we have to come running to the ward, quite often for things that could easily have been avoided if there were enough staff to reassess a patient’s condition on a regular basis.

It is baffling to me that not more people die over long weekends in hospital. If you make it to the end of a shift without an “adverse outcome” it feels like it is more a result of luck than anything else. If we had even one more doctor on shift it would feel less unsafe. I know multiple doctors who would rather work twice the number of on calls with adequate staffing than half the number and feel unsafe. But I know it is all about money. We seem to have an endless pot to fund terrible locum doctors at the drop of a hat, but never enough left over to create a more tenable working rota, which would hopefully decrease the need for the locums in the first place. 

And meanwhile, people like me come into work dangerously unwell, and then take up a bed in ED for assessment – further adding to the workload of an already overstretched system.

O&G: a rotation of fingering vaginas and covering my ass.

So, I am coming to the end of my rotation on O&G. I have exactly 5 shifts left, and that is 5 shifts too many. O&G is essentially A&E but more stressful, and with exclusively hysterical women, babies coming out of teeny tiny holes, and various permutations of bleeding and diseased vaginas. You aren’t really taught much of the theory at medical school, so starting as an SHO on Gynae basically entails feeling like a moron 100% of the time. You are put in a position of authority, asked to examine and assess patients for conditions, most of which you have never even heard of. Dr Google has legitimately been my best friend. It is ludicrous. There is a baseline expectation of competency.  You are a SENIOR house officer now; you must know shit. Clearly somewhere in the small print of my contract it told me how to pull knowledge about complex gynaecological presentations out of my ass but I must have missed it.

The pressure is immense. There is a culture of litigation, and as such I would say that 70% of all decisions made in the specialty are about covering the clinician’s behind. Everything has to happen immediately. With no prior training you are expected to juggle women in dangerous pre-term labour, women hosing litres of blood from their uteruses (uteri?), women potentially unstable due to ectopic pregnancies, to distinguish between idiotic and urgent referrals, and do all of this calmly and competently, all the while smiling sweetly at the midwife who was called you to perform an urgent ECG that has been waiting all day because for some reason no one thought it necessary to train midwives how to use the machine, or to print off a discharge summary STAT because the patient absolutely has to go home immediately and midwives don’t have access to the discharge system, or to come and take blood cultures off of someone who has spiked a temperature because instead of re-cannulating them the nurse decided to switch their IV drugs to oral because, they’re the same thing, right?

This leads me to a side rant about the ridiculous lack of competency assessment we have as doctors. I have lost track of the number of times I have been asked to administer a drug because a nurse hasn’t been trained how to, or perform a procedure that a midwife isn’t competent to do, that I myself have had no training in. As doctors, we are expected to be able to just get on and do things. There is very little sympathy for the line “but I don’t know how”. And this is insane. If anyone asked me to produce evidence of competency in giving calcium gluconate, or administering methotrexate, or misoprostol, I would be screwed. Yet I do it frequently. 

O&G though, is on a whole different level. There is a guideline for EVERYTHING, but it is never exactly followed. You can assess a patient, make a correct diagnosis, initiate management according to the guideline, and be entirely decimated by a Consultant who has decided, on a whim, that it is not appropriate to give this particular pre-term labourer steroids. And that will be your fault. Acceptance of incompetence, and acceptance of culpability even when it is not your fault are necessary attributes for a successful rotation.Oh, and skin as thick as a rhinoceros.

So, I have compiled a list of possibly helpful, hopefully amusing tips for anyone who may be about to enter an O&G rotation. 

Top tips for anyone doing O&G as an SHO:

  1. ALWAYS put in the biggest possible cannula – when these women bleed, they lose their entire circulating volume in minutes. Plus, its so satisfying doing locum shifts in ED, waltzing into resus and placing a grey cannula without batting an eyelid. SKILLS.
  2. Regardless how young, virginal, or skanky a woman is, she is pregnant until the labs have excluded it.
  3. Following on from this, it is an ectopic pregnancy until proven otherwise.
  4. You will be referred at least one woman who is legitimately on her period. A&E will inevitably want you to admit her.
  5. Speculums are things we are ALL taught to do in medical school. The line from ED/UCC/Surgical/Medical Docs of “you’ll only repeat it anyway” is pure laziness, and their impression will be at least as good as yours. Whether you fight this one is personal choice. Frankly, it is irritating but not worth your breath.
  6. “Asian Pain Syndrome” is multiplied exponentially in pregnancy. 
  7. Headaches in pregnant people = NIGHTMARE. Even if it is definitely a migraine, you will go home convinced they have a thrombus and are going to die.
  8. Specialty tennis between surgeons and gynae for the women with abdominal pain helps no one. Gynae is seen as the easier option, which can be frustrating, but remember that there is a woman, possibly in agony, probably scared out of her mind, sat somewhere waiting for answers. Accept the patient. Get an USS. Yell at the surgeons later. 
  9. Secondarily to the above: Right Iliac Fossa pain in someone who still has their appendix is appendicitis until a surgeon has written that it is not. Regardless of how snarky they are on the phone. No one likes appendicitis because it is a difficult clinical rule-out, but that does not make it an ovarian cyst. Sort your shit out.
  10. “Gynae pathology” is NOT a diagnosis. I have had a lot of fun with this one. If they cannot give you a legitimate differential, then you don’t see the patient.
  11. Run absolutely EVERY decision by someone senior. Even prescribing antibiotics. Even following a guideline. They will look at you like a moron, but you get used to that pretty fast. There is no room for autonomous decisions in O&G, unless you want to be on the receiving end of a court case. Better to look like a moron than be proven one in court. 
  12. Remember this rotation is temporary. This is not your life. Soon you can be back doing something you enjoy, unless, of course, you are an O&G trainee, in which case, I salute you, and am getting you a psych evaluation.

A&E as a symptom, not the disease.

WARNING
This is a long, boring post on the difficulties facing A&E in the current climate. Complete with the disclaimer that my views are entirely my own and should not be used to represent any organisation that I work for yadda yadda yadda….

ED (as A&E was renamed years ago, in the hope of cutting down the number of accidents that present there that are neither life-threatening, nor emergencies) has become somewhat of a hot topic.

Not a surprise: it is a hugely political system, and we are in an election year. Labour MPs are decrying the Tories’ management of EDs, stating that they have “betrayed patients”; David Cameron has made several glib remarks about EDs being busy, but coping “heroically”, there has been much talk about failure and little offer of solutions. This is because we are focussing on the wrong problem.

Increased waiting times and poor performance in EDs are a symptom of failure of our healthcare system at a much deeper level. The issues are admittedly most obvious when you are sat waiting 5 hours to see a doctor with a broken hip or a breathing problem. However, the root cause of this wait is not solely based on occurrences in ED, nor in a failure of pre-hospital systems to avoid unnecessary admissions.

Below is a brief outline of some of the major factors involved in the ED crisis.

  1. Inappropriate access of services:

    Despite what the media will have you believe, inappropriate presentations to Emergency Departments are not a direct result of lazy GPs. Most A&E attendances occur between 9-5, when people’s local GP surgeries are open, often with specifically designated emergency appointments available. It is interesting to note that a patient’s impression that they “would not be able to get a GP appointment” is not proof that they have actually tried. We have the media to thank for this one.

    Additionally, advice helplines such as 111 make a valiant effort to point people in the right direction. However, it is incredibly difficult to accurately assess someone over the phone, and they largely err on the side of caution and send people unnecessarily through to ED. This is obviously preferable to the alternative end of the spectrum, but again clogs up the Emergency Department unnecessarily.

    Patients do not understand that the ED cannot help you with all medical problems. I would see many people who presented due to (perceived) lack of access to their GP, with stable conditions that needed outpatient investigation. Thanks to the NHS restructuring, putting the burden of budgeting onto GPs, we are no longer allowed to refer in to clinics from ED, and as a result the poor patient has had a wasted trip, an unnecessary 4 hour wait, increased the waiting time for others in the department who may actually require emergency care, and has to go to their GP in the end anyway.

  2. Social care funding:

    Cuts to social care funding have led to less support for people at home. Vulnerable adults are therefore left without vital support and end up presenting to ED with entirely preventable falls, infections, and loneliness.

    Outreach community services such as district nurses are under increasing pressure. In a report published last year, the Royal College of Nursing cited great difficulty recruiting nurses to these roles. The numbers of nurses are decreasing at a time when the demand for their services is exponentially rising. Patients presenting to ED with dressings that need changing, catheters that need unblocking are entirely preventable with good community care.

  3. “Bed blocking”

    A significant contributor to increased waiting times in ED is the lack of available beds in which to put the 1 in 5 attendees that are admitted to hospital. This is due to a number of factors, not least:

    Out of Hours investigations (or lack of). Patients admitted to hospitals acutely are often stabilised and managed within 24-48 hours. The remaining tests could often be done as an outpatient – things like CT scans and 24-hour tapes. However, it frequently takes a millennium to arrange these tests once someone has left hospital. As a result, relatively stable people stay longer in order to get faster access to specialist tests. Additionally, when people are admitted on a Friday night, they regularly have to wait until Monday morning for a specific investigation, or to see a Consultant specialist, which clogs up beds.

    Delayed discharges. These are due to many factors – patients admitted with acute medical problems are often found unable to cope at home, with discharge back to their pre-admission state impossible. In-hospital teams such as Physiotherapy, Occupational Therapy, Speech and Language etc. are amazing, but implementing the much-needed changes takes a huge amount of time. Most of this is due to workload, and the difficulty liaising between hospital care and community services. Social service teams are frequently understaffed and over-worked, and when someone requires state funding for home adaptations or care packages they might as well spend the rest of their lives in hospital.

  4. Lack of senior staff and training doctors:

    Although, as I said above, there is too much attributed to the levels of staffing in ED, there is not enough recognition of lack of senior nurses and doctors in training. The importance of this cannot be overstated. Having a Consultant triaging attendances with the experience necessary to stream patients without waiting for investigations is vital. Having experienced nurses ordering the necessary tests before the doctors see the patient avoids pointless delays whilst you await blood tests and other investigations. Having a higher number of registrars and consultants as compared to junior doctors means better and faster decision-making.

    Having doctors in training and nurses on contracts is greatly beneficial to a smoothly run department. The reliance on locum doctors and bank nursing staff means that not only is there less of a team mentality, but there is also a lack of knowledge about how the specific hospital operates. Teaching a new nurse where to locate equipment, how to find the IV medications, where to put the CAS cards when they have done an assessment wastes valuable time. Showing locum doctors how to use the computers, where to assess patients, how to refer to specialty teams wastes valuable time. Doing this over and over, day in day out is exhausting for all involved.

  5. Lack of responsibility for our own medical conditions:

    There has been a huge drive forward in recent years with regards to health education. We can no longer say that we are unaware of the dangers of smoking, drinking, over-eating, doing next to no exercise, and using recreational drugs. Our jobs as health professionals is to give people the best possible information about how to live as long and as well as they can. It is up to them how much heed they pay us. I have no problem with people choosing to ignore us – I do most of the above list myself. However, we cannot expect our poor healthcare system to pick up the slack for us. We do not have the right to act surprised when we turn up at an ED unable to breathe/with liver failure/diabetes. We give ourselves complex diseases, which are costly in both money and time to treat, and we clog up Emergency Departments due to our own lifestyle choices. We then complain about how long we have had to wait.

  6. A&E as a political football:

    A&E is the most easily measurable indicator of how the NHS is functioning as a whole. The 4-hour target, for good or bad, gives a readily accessible measurement for performance across trusts. The NHS is a great source of national pride; we still have the impression that our healthcare system is the best in the world, unique in its vision to offer free at point of service healthcare to all. This is false. However, as a result of this, the NHS is a huge political item. In the lead up to our election year, we will no doubt hear many more ludicrous statements about how best to manage the NHS, and inevitably how best to operate our Emergency Departments. We don’t leave one system alone long enough to accurately assess its efficacy. As doctors, we are simply trying to do our jobs, treat as many people as humanly possible, and do the best we can for our patients. We can do without the vague political platitudes that exalt us for doing “heroic work” in the face of extreme pressure. We don’t do it for the glory. We need practical change, implementation of legitimate management plans to increase social care funding, to incentivise substantive A&E training posts, to improve communication between primary and secondary care, to aid discharges into the community, to offer 7 days a week scanning, to have proper Consultant cover on the weekends, to employ more district nurses, paramedics, therapists.

There is so much that could be changed for the better. There are so many factors affecting our hospitals, our A&Es, our NHS. Pick one, and move on from there. Stop disagreeing with politicians from different parties for the sake of it. Stop reveling in the disappointments of others. Fix our damn healthcare system before it is too late.

End rant.

Doctor, your patient is going to breach…

Last week saw the “worst week in A&E” since monitoring began in 2010.

Much has been made in the media about the number of people breaching the four-hour target. There is also a shocking lack of understanding of what the four-hour target actually means.

The target is not for patients to be seen by a doctor in four hours. The target involves patients being booked in at the front desk, assessed by nurses, triaged by frontline Consultants, having blood tests and other investigations performed, being fully clerked and examined by another doctor, having a diagnosis made, being referred to a specialty team, and then leaving the department to go to a bed on the ward, or being discharged home.

I don’t have to point out that the potential for delay here is almost unquantifiable.

During my shifts in ED I would frequently pick up patients who had twenty minutes to go. I would sometimes pick up patients who had already breached. Usually, these patients had been streamed to the urgent care centre, and then referred on to ED. Because it is technically the same department, they come through on the same clock… So, from the point of view of the four-hour target, we have failed before we have even started.

The target has good and bad points. It is an arbitrary, statistically useful but morally obsolete tool, to aid us in defining our parameters and assessing our performance. It is as useful or useless as any predetermined timeframe, and the number itself is not the issue. The problem occurs due to the fixation on the target above other priorities. Used properly, the target helps us identify areas of weakness, and departments that are struggling to see their patients safely. In an ideal world, departments with more breaches should get more funding, for higher staffing levels, for increased number of observation beds, for larger majors areas. In reality, breaching leads to stressful conditions, forced decision-making, and compromised patient safety.

There are a few funny internet memes floating around about the ED. One of them states “save three people’s lives and no one bats an eyelid; breach one patient and all hell breaks loose.” I have been blessed with working in an ED where there are excellent working relationships amongst the staff, and patient safety is consistently a priority. Even so, I have often felt pressured to make a quicker decision about a patient, to take down the half bag of saline still running, to amend the timing of my medical entries in order to have one less breach.

Quite often, the balance of admission or discharge in ED hinges on a period of observation. It is impossible to accurately assess a patient’s condition in 20 minutes. The luxury of allowing them to sit in the department, with regular observations, and pain relief/a bag of fluids is often all that is needed to avoid an acute admission. Where I am working currently, they have recently reduced the number of ED observation beds from 20 to 4. This is in order to build a much-needed Acute Medical Unit, which in turn helps free up the ED by providing an exit strategy for medically accepted patients. However, this has significantly reduced the number of people we can observe prior to admission. These people are now sat on the AMU, occupying the beds that they would have occupied on an observation ward, only now they are being clerked by an additional team; there is a whole host of admission paperwork; and they will inevitably stay overnight, costing the NHS an additional £600 per patient.

The media is making much of the fact that higher ED attendances are leading to overcrowding and pressures on departments. This is only partially true. Yes, there has been a steady, expected increase in attendance leading up to winter. However, the total number of ED attendances in the “worst week”, were actually lower, nationally, than a comparative week in July of this year. So why the inability to cope?

Frequently, the reason for the backlog is the occupation of ED beds and trolleys by patients who have already been referred to specialties, but are either too unstable to transfer, or there are no beds on the ward. Obviously, if someone needs monitoring, and the only monitored bed is in Resus, then we are not going to chuck them out just because they are at 4:01. This has its own issues – what do you do with these patients when you have another blue light come in?

There have been so many headlines over the past few weeks:

A&E forced to turn away patients; Patients waiting 24 hours to be seen in A&E(!); A&E closures: the meltdown…

It doesn’t take much assessment to realise that when you close down an ED, the patients that would usually attend there will need to be seen somewhere else. And yet, it seems to have come as a massive surprise to everybody that in the wake of the closure of Hammersmith ED, the surrounding hospitals have seen increased waiting times, and Northwick Park Hospital has almost consistently been on divert, causing ambulance crews to telephone ahead and take patients to other EDs in the area. 

I am a huge proponent of closing dysfunctional departments. Having worked in a failing DGH last year, I strongly feel that no ED is better than a failing ED. However, there seems to have been no foresight with the closures, and the government very much seems to be expecting existing departments to pick up the slack with no extra room, resources, or staff. Yes, there are planned improvements to the services under strain, but it all feel a little perfunctory, and will likely be too little too late. Northwick Park’s escalation measures involve turning corridors into patient beds; this is not a sustainable situation.

The College of Emergency Medicine has produced several recommendations for fixing our ailing EDs. One of these is the STEP programme, which is basically common sense. It states that there needs to be higher staffing levels, more inpatient beds to free up ED assessment trolleys, and better access to, and knowledge of, primary care services. All of this feels a little obvious, and one wonders why there is less about how we can implement this in the media. But, I suppose, it makes a less catchy headline than “A&E 4 hour wait crisis”.

Frustration

Last Saturday, I cried for the entire journey home.

The day had been hugely stressful, the usual A&E combination of too many patients and not enough staff. It was largely my own fault – I had been hoping for a quiet shift in order to get some revision time in for an exam I was taking the following week. I did not stop from the time I entered the department until an hour after my shift finished when I finally dragged myself home. I had not had food, drink, or a wee for 12 hours. None of this was new. What was different on Saturday was that, for the first time since starting this job 4 months ago, I felt overwhelmed.  Patients with non-urgent problems were saturating the department, and as a result there were too few of us to see the seriously ill patients that required immediate care.

The fact that our current Health Secretary has publicly stated that he takes his children to A&E because GP waiting times are too long, shows us that there is a complete lack of public education concerning appropriate places to seek medical help. There are very few things more frustrating than seeing a patient in A&E who is annoyed at having waited three hours, and then telling them that there is nothing that you can do for them. Sending people back to their GP is a vicious cycle – they most likely presented to A&E because it takes ages to get an appointment, and although their condition is not life threatening, they want it sorted. This is entirely understandable. What the public as a whole do not realise though, is that unless your condition is serious enough to require admission to hospital, or something that can be sorted with a one off course of antibiotics, A&E is the worst possible place to go.

Since the restructuring of the healthcare system, which has put commissioning and budgeting in the hands of GP surgeries, we are no longer able to refer into specialist clinics from A&E. If I see someone who has come with palpitations, I have to send them back to their GP for a referral into a cardiology clinic for monitoring. If I see someone with angina-type chest pain, the referral to the “rapid access chest pain” clinic no longer comes from A&E; it comes from the GP. The problem with this, of course, is that many people still present to us in the hope of circumventing the waiting time at their GP surgery, only to find out that they need to go back there for the necessary investigations.

It is hugely frustrating as an A&E doctor to see someone, know exactly what investigations they need, and essentially have no way of ensuring that they happen. Good GPs, of which there are many, will look at the discharge and arrange appropriate tests. Good A&E doctors will write letters to the GP, which the patient can take with them to explain what investigations have been done and what are outstanding. The frustrating aspect occurs when the GPs are slow, or the communication breaks down, and then the person gets lost out in the community until they have another, non-urgent problem, and present to us again.

We have just changed jobs, and last week was my final shift in A&E for a little while. A lady presented whom I had seen 7 weeks previously, and had discharged home. She was in her eighties, and had probable new onset dementia. When she had first presented, her husband and daughter, frustrated with the lack of access to their GP, brought her to A&E because they were worried about the decline in her cognition. After discussion, we agreed that she did not need admission to hospital; they were coping at home, but were keen for a diagnosis and some social support. We did a basic infection screen, and I wrote a three-page summary of her presentation and the family’s concerns. The husband took the letter to their GP the following day. The crux of situations like this is that you cannot get social support until there is a formal diagnosis of dementia. Until there is a diagnosis, families struggle on by themselves, with inadequate resources, and little understanding of what they are undertaking.

If the woman had an infection, or was dehydrated, or ill enough to require admission to hospital, the diagnosis of dementia would likely have taken a few days. However, she was able to go home, and things move at a much slower rate in primary care. Unfortunately, in the intervening weeks, none of the investigations happened; no support materialised, and as such the same family represented to A&E on my final shift, after the lady had attempted to assault her husband because she didn’t recognize him anymore, and he had to lock all the doors in the house to stop her running out into the cold.

So, the family is back, again with an inappropriate presentation to A&E, but a presentation out of desperation. By some cosmic cock-up, they are seen again by the very doctor who discharged them into the community last time, with the promise that this would be investigated and they would get the help that they so clearly needed. Again, this lady’s infection screen was normal, bloods were normal, and there was no clear indication to bring her into hospital. I found myself – a compassionate, sensible doctor, advising this family to essentially abandon their elderly relative in a busy A&E department, alone and confused, because then we would have a reason to admit her for investigation. There is so much wrong with that picture that I don’t know where to start. When we, as clinicians, are reduced to hoping for abandonment as an excuse to diagnose an elderly lady and give her home support, it is a glaring example of the failings of our healthcare system.  

We need integration and communication between primary and secondary care. We need education for the general population on where to seek medical help. Lord knows there are enough YouTube videos around advising of where to go when you have the flu/need antibiotics/have run out of medication. I don’t know what the solution is, which is probably why I am not the Health Secretary, although he doesn’t seem to have this figured out either. All I know is that a system that leaves vulnerable people without support is not good enough. We are better than this.  

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