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.

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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