Blame Culture

Today we woke up to the news that the GMC has won its appeal to the High Court, and has struck off Dr Bawa-Garba.

Imagine, if you can, returning to your job after a prolonged leave of absence (maternity leave in this case), beginning your role afresh in a new environment with which you are not familiar, and being told that your colleague couldn’t be in today, and could you please do their work too? Additionally you find out that your boss is uncontactable, the other members of your team all started 2 weeks ago and are just finding their feet, and the IT systems are down. Someone else, in a different team, makes a mistake for which you are punished, and at the end of a gruelling workday you make an entirely avoidable mistake, which leads to catastrophic consequences. Are you no longer qualified to do your job? Do you lack the qualities and experience necessary to carry out your day to day duties? Or are these exceptional circumstances, and an entirely understandable lapse in judgement?

This is what happened to Dr Bawa-Garba. She made a mistake, on the back of incredibly hard working conditions over the course of a 13 hour shift, and a 6 year old boy died. Initial investigations into the case found that her mistake may not have influenced the end result of the resuscitation effort – the outcome may well have been the same. As so often happens in medicine, the SUI team found multiple contributory factors leading to this horrific outcome, and ruled that no specific person was at fault. However, Dr Bawa-Garba was convicted of manslaughter, suspended from the GMC register for a year, and has now been completely struck off.

We hold clinicians to a higher standard than most. It is understandable – our mistakes carry higher stakes. There are horrendous consequences to our failings. However, can we blame individual doctors for an outcome that has occurred in a working environment that no sane person would find acceptable?

We, as doctors, often work shifts where you go 13 hours without eating, drinking, weeing, or sitting down. I have often joked, whilst on call, that I am treating a patient for hypoglycaemia or acute kidney injury, but that my blood tests may well be worse than theirs. We prioritise the need of our patients consistently above our own basic, human needs. We work in conditions that you would be sued for trying to impose on any other profession. And the worst thing is, we impose those conditions on ourselves. We consistently state that our working arrangements are unsafe, no one in their right mind would think that staffing a 500 bed hospital overnight with a medical team of 3 people is a good idea. Wards of 30 beds go from a team of 3-5 doctors during the day, to sharing the 3 on call doctors with the other 470 patients in the hospital. Even on days when the rota is fully staffed and all the systems are working, it is a disaster waiting to happen. Medical ward cover consists of running from one fire to the next, never feeling like you are winning. How are you supposed to prioritise your need to eat when a succession of patients are, literally, trying to die on you?

But hungry, exhausted, overstretched doctors make mistakes. It should not be news that we aren’t at our best when our last meal was 12 hours ago. I remember clearly finishing one day on call on the maternity ward, and passing out on the walk to my car. On reflection, I hadn’t had a meal since dinner the previous night. I was concerned about my ability to drive, and called a cab home. 45 minutes previously I had been responsible for resuscitating a patient, solo.

During my time as an intensive care doctor, I frequently covered a ward of 14 critically unwell patients, with no Consultant cover on site. I started the job, on a night shift, with no induction to the computer-based notes system, no idea how to review medications or change doses. No understanding of how the filtration machines or ventilators worked. The fact that both I, and the patients, survived those on calls is testament to the incredible standard of nursing care. The nurses on that unit saved me more times than I can recall. But it should not be the responsibility of the nurse to educate the doctor. By that logic, there is no point in me being there. I reflect on that unit, and the fact that nobody died as a direct result of my lack of training or experience is frankly baffling.

The GMC has gone on nothing short of a witch-hunt. Bowing to tragically bereaved parents, making an example of someone who did nothing more wrong than any one of us has done on countless occasions, but got away with due to circumstance. The CEO of the GMC released a statement following the outcome:  “We are totally committed to engendering a speak-up culture”.

How do you expect to foster a culture of speaking out, when you victimise people attempting to reflect on, and learn from, their mistakes? Doctors are human. We will all make errors in our careers. I have personally made management decisions that have contributed to a patient’s death. We are a cohort of professionals that go into medicine in order to improve people’s health and lives. Nobody can make us feel worse about our failings than we already do. Nobody can berate us more than we berate ourselves. We worry about doctors’ mental health. We worry about a culture where no one wants to accept responsibility or blame. And then we have a doctor, with an exemplary record, who reflected on a difficult case, gave evidence to an investigation panel, and then had her reflective evidence used to bring a court case against her.

We are all Dr Bawa-Garba. I don’t need to know the case specifics to know that similar situations are happening across the NHS on a startling scale. That the people responsible for safe staffing and rostering are not the people living with the effects of shortages on the frontline. That the people who have made a scapegoat out of this doctor get to go home at 5pm each day, and never have to hold a person’s life in their hands while trying to remember the last time they had something to eat.

It’s okay not to be okay.

I am British to a fault.

I have been ruminating on aspects of our character that we may be unaware of. My other half is an Aussie, and when we first got together we had numerous arguments based around the different connotations of the word “fine”. Myself, a Brit, would tell her that something was fine, and expect her to infer that it was anything but. She, in typical Aussie fashion, took everything at face value and then was unable to understand why I was miffed (another classic British understatement).

When she moved over here she commented on our typical British greetings “Hiya, you alright?” and how there was no acceptable response to that other than “Yeah fine thanks, you?” We are not asking after the other person’s well-being, and if someone were to deviate from the script it would be awkward to say the least.

These discrepancies can be amusing, but our idiosyncrasies sometimes inhibit our ability to let other people in. This can have devastating consequences, particularly in Medicine. In addition to the British avoidance of talking about feelings, people in Medicine are also reticent to admit what they perceive as weakness, and emotional responses and feelings often get bundled away and taken home, not aired and explored in a positive atmosphere. Mental Health is still not addressed as it should be, and we continue to perceive the demonstration of emotion as a sign of fragility.

When you work it every day, it is easy to forget how emotionally taxing our job is. We see people at their worst, both physically and emotionally, and the range of conditions we have to deal with on a daily basis can often be a complete mind-fuck. You go from treating 4-day-old babies with sepsis, to trauma calling a teenager who tried to commit suicide, to dealing with the aftermath of a neglect case. There is often no time to think about it, no time to dissect your feelings about a case, and definitely no time to deal with the emotions that either of those actions would inevitably stir. You have to develop a way of coping that allows you to move on to the next patient, the next parent, and the next disaster. It is a fine balance. We traditionally shut off the parts of ourselves that struggle to process the things that we see, and we notice ourselves become less affected by our daily exposures. But this is not healthy, and it only takes a small thing to tip the balance.

Between 10-20% of doctors become clinically depressed at some point in their careers, and there is a higher rate of suicide than in the general population; particularly in the acute specialties, where there is a “stiff upper lip” attitude and a tendency to push forward in the face of signs that we are perhaps not as okay as we seem.

This has repercussions not just for us as physicians, but also for the way that we treat our patients. Up to 50% of Emergency Medicine trainees resign prior to completion of their training. As a specialty we are seeing the highest rates of burnout in the history of the healthcare system. EDs are becoming like warzones, and our already fragile mental health is about to snap. The higher rates of burnout correlate with self-reported depression rates of up to 40%, with associated lack of empathy and altruism, and increased rates of errors. Over the last few months, I have actively felt myself becoming more cynical, and less motivated to help people. A parent books in with their sick child and I am annoyed that they are there. The very reason that I trained to do this job has become a source of irritation.

This façade spills over into our home lives too. I am so used to shutting off my feelings about things that happen at work, that I attempt to do the same with things that happen at home. Over recent months I have been endeavouring to insulate myself from my feelings about both issues at home and difficult cases at work. And my mind simply doesn’t have the capacity.

I have recently considered going to a counsellor to help me unpack all the emotions I carry around with me, both from my personal and professional life. It has taken an almost daily struggle to keep those emotions under the surface to illustrate to me how important it is to deal with your responses to situations instead of packing them away, and using the traditional dark humour to cover them up. I have been less than keen to address these issues, due to both an inbuilt, British avoidance of talking about “feelings”, coupled with a desire not to seem nauseatingly American by attending therapy; but also due to the inescapable concern that it makes me a weaker person. That other people are managing, and by my admission I am not. That this somehow makes me a lesser doctor, a lesser person.

Acknowledging emotions is not a sign of weakness. Unpacking your response to a patient, or a situation, or your relationship, is the healthy way to deal with it and move forward. We need to stop prioritising relentless, emotionless work ethic above the ability to be normal, functional, people. We need to allow ourselves to be human.

Some of this needs to stem from a revision of NHS culture, for the establishment to recognise that lack of debrief, lack of NHS counselling, lack of self-care for our emotional selves is damaging to our productivity as a workforce, but most of it can stem from us, as individuals. If we are affected by something, take the time to feel it. Discuss it, dissect it, and get different perspectives on situations. Maybe not at the time, but we should prioritise debrief, prioritise acknowledgement of an emotional response. Allow ourselves to care.

We need to recognise, as individuals, that we are not built to carry all our stresses around with us. That showing compassion towards our patients begins with showing compassion towards ourselves, that when you are saturated by stress and emotional baggage you lack the capacity to truly help the patients that put their trust in you. We need to understand that overexertion and dependence on 3 coffees to get through the day is something to be avoided, not romanticised. That working hard doesn’t have to mean running yourself into the ground, and that taking care of our mental health is paramount to being empathetic, successful physicians.

Paediatric Pearls

Things I have learned so far in kiddies ED:

  1. Bubbles have magical qualities and fix tachycardias ALMOST every time.
  2. There is no such thing as a “quick look” at a child in triage.
  3. Play specialists = HEROES.
  4. Early ametop application in triage is one of life’s greatest gifts.
  5. ALWAYS take a second cap gas because the machine demands one as a sacrifice.
  6. Sometimes kids just get rashes, and we don’t know why.
  7. All children in London are constipated.
  8. Parents never give paracetamol, for fear of us not believing that their child was in pain/hot. We berate them for it, and then don’t believe them that their child was hot at home if they aren’t hot here.
  9. I can now identify which antibiotics someone has been given based on what colour it is, what it tastes like, and what bottle it comes in.
  10. Suctioning bronchy babies and watching them instantly perk up before your eyes is one of life’s great pleasures.
  11. Sometimes a sympathetic face and time to listen is all it takes. Parents’ scope to worry about their children knows no bounds, and reassurance costs nothing. Be patient.
  12. A good number of midwives scales are broken.
  13. If the umbilical cord looks infected, it usually isn’t. When it is, it is a BIG deal.
  14. Getting a line into a 1 day old baby gives you the best high.
  15. Paramedics and GP surgeries NEVER have paediatric sats probes and this frustration will be felt DAILY.
  16. When you get cocky about your abilities you will inevitably do something insanely stupid like glue a child’s eye shut.
  17. When you finally know the doses for paracetamol and ibuprofen without looking them up you feel like a GOD.
  18. SOME babies ARE cute, and you have to remember to give them back to their parents when you are finished examining them.

Find your tribe.

Choosing a specialty is a funny old thing.

We spend a lot of time in medical school, and post graduation, trying to decide which area of Medicine we are suited to. It is an important decision, as it decides your career path and length of training, and although there is some potential for movement, it often entails further years in training if you get halfway down one path and decide you would rather be on another.

Some people are fortunate enough to be certain in their career aspirations, and know which path they want to pursue. I was never like that. I have found myself ambivalent about the specifics of Medicine. Nothing particularly excites or drives me more than anything else. I am generally doing the job because it seems a waste of a medical school education to do anything else.

It is bizarre then, that I have chosen Emergency Medicine. Ostensibly, this is the most stressful, involved, high pressured area of Medicine. You have to know lots about lots of things and for someone unexcited by various aspects of medicine, seeing patient after patient with a cough or a toe injury or a rash is hardly enthusing. Intersperse that with the seriously unwell patients who keep attempting to die on you, and on paper it sounds even less like something I would enjoy doing.

But the people. My God, the people. I remember walking into my first ED job, seeing the nurse in charge rip the shit out of the on call doctor with a crass and frankly too easy joke, and thinking “I have found my tribe.”

I firmly believe that it is not the type of job that you need to base your career decision on, but the type of people you will have to work with. And there is no better bunch than the ED team. Nowhere else in the hospital do nurses and doctors work so closely together. The relationship can be beautiful. You have the opportunity to understand each other, and ED teams become like family (a replacement for the family you have at home that you never see due to an unforgiving rota).

I have just finished a shift where it would be understandable if I was a broken person going home. Presentations were relentless, the board was out of control, not enough doctors, too few nurses, several angry patients – the usual ED shift. But instead, it was one of the better days I’ve had in a while. My personal life is a little rubbish at the moment and it is nice to be able to come into work, and have a good laugh with a genuinely great group of people. You don’t go into Emergency Medicine unless you are hardworking, sarcastic, fun, and have a thick skin.

I am in my 3rd year of ED training now, and during those years I have had to spend several months out of the department getting experience in other areas of medicine. And each time I have come back to ED I have felt the same sense of relief. Mainly the relief of no more ward rounds, no more clinics, and no more dealing with patients for longer than 4 hours (I have a ridiculously short attention span)! But also happiness that however rubbish the shift, however overworked, underpaid, generally under appreciated we all are, there will be piss-taking and merriment, and, if I have had time the night before, homemade cakes and biscuits. You can’t ask for more than that.

Welcome to A&E

confessionsofajuniordoctor:

I have no idea what it is that I like about Emergency Medicine.

The hours are terrible. The rota is indecipherable. You cannot plan to attend a friend’s birthday or a family gathering. Your social life is non-existent. The patients are largely rude, drunk, smelly and irreverent. There are never enough staff on shift. The urgent care centre referrals are sometimes ludicrous. The GPs send in UTIs as renal colic, PID as appendicitis, persistent patients that they can no longer placate. The specialty doctors think we are either lazy or lobotomised. You spend more time than you should at the centre of “specialty tennis”.

The four hour wait is a travesty. There are never enough observation beds. The pressure is immense. The clock never stops. There is always another patient waiting, another test to order, another result to check. There is always a diagnosis to be made, and treatment to initiate, a conversation to be had. You go from renal colic to brain tumours to heart attacks. You see depressed people, drunk people, old people, children. You see people at their worst. You see time wasters and hypochondriacs and then sepsis and deaths. You don’t have time to process. You don’t have time to think. You see, treat, refer, discharge.

People complain about the waiting time, disagree with your assessment, believe google before they believe you. You go home at night paranoid about the patient you sent home; constantly questioning your decisions, your abilities and your sanity. You see multiple patients simultaneously, you are a porter, a nurse, a cleaner, a friend, a confidant. You tell people good news, bad news, sad news.

You are charged with the unhappy job of treating people’s liver disease from excessive alcohol, lung disease from smoking, diabetes from overindulgence. People expect you to take responsibility for their lifestyle choices. You endure the abusive drunkards, the psychotic schizophrenics, the deranged elderly. You put up with the people who have neither an accident nor an emergency.

You exhaust yourself looking after these people, so much so that you go without food, without bathroom breaks, without the most basic of human needs. You are vilified by the media, who feel you are paid too much for what you do. You are misunderstood by friends and family who watch too much ER and Casualty. You become unacceptably irked by poor resuscitation techniques on TV shows. You complain about unnecessary attendances and then carry out wholly unwarranted tests because you are scared of being sued. You will inevitably have complaints filed against you for merely doing your job. You will make poor management decisions and people will die. You will make excellent management decisions and people will still die. You will defy the odds: CPR will work; the patient will recover from sepsis; be discharged from hospital, and then die at home a week later.

You will miss things. You will be wrong on a daily basis. Everyone thinks they know more than you. You finish a shift and barely have the energy to walk to the car; let alone drive home. You spend at least half of your days off comatose in bed. You don’t see your housemates for weeks due to opposing shift patterns. You do locum shifts during your time off because there are never enough doctors and you know how awful it is to work when they’re short staffed. The barista at Costa knows what sort of day you’re having based on whether you order a medio cappuccino or a double espresso. The packed lunch you brought 3 days ago is still sat in the refrigerator. Once you leave work you are unable to make the smallest of decisions because you have used up all of your brain cells.

You are stressed out, overworked and rarely thanked. And I can’t think of any specialty that I would enjoy more.

I wrote this post over a year ago. I am now back in ED as a specialty trainee, and the above is just as true as it has ever been.

I have loved this job in the face of so many reasons not to, and it will take more than contract changes or incompetent health secretaries to change that. Do your worst Jeremy, we will be doing our jobs long after you have finished doing yours.

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.