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”.


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.  


Welcome to A&E

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.

“Each man is capable of doing one thing well. If he attempts several, he will fail to achieve distinction in any.” Plato

It is interesting that general belief appears to be that the NHS is an anomaly. A shining beacon of socialism with the rare quality of providing healthcare for all, regardless of income. In 1948, this was definitely true. In a post-war era, the founding of the NHS was a spectacular leap forward.

I found it faintly baffling in the Olympic Opening Ceremony, when we devoted a significant portion of the proceedings to the founding of the NHS. It underlines the national feeling of pride about our healthcare system, and an assumption that other countries are not as fortunate. This is false: almost every other developed country has a comparable system. Some are taxation based, some work on compulsory insurance, but the general principle of universal healthcare unrelated to income is now implemented across Europe and the developed world. 

It is the misconceptions about our healthcare system, both about ideology and practicality, that lead to the discrepancies of opinion between public demand and system reform. There is a general feeling that reorganisation and specialisation are undermining the ethos of our healthcare system. There is public disgruntlement about local hospital closures and apparent diminishing services in district hospitals.

I have completed almost a year working at Ealing Hospital, where there is much uncertainty regarding the future of various specialist services in view of the proposed merger with Northwick Park and North West London hospitals. Daily, I walk past protestors on the way into the hospital, campaigning for the A&E department to remain open, and for the retention of specialist services at their local hospital.

On the face of things, it appears to be detrimental to shut local services, but this is not the case. If you were to have a serious heart attack, your best chances of surviving would be to get you to a catheterisation suite, where a specialist heart doctor could inject dye and map your arteries, re-inflate areas of blockage with a balloon, and probably stent the arteries in order to ensure continuing blood flow. To be effective, this needs to ideally happen within 90 minutes of you first experiencing symptoms. This has many barriers, not least the amount of time it takes the average person to realise that they may be having a heart attack. Logically, to the public, it seems rational that getting to an A&E 10 minutes away will improve your survival rather than travelling an extra 15 minutes down the road. 

However, the precision and speed at which these services are deployed increase with every person treated. If you are blue lighted to the Harefield, a specialist cardiac hospital, then they will have seen hundreds of thousands of the exact same case, everyone will have a preordained role and, on average, they can get you from ambulance to catheterisation in 30 minutes; assessment, examination, and diagnosis all happen on the move to the theatre. 

Now take Ealing. Admission to A&E, running an ECG, taking confirmatory blood test and diagnosing a heart attack will inevitably take around an hour. We just don’t have the specialist set up. Additionally, Ealing doesn’t do out of hours catheterisation, so most people will sit overnight awaiting operation in the morning. Somehow, the extra 15 minutes doesn’t seem so bad. The cardiac team at Ealing are exceptional, they are perhaps the best functioning team in the hospital, however, there is only so much you can conceivably do in a district hospital, and there just aren’t the facilities for specialist treatment.

Specialisation of services is not a bad thing. Yes, it is incredibly frustrating for the cancer patients who have to attend multiple hospitals for treatment – radiotherapy at one, surgery at another, follow up at their local hospital. Yes, it is a pain in the ass travelling continually for medical treatment. But if the alternative to that is sub par medical care, I think I would do the travelling. 

A Good Death

Everyone has an opinion about the Euthanasia Bill.

For most people with an opinion, the number of times they will be affected by the bill in their lifetime could be counted on one hand. For me, in my current placement, it would affect me daily. I regularly deal with frail, elderly people with terminal diseases. On the whole, they are managed very well, and are often discharged to die at home with dignity, surrounded by their families, supported in the community.

However, there are regularly people who slowly waste away in side rooms in hospitals, with their poor families spending hours, days, weeks in a horrible limbo awaiting their inevitable, but strangely reticent, death. Desmond Tutu has recently been quoted as saying that a “dignified death is our right”. There is nothing dignified about a prolonged dying process. There is nothing sacred about the last few days spent rattling, gurgling and unable to communicate.

I recently had a patient who expressed the wish to die constantly. He was an elderly gentleman who had lived an incredibly full life and was immeasurably frustrated at his current inability to do all the things he wanted to. He was not coping at home, but refused help, and was repeatedly hospitalised due to falls or chest infections. He refused antibiotics for his third pneumonia, and eventually wasted away after a long period of discomfort in a side room in hospital.

Of course, the situation will invariably be more complex than this. The proposed Bill would allow doctors to provide fatal medication to people judged to have less than 6 months to live. As with everything in medicine, there are no certainties. There is new information emerging all the time; scans can be reported poorly and treatments can work better or worse than expected. Estimating survival time is my least favourite part of my current job in Geriatrics. You will inevitably be proven wrong by a patient living months rather than weeks or hours rather than days. People towards the end of life fluctuate regularly with regards to wishes and needs. They are scared. They are frustrated. They are dying. These are difficult situations. But just because something requires thought, and safeguarding, does not mean it is not worth implementing.

I am not suggesting that we approach terminal illness in any way differently with regards to our palliative care input, and our social support systems. These systems are, by and large, incredible, and hugely beneficial to both the patients and their families. However, I think that we have a right to make decisions about our own lives. We are already able to refuse life-prolonging treatments, we can say no to life saving procedures. However, we are unable to actively end our own lives, and that is contrary to our right to autonomy as human beings.

Bishop Egan is calling for group prayers across the UK prior to the discussion in the House of Lords. Apparently, legalising euthanasia would mark the “catastrophic collapse” of the respect for life. Unsurprisingly, I disagree.

As always, religious arguments that hinge on our lives not being our own to dispose of baffle and vaguely amuse me. The argument centres on the fact that God knows what is best for us; life is a gift from God and we should appreciate it. If we take this viewpoint to its full force then where do we draw the line with medical treatments? It is bizarre to me that it is deemed acceptable to do things to prolong our “God given” life, and yet not to shorten it. Surely if God should choose when we die then neither of these things are acceptable. Surely there is an argument that if God has given us the knowledge and ability to heal people, He would be in favour of us using that knowledge to hasten a hideously prolonged wasting away of a previously fiercely independent octogenarian with incurable metastatic disease.

Not all opposition for legalising euthanasia stems from religion. There are people who worry that allowing people the option of ending their lives will lead to a lack of respect for those who don’t, a pressure on the elderly to end their lives prematurely, a reduction in the importance of good palliative care and end of life management.

Safeguarded correctly, no one is going to be forced to die early. Just because euthanasia might be legalised does not mean it will be imposed on the whole population. If you don’t agree with it, then don’t choose it. But people should have the right to decide what happens to them in their final days, a right to die comfortably, quickly, and at a time of their choosing.

Aneurin Bevan is my hero

The NHS gets a bad press. 

As an organisation founded in 1948, it is no wonder that it is struggling to keep up with the growing demands and expectations of an ageing population. The fundamental principle of a free at point of service healthcare system for all, is something that I am immensely proud to be a part of. It is consistently portrayed as a decaying and inefficient system, with no option other than privatisation viable to sustain it. 

I think this is a mistake. 

I have first hand experience of the dedication of NHS staff to ensuring effective and timely management for patients regardless of their social status. With privatisation will inevitably come prioritisation, and we will be in severe danger of losing the ethos of our healthcare system.

Despite the overarching belief that the NHS is an outdated model which needs renovation, England still has the best healthcare system in the world. I think it is pretty spectacular that from first presentation at A&E to diagnosis and initial management of complex diseases such as cancer and heart failure takes on average only 48 hours. And 4 of those will be spent waiting in A&E…

My colleagues and I consistently stay beyond our finishing time in order to update families about patients’ progress, or to deal with emergencies that inevitably seem to occur at 5:30 when you are crabby and tired after a long day and should have left the hospital already. There is a sense of shared responsibility, a sense of duty and an underlying pride at being able to provide the world’s best medical input for people who would be otherwise unable to afford it. Yes, there are days when the inefficiency stifles me, when I get irreparably frustrated with our lack of resources and the dissatisfaction of patients and staff alike, but on these days I try to take a step back and remember the principles that our system is based on, and the ethos we are working for, and then the shortcomings don’t seem to matter as much.

The NHS has become a political model, and as such it is not left alone long enough to gain level footing. Every new government has to have a different plan for saving the NHS, and as such none of them are given time to work. Instead of giving up on it, we need to accept that as an organisation it is always going to require more funding, it is always going to be inefficient (because how can you legitimately price health?)..instead of lamenting this, we should be proud of it. There are few better things to spend our money on than health provision. We should be praising NHS staff, and supporting them, bankrolling them, celebrating them. We still have a reason to be proud of our healthcare system. We should not condemn it just yet.