Government rejects call for summit to tackle A&E crisis
‘I still haven’t had a break. I’m tired and hungry. We still have 35 patients in A&E. It never stops.’ Photograph: David Levene/The Guardian
I am a senior registrar A&E doctor in a major teaching hospital. I qualified over 10 years ago and have been an A&E doctor for three quarters of my career. On most daytime shifts, I am in charge of a section of our department, such as the resuscitation room, majors, minor injuries, children’s A&E or clinical decision unit; when I work night shifts, I am in charge of the entire department, covering all those areas.
The difficulties we are facing this winter arise from patient and population factors, issues around senior staffing of A&E departments, and problems with the broader health and social care system. Most of the difficulties are not new, but the chronic strain they have been putting on the system for years has, for many reasons, been felt particularly acutely in 2014. It’s being called a winter crisis, but the summer of 2014 was the most difficult I have seen in my career; winter is only making matters that little bit worse – and so far, we are lucky that there has not been a big spike in influenza cases.
I’ll try to explain the problems using the format of a diary of a typical night shift in my A&E department.
10pm
I start work and take a handover of all areas of the department.
There are 72 patients in A&E. Half of them haven’t seen a doctor yet. Ten of them haven’t even seen a triage nurse who will decide how serious their case is. We don’t have enough space for them all.
All the beds in the resuscitation room (“resus”) are full.
Patients with chest pain are sitting on chairs, waiting for up to an hour for an electrocardiogram (ECG) to make sure they’re not having a heart attack.
Patients with minor injuries have been waiting for more than three hours to see a doctor. The day shift is finishing; more doctors are going home than are starting for the night shift. That waiting time is going to get longer. I cannot divert more doctors to see those patients because I need them with me in majors and resus to see the more unwell cases.
Three of the six doctors working under me tonight are locum doctors. They are not employed full time; they pick up the shifts they want, when they want, at different hospitals, for two or three times the pay I’m getting for tonight. Some of them are great doctors; others not so good. Two of them have never worked in this department before, so I’m going to have to show them round, explain our local policies, and teach them how to use the computer system before they can even see one patient. The reason? Nobody wants to take up full-time jobs in A&E any more – especially the more senior posts like registrar and consultant.
And why would they? For the same amount of training and experience, I could be a dermatologist or a kidney doctor. I’d work the same number of hours for the same pay, but much less (or no) evening and nighttime work, with regular, predictable, scheduled activities in my day, time for lunch, and no drunk people to deal with. Most of my patients wouldn’t be acutely unwell; I wouldn’t be making life-and-death decisions every shift. So why choose A&E, with constant pressure from dealing with really sick patients, drunks causing havoc all night, often no time for a lunch or dinner break, and frequent evening and night shifts? So – we’re really short of senior doctors, every day.
11pm
The ambulance service calls to say they’re bringing in a very unwell 80-year-old with difficulty in breathing. He’s going to need the resuscitation room, but it’s still full. I have to decide which of the sick patients in there can come out to a less high priority area.
The population is getting older and carrying a higher burden of serious illness. Patients with longstanding heart, lung, or kidney disease can become extremely unwell very quickly, especially if they catch flu or a vomiting bug. We are getting better at treating them. There is more we can do, but it takes a huge amount of resources. It’s expensive. The result is people do get better; they live longer with their chronic illnesses; and they keep coming back when new complications arise.
Minutes later, another call from the ambulance service. They’re bringing in a drunk man with a head injury who is being aggressive and difficult to manage. Maybe he’s being difficult because he’s drunk; maybe he’s always like that; but maybe he has a brain injury that’s causing this behaviour. He’s going to need to be in resus as well, and he will take four or five members of staff to sort him out.
1am
I’ve stabilised the two new resus cases. But my junior doctors are waiting to discuss their cases with me. Because I’m the only senior doctor on duty tonight, and I’ve been busy in resus, the juniors haven’t been able to make any real decisions about the patients they’ve seen. The queue, and the waiting time, is getting longer by the minute.
One of the patients they need to discuss is a 96-year-old whose relatives called an ambulance early in the evening because they couldn’t get her GP to visit her and treat what is probably a minor chest infection. But now it’s nearly 2am, so although she is not very unwell, she’s going to have to stay in hospital overnight: it’s not fair to send her home alone at this time. In hospital, she will occupy a bed unnecessarily.
Outside her familiar home environment, she is at increased risk of getting confused or falling over. And she may be at risk of contracting a hospital-acquired infection. If her GP could have visited her, she would have avoided all those risks, and we’d have another bed free. It’s not her GP’s fault: the GPs are terribly overstretched and under-resourced, too.
2am
The last four patients to arrive by ambulance were drunk. Very, very drunk. They’re taking up A&E cubicles and nursing staff, meaning that the old man who got a taxi here with chest pain (he “didn’t want to bother” the ambulance service) doesn’t have a cubicle or a nurse. One of the drunk patients is shouting and swearing. He urinates all over the floor. It’s upsetting for the family of the dying cancer patient next door. They should be spending these last days together in a hospice, not in A&E – but all the local hospices are full.
We’re seeing more and more drink-related problems. Drunk patients take up a lot of resources and they’re often frightening for other patients and relatives in the department.
3am
A woman arrives with her three-year old son in an ambulance. The boy has had a runny nose for three days and vomited once tonight. There’s no way they should be here, at this time, when he just has a cold – and they certainly shouldn’t have called an ambulance – but we have to see him anyway. She’s never heard of NHS 111.
4am
Phil has arrived in an ambulance. It’s the third time in the last 24 hours, the tenth time this week, and the 20th time this month he’s come to A&E, every time by ambulance. He has heart disease, it’s true, but every time he’s come to see us this month, we’ve found nothing acutely wrong with him. Maybe he’s lonely. Maybe he thinks it’s funny. Maybe he actually thinks there is something wrong. I’m not sure. But I do know we’ll have to do an ECG again, and a doctor is going to have to spend time carefully examining him to be sure that this isn’t the time when he actually is unwell.
Phil isn’t the only patient like this is our area. There are maybe eight or 10 of them. They take up a lot of time and resources unnecessarily, but there doesn’t seem to be much we can do about it.
5am
I still haven’t had a break. I’m tired and hungry. We still have 35 patients in A&E. It never stops. A few years ago, you could sometimes hope to get A&E empty by 4am and have an hour or so for the team to eat and freshen up, maybe do some teaching for the juniors. Not any more.
Patients want a 24/7 health service. Only A&E provides that. So they come, and they come, and they keep coming, all times of day and night.
The hospital is full. There are no more beds. If we decide to admit anyone else, they will have to stay in A&E for hours until mid-morning, when patients get discharged from upstairs. The hospital simply isn’t big enough. Part of the reason is that it’s so hard to put in place social care packages for patients who are medically well but need help looking after themselves at home. So they have to stay in a hospital bed until social services which are grossly underfunded – can organise a carer.
7am
Another priority call from the ambulance service. An 86-year-old man was found on the floor of his home by his son, who was going to pick him up for a hospital appointment. He’s been on the floor for 36 hours, lying in his own urine and faeces, shouting for help, because no one visited him yesterday. He has a broken hip and he’s gone into kidney failure. He might not survive. Maybe if people looked out for their elderly neighbours a little more, he could have been found sooner and he would have been much less unwell when he got to us.
Meanwhile, a man in his forties with a three-year complaint of back pain wants to know why he’s been waiting for over two hours to see a doctor. And why are there doctors sitting at the desk “not doing anything” when he is waiting to be seen? He came here instead of going to his GP because he couldn’t get an appointment until next week.
I want to ask him why it’s so urgent now, after three years and nothing’s changed, but hold my tongue. (The doctors at the desk aren’t “not doing anything”. They’re writing up notes on the patients they have seen – detailed, accurate notes are essential for delivering safe ongoing care – checking blood test results and scans, and discussing their patients with me and with specialist teams to decide on the best course of action for each case. And besides, none of them have had a break tonight.)
8am
Time to hand over to the day team. I’m past being hungry now; I just want to crawl home and into bed.
As I’m leaving, I see a man arriving with a blocked urinary catheter. The district nurse is meant to change it, which would solve the problem, but there weren’t any district nurses available this morning. So, like everyone else, his fallback plan is to come to A&E. It’s unfair on him – much better for him that he be treated at home – and it places even more pressure on our department, with too few senior staff, not enough space to see patients, and no beds for people if they need a hospital stay.
The day shift is short of nurses. Maybe that’s because half the senior charge nurses in our department have resigned in the last year or so. They’ve gone to find less stressful work in other specialities – or even other countries.
As well as too few nurses, there are two unfilled consultant shifts and three unfilled junior doctor shifts. Nobody wants to do A&E. I’m starting to see why.
This piece was submitted to the Guardian via GuardianWitness. You can read more from the assignment here.
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