A&E in crisis: The junior doctor's inside story

We all hear the stories about hospitals in crisis and an NHS pushed to breaking point, but what's life really like on the inside? A junior A&E doctor shares her experiences with James Moore

Having read my blogs and articles on dealing with disability following a serious road accident and my experiences of the NHS, I was recently contacted by someone I shall call Dr Maitland to protect her identity.

Would I listen to the story of a junior accident and emergency (A&E) doctor in a system close to breaking point? We have heard from a consultant – Dr Rob Galloway, of the Brighton and Sussex University Hospitals NHS Trust, last week challenged David Cameron to debate the issue – but consultants are at the top of the ladder. They have clout and can go public without endangering their career prospects.

Juniors have it tougher. They would be taking a big risk in speaking out. They would be potentially putting their futures at risk. So she and I agreed to an off-the-record conversation over a quick dinner.

Dr Maitland is a locum – a freelancer, who can earn more from taking shifts at various hospitals than from a steady staff job. She is not a greenhorn – she has been out of medical school for some years – but she still looks tired, which is hardly a surprise. It's also not a surprise that she is unhappy about how she and her colleagues are sometimes portrayed in the media as being lazy and overpaid. Nor is it surprising how let down they feel by managers, politicians and a system that is steadily grinding them down and causing too many of their colleagues to depart.

But she is adamant about one thing: she loves the NHS. She says that it works, and could work well, but targets, particularly the hated four-hour A&E maximum waiting time, are making doctors' lives a misery and leading to perverse outcomes. The four-hour target requires that all patients should be seen and either discharged from the treatment area, or assigned to a ward for further treatment, within four hours. However, that leads to the absurdity that patients who are waiting for blood results have to be transferred to a ward even when they could perfectly well handle sitting in the waiting room. (The "blood ward", they call it.)

Another bugbear is the 111 phone service for non-urgent health issues. "They just seem to tell everyone to go to A&E. We get people turning up saying, 'I don't really know what treatment I need, but 111 told me to come here'."

Dr Maitland believes that the NHS is worth fighting for. "But if people end up dying it's not health carers who are to blame," she says. "It's the Health Secretary Jeremy Hunt and his legions of healthcare mis-managers."

This is Dr Maitland's story of life in an A&E in crisis:

"I wonder if there's ever been a worse time to work for the NHS. It used to be that doctors from around the world flocked to it, even when they had potentially more lucrative opportunities elsewhere.

They felt, as many did and some still do, that we had the very best health service, training and working conditions. Sadly, as a modern junior in today's NHS, I don't share the optimism and pride that previous generations started out with.

We may have a noble tradition of healthcare and healthcare staff in Britain, but you would be forgiven for feeling pretty despairing if you were to spend a Friday night in some of London's accident and emergency departments. (Last week, Croydon became the first London hospital to declare a 'major internal incident', where special measures are needed to cope.)

We have some great doctors, and other healthcare professionals, working in Britain, but they are battling in a system in which something has gone badly wrong.

I know that there is much that young doctors don't understand about healthcare management as exhausted triage monkeys. [Triage is the system by which doctors determine a patient's priority for treatment.] But perhaps, instead of closing reasonably functioning smaller casualty units with the promise of super casualty mega-departments, the powers that be could have just left good enough alone.

It certainly doesn't help that, in the midst of a profound crisis, we feel as if we are getting trashed in the media as a load of overpaid lazybones. There are many reasons why so many British emergency doctors want to leave and work abroad (recent figures from the General Medical Council show that there has been a 20 per cent increase in doctors applying to practice abroad in the past five years), but that's one of them, right there.

Here's what has caused the rash of recent headlines about the growing crisis in A&E departments: the health service is grappling with austerity-led cuts while trying to weather a perfect storm. Getting an out-of-hours GP is extremely difficult. We have a booming urban population and a recruitment crisis in emergency medicine. Put that all together in the middle of winter and you have got a problem. As doctors, we work in what should be a fabulous system, one where class, wealth, geography and age should be no barrier to receiving world-class healthcare. That potential is being squandered. Government policy is out of touch with realities on the ground. Economies of scale that might work for factory lines are being applied to healthcare. There will be a change in quality. The service will suffer. It's inevitable.

Let me illustrate with my experience at a major hospital in London. It's one that has been very vocal about receiving millions of pounds of investment in emergency care and theatres. But working some 10-hour night shifts there recently was a sobering experience.

The powers-that-be had previously closed down a couple of other casualty departments last year – in an area with a booming population and a fair amount of deprivation-linked ill health – and had advertised that the resulting investment in the remaining casualty department would result in a world-class service. So, of course, extra sick people began to arrive. Ah, but – whoops –none of that extra investment appeared to have turned up when the other casualty departments were shut.

On Fridays, when I started work at 10pm, the waiting room would be heaving with people. They would be sat on the floor and leaned against walls. The staff would work furiously all night, but ambulances just kept bringing more people who needed resuscitation. That took staff away from chipping away at the coalface of urgent ill health that was not yet immediately life-threatening. The other doctors, healthcare staff and I, we would look at each other and roll our eyes: a tide of wounded and unwell was not being looked after to the standards that we were trained to expect of ourselves, let alone the targets that we had been set. It was an impossible environment to cope with.

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Emergency medicine is uniquely demanding at the best of times. But this? This was working until I felt sick and weak at the knees. I was afraid to take a loo break because I feared that one of the balls I was juggling would crash down if I did. Every now and then, an angry patient would get past the triage nurse who sits between the treatment area and the waiting room and demand to know when they would be seen as their head was really hurting, their cut was bleeding, they were vomiting into the bowl they'd been given and were feeling really bad.

The nurses somehow managed to turn patients like this away calmly. But some eventually left after having waited five hours for their urgent ill health. To go where? It didn't bear thinking about. Of course, the shift that I am talking about is just one shift. It was an awful shift. But the problem is that awful shifts happened at this place every Friday and Saturday night without fail. And on many other days, too, as I can testify from my experience there.

"Sometimes, I would ask myself why those other two casualty units were closed. Rumours filtered down from more senior doctors that the much-publicised investment was just a cosmetic makeover. Shiny new paint and some building work had been funded for the accident and emergency department, but there was not a single new acute bed in the trust to allow for the increased numbers of patients. (We call this perverse situation 'exit block': it means we can't meet our four-hour targets because there are no ward beds to which we can send people.) So, without the increase in beds, and nurses to tend their occupants, the exit block could not be resolved and patients would stay too long in casualty. Result? We faced being castigated as useless and failing and money-grabbing.

Some casualty departments I remember for the smell of bleach, some for having the funniest nurses, or the best conversationalists among my junior doctor colleagues. Some for having the most rugged-looking consultant. Every A&E has something, as any doctor will tell you. This one I remember as my personal pit of hell. I'm an A&E doctor. I was sucked into doing shifts at this A&E because, like so many other doctors suffering the exorbitant cost of paying rent in London, I needed to earn extra cash. Even though I don't know of any doctors earning the £2,000 a day that was reported in The Sunday Times in the first week of the new year, the pay can be good and at this stage in my career, locum work suits me. But working shifts at that place left me with such a lasting negative impression that I have since spent many drunken hours questioning if I am cut out for emergency medicine after all.

As one of my colleagues once said to me, 'I don't know why anyone would want to work here long term'. The reward of lots of hard work is that you get given more hard work. It never ends, there is nothing to work towards.

Really, starting a night shift there felt like standing at the bottom of a mountain that could never be climbed. The day-shift medical doctors started the day with a long list of people that the night team had not seen. The night doctors then started the night with a list of patients into double figures that the day team had not seen: all unwell, some irate at the long delays, all who should have been seen earlier.

The wait for a casualty doctor was often six hours plus. Ambulances naturally brought the life-threatening emergencies directly through to A&E. The very nature of these cases meant that they took up a lot of time. Because of this, and because of the lack of staff, other people in discomfort with real illnesses that needed attention ending up just waiting and waiting... I remember the dim yellow light and the feeling that my soul was being sucked dry.

I remember feeling inadequate as, despite seeing people super fast, it made no impact whatsoever on the throngs in the waiting room. At about 2am in casualty, there is normally a lull when the majority of the work has been done and people can relax. There was no lull there. It felt like being in a war zone. Navy-uniform sisters would circle us doctors with acerbic demands for less chat and more work, or less time with each patient, followed by a running commentary on how many were still waiting to be seen in each department, as if to remind us of our appalling failure to make a complex diagnosis in less than five minutes flat.

Everywhere, I was assailed by long faces and grimly set mouths. Everywhere were very sick patients, elderly patients unable to communicate clearly, with complex medical histories, patients who did not speak English and had no one to translate but who still needed to be treated. Drunks who would lunge at me when I woke them to check that their stupor was definitely from intoxication and not a skull fracture.

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Exit block is the nightmare of casualty. Some patients who are very sick need a specialist to come to assess them right away. But there is always a wait. And at that particular hospital, when the specialty doctor turns up there is no room anywhere to put the patient as all the beds in the hospital are full.

Even if I could beat the clock, do all the right things for a very sick person, call the big specialist team to do their clever specialist things, I would often still commit the cardinal sin of casualty – keeping a person in the department for more than four hours.

The four-hour wait is completely arbitrary, a joke. It may be broken even though a patient has been seen within 30 minutes of pitching up, simply because they could not be moved on to whatever bit of the hospital they needed within four hours.

The only realistic way to meet such a facile target is more beds, and more nurses to tend them. Could it be so simple? Er – yes. Either that, or rework and revise the targets so that they reflect the reality – as with blood tests, for example. In the meantime, how about an end to those headlines saying that we are rubbish? It might not stop the bleeding of staff away from NHS emergency medicine. But it would at least be a handy piece of sticking plaster. Right now, we could really, really use some of that. And a lot more besides."

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