Patricia Hewitt's budgeting may have made the NHS healthier in a financial sense, but at what cost? An A&E doctor reveals all...

Everyone expects working in an emergency department to be stressful at times. Can you get intravenous fluids quickly enough into the alcoholic whose gullet has started to haemorrhage, particularly as he's had so many blood tests recently that none of his veins are visible? Can that child with a fever be sent home safely, or is it the early stages of meningococcal septicaemia, which can be life-threatening?

What you don't expect is to worry whether your department is safe. To be concerned that there may not be enough qualified staff on duty to care effectively for the patients. "Care" in this context does not mean moppingfevered brows and brewing tea (both abandoned a while ago), but preventing patients getting any sicker before they are properly assessed.

In June last year, the Health Secretary Patricia Hewitt promised to resign by this month unless the NHS balance sheet turned from red to black. It looks as though her job is safe, but the real cost of this apparent financial stability is far higher than it looks on the accounts.

Last summer, when Mrs Hewitt made her prediction for NHS finances, we had around seven trained nurses on most shifts in my department. Now we usually have four, or on a bad day, three. Nowhere in a hospital is the quality of nursing staff more important than the emergency department, and at no time has this invaluable resource been more stretched, with some ambulance services reporting a recent rise in call-outs of up to 20 per cent.

In departments that are mainly, particularly at night, staffed by quite junior doctors, the nurses are often relied upon for immediate advice on everything from how to manage the man threatening to take home the daughter he is suspected of abusing, to knowing where the gauze swabs are kept. So it is shameful that the books of the NHS are being balanced, in part, by cutting back on this essential part of the service.

My department is under such extreme pressure to help the hospital meet its financial targets, that no one can seriously argue that patient care is not being compromised. Certainly not the nurse in tears of frustration as she battled with a computer to cross-match blood for the young patient knocked down by a car, whose spleen was releasing what blood he had left into his abdomen. It's a job that used to be done by clerical staff, staff that they say we no longer need.

"They", the managers, don't talk of cutbacks, but of "rationalisation". In the Alice-in-Wonderland world they inhabit, replacing two or three trained nurses per shift with cheaper, unqualified assistants is not about saving money, but about extending roles and enabling stakeholders in the client-care pathway.

The managers are the politicians' foot soldiers. Usually, they are not around to see the results of their decisions. These range from minor annoyances, such as not being able to spend as much time as you should with a bereaved family to the potentially catastrophic; the missed septic patient, nearly sent home because someone had forgotten to check their temperature.

Training budgets have been cut back, or simply suspended. As a direct consequence, when our new defibrillator appeared, nobody had been trained in its use the first time a patient needed it. On another recent shift, of the three qualified nursing staff present, one was dealing with aman who had bled into his brain. Another was helping control seizures in a three-year-old, and the third one was transferring a patient to theatre whose thigh bone was poking out through his jeans.

Which left two unqualified assistants with three months' A&E experience between them, to temporarily look after 10 or so "trolley" cases, from backache to threatened miscarriage. They also had to make sure the department was clean to prevent the spread of MRSA, answer the phones that never stop and keep an eye on the junior doctors.

While the trust I work in has more financial problems than some, it is hard to believe that practices similar to those I have witnessed are not being repeated throughout the country. Indeed, we are far from the top of the list of "overspent" trusts.

About the only marker of patient care available to auditors is the time patients spend in A&E, which is never supposed to exceed four hours. Many within the service despise this system, which can encourage rushed judgements, inappropriate discharge or admission, and tells you nothing of the real level of care being provided. But the four-hour target may turn out to be a friend in disguise.

With those in charge deaf to our concerns, but mindful as ever of the daily numbers game, increased "breaches" of the four-hour target may be the only way we have of trying to demonstrate how unacceptable things have become.

The writer is a doctor at an NHS hospital in the south of England