With hospital admissions increasing, why aren't medical staff numbers going up?

A case of "too many cooks spoil the broth".

Recent news regarding a 37 per cent increase in emergency hospital admissions comes as no surprise. There has been significant advancement in diagnostics and management intervention over the past decade and beyond and hence people are simply living longer. Many individuals suffer from chronic conditions where relapses occur and do so frequently. A patient with ischaemic heart disease may present regularly with chest pain, a patient with chronic bronchitis may present with a chest infection and someone with diabetes may be admitted with excessively high blood sugars. Therefore patients are admitted to hospital to achieve optimisation of their clinical state and appropriate care to see them through the acute phase.

Having worked in the NHS for five years I am for one proud of the care we deliver – this may be a biased opinion but it is an institution we should be proud of and continue to support whole heartedly. One of its detriments however is the simple lack of its workforce. Hospital specialty teams are typically led by a consultant, a specialist registrar, and if lucky a couple of senior house officers and house officers. Of course not all members of each team are present at any one time in view of on call commitments, leave post shift work and additional training commitments which fall under the continuing medical education (CME) umbrella. Therefore it can prove quite a challenge to serve the ever increasing patient admission rate with a not so concrete workforce.

In 2010, the government introduced the NHS 111 service with its aim to eventually replace the current NHS Direct service by 2013. Individuals are advised to call 111 if:

  • You need medical help fast but it's not a 999 emergency.
  • You think you need to go to A&E or need another NHS urgent care service.
  • You don't know who to call or you don't have a GP to call.
  • You need health information or reassurance about what to do next.

(Available from www.nhs.uk)

According to the website’s section entitled "How does it work?", the service is manned by "fully trained advisers supported by experienced nurses who will ask you questions to assess your symptoms, then give you the healthcare advice you need or direct you straightaway to the local service that can help you best."

Now I may be wrong, but if I was unwell no matter how severe I would personally choose to see a doctor in person and not talk to some random on the phone. Similarly if I chipped my tooth I would surely see a dentist and if I strained my hamstring playing football I would surely benefit by seeing a physiotherapist.

In the north west of London there are now plans to close four A & E units. The medical director for NHS North West London, Dr Mark Spencer, said: "hospitals here face considerable clinical and financial challenges." Now bearing in mind the rise in acute hospital admissions surely it doesn’t seem feasible to proceed with such plans?

Research by the Dr Foster group has shown an increase in patient mortality if admitted as an emergency over the weekend as well as higher mortality rates in hospitals with the fewest senior doctors available at the weekend. In response to these findings, the Royal College of Physicians is now working on plans to ensure consultant cover is present around the clock. We have of course all read about the apparent horrors of "Black Wednesday", the first Wednesday in August, where freshly faced junior doctors start working and have been deemed responsible for an apparent 6 per cent rise in emergency admission mortality. It begs the question therefore that if these juniors are responsible for such a killing spree why are seniors not actively training them from the moment they set foot in medical school to ensure they are fully capable and confident in dealing with acute medical and surgical problems instead of brushing them under the carpet and making them someone else’s problem.

So what is the solution? Well of course there is no easy answer but with simple deduction, if the number of patients being admitted are increasing, increase the number of doctors suitably trained to deal with the problem first hand, and of course with that follows the number of multidisciplinary staff, such as nurses, physiotherapists and occupational therapists.

I guess what we have here is a case of "too many cooks spoil the broth" or as an alternative "there are too many chiefs and not enough Indians".

Whichever you prefer.

Neel Sharma is a Medical Doctor and Honorary Clinical Lecturer at the Centre for Medical Education, Barts and the London School of Medicine and Dentistry

The A & E department at the Queen Elizabeth in Birmingham. Photograph: Getty Images
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I am special and I am worthless: inside the mind of a narcissist

There's been a lot of discussion about narcissists this week. But what does the term actually mean?

Since the rise of Donald Trump, the term “narcissistic” has been cropping up with great regularity in certain sections of the media, including the pages of this journal. I wouldn’t want to comment about an individual I’ve never met, but I thought it would be interesting to look at the troubling psychological health problem of narcissistic personality disorder (NPD).

People with NPD (which is estimated to affect about 1 per cent of the population) have a characteristic set of personality traits. First, they have a deeply held sense of specialness and entitlement. Male NPD sufferers frequently present as highly egotistical, with an unshakeable sense of their superiority and importance; female sufferers commonly present as eternal victims on whom the world repeatedly inflicts terrible injustices. In both cases, the affected person believes he or she is deserving of privileged treatment, and expects it as a right from those around them.

Second, NPD sufferers have little or no capacity for empathy, and usually relate to other people as objects (as opposed to thinking, feeling beings) whose sole function is to meet the narcissist’s need for special treatment and admiration – known as “supply”. In order to recruit supply, NPD sufferers become highly skilled at manipulating people’s perceptions of them, acting out what is called a “false self” – the glittering high achiever, the indefatigable do-gooder, the pitiable victim.

The third characteristic is termed “splitting”, where the world is experienced in terms of two rigid categories – either Good or Bad – with no areas of grey. As long as others are meeting the narcissist’s need for supply, they are Good, and they find themselves idealised and showered with reciprocal positive affirmation – a process called “love-bombing”. However, if someone criticises or questions the narcissist’s false self, that person becomes Bad, and is subjected to implacable hostility.

It is not known for certain what triggers the disorder. There is likely to be a genetic component, but in many cases early life experiences are the primary cause. Narcissism is a natural phase of child development (as the parents of many teenagers will testify) and its persistence as adult NPD frequently reflects chronic trauma during childhood. Paradoxically for a condition that often manifests as apparent egotism, all NPD sufferers have virtually non-existent self-esteem. This may arise from ongoing emotional neglect on the part of parents or caregivers, or from sustained psychological or sexual abuse.

The common factor is a failure in the development of a healthy sense of self-worth. It is likely that narcissism becomes entrenched as a defence against the deep-seated shame associated with these experiences of being unworthy and valueless.

When surrounded by supply, the NPD sufferer can anaesthetise this horrible sense of shame with the waves of positive regard washing over them. Equally, when another person destabilises that supply (by criticising or questioning the narcissist’s false self) this is highly threatening, and the NPD sufferer will go to practically any lengths to prevent a destabiliser adversely influencing other people’s perceptions of the narcissist.

One of the many tragic aspects of NPD is the invariable lack of insight. A narcissist’s experience of the world is essentially: “I am special; some people love me for this, and are Good; some people hate me for it, and are Bad.” If people with NPD do present to health services, it is usually because of the negative impacts Bad people are having on their life, rather than because they are able to recognise that they have a psychological health problem.

Far more commonly, health professionals end up helping those who have had the misfortune to enter into a supply relationship with an NPD sufferer. Narcissism is one of the most frequent factors in intimate partner and child abuse, as well as workplace bullying. The narcissist depends on the positive affirmation of others to neutralise their own sense of unworthiness. They use others to shore themselves up, and lash out at those who threaten this precarious balance. And they leave a trail of damaged people in their wake. 

This article first appeared in the 16 February 2017 issue of the New Statesman, The New Times