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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The most terrifying thing about Donald Trump's speech? What he didn't say

No politician uses official speeches to put across their most controversial ideas. But Donald Trump's are not hard to find. 

As Donald Trump took the podium on a cold Washington day to deliver his inauguration speech, the world held its breath. Viewers hunched over televisions or internet streaming services watched Trump mouth “thank you” to the camera, no doubt wondering how he could possibly live up to his deranged late-night Twitter persona. In newsrooms across America, reporters unsure when they might next get access to a president who seems to delight in denying them the right to ask questions got ready to parse his words for any clue as to what was to come. Some, deciding they couldn’t bear to watch, studiously busied themselves with other things.

But when the moment came, Trump’s speech was uncharacteristically professional – at least compared to his previous performances. The fractured, repetitive grammar that marks many of his off-the-cuff statements was missing, and so, too, were most of his most controversial policy ideas.

Trump told the crowd that his presidency would “determine the course of America, and the world, for many, many years to come” before expressing his gratefulness to President Barack Obama and Michelle Obama for their “gracious aid” during the transition. “They have been magnificent," Trump said, before leading applause of thanks from the crowd.

If this opening was innocent enough, however, it all changed in the next breath. The new president moved quickly to the “historic movement”, “the likes of which the world has never seen before”, that elected him President. Following the small-state rhetoric of his campaign, Trump promised to take power from the “establishment” and restore it to the American people. “This moment," he told them, “Is your moment. It belongs to you.”

A good deal of the speech was given over to re-iterating his nationalist positions while also making repeated references to the key issues – “Islamic terrorism” and families – that remain points of commonality within the fractured Republican GOP.

The loss of business to overseas producers was blamed for “destroying our jobs”. “Protection," Trump said, “Will lead to great strength." He promised to end what he called the “American carnage” caused by drugs and crime.

“From this day forward," Trump said, “It’s going to be only America first."

There was plenty in the speech, then, that should worry viewers, particularly if you read Trump’s promises to make America “unstoppable” so it can “win” again in light of his recent tweets about China

But it was the things Trump didn't mention that should worry us most. Trump, we know, doesn’t use official channels to communicate his most troubling ideas. From bizarre television interviews to his upsetting and offensive rallies and, of course, the infamous tweets, the new President is inclined to fling his thoughts into the world as and when he sees fit, not on the occasions when he’s required to address the nation (see, also, his anodyne acceptance speech).

It’s important to remember that Trump’s administration wins when it makes itself seem as innocent as possible. During the speech, I was reminded of my colleague Helen Lewis’ recent thoughts on the “gaslighter-in-chief”, reflecting on Trump’s lying claim that he never mocked a disabled reporter. “Now we can see," she wrote, “A false narrative being built in real time, tweet by tweet."

Saying things that are untrue isn’t the only way of lying – it is also possible to lie by omission.

There has been much discussion as to whether Trump will soften after he becomes president. All the things this speech did not mention were designed to keep us guessing about many of the President’s most controversial promises.

Trump did not mention his proposed ban on Muslims entering the US, nor the wall he insists he will erect between America and Mexico (which he maintains the latter will pay for). He maintained a polite coolness towards the former President and avoiding any discussion of alleged cuts to anti-domestic violence programs and abortion regulations. Why? Trump wanted to leave viewers unsure as to whether he actually intends to carry through on his election rhetoric.

To understand what Trump is capable of, therefore, it is best not to look to his speeches on a global stage, but to the promises he makes to his allies. So when the President’s personal website still insists he will build a wall, end catch-and-release, suspend immigration from “terror-prone regions” “where adequate screening cannot occur”; when, despite saying he understands only 3 per cent of Planned Parenthood services relate to abortion and that “millions” of women are helped by their cancer screening, he plans to defund Planned Parenthood; when the president says he will remove gun-free zones around schools “on his first day” - believe him.  

Stephanie Boland is digital assistant at the New Statesman. She tweets at @stephanieboland