I’m an emergency physician. My duty of care is not understood by many of my colleagues.
It is being able to provide, at a moment’s notice, the emergency treatment anybody in my catchment area might need. That anybody could be a blue baby rushed out of a car, to someone having a stroke or a heart attack. Or it could be the more mundane things – the injuries, fractures, and mental and social crises. I take professional pride in dealing with each case well, by which I mean humanely, quickly, efficiently and safely.
For the past two weeks, however, my Emergency Department has been struggling to do this. Our space in the hospital is finite, yet we are expected to turn it into a magical Tardis to solve the problems of increased demand, sicker patients and yes, the fact that large parts of the health and social care workforce have had two bank holiday weekends, if not an entire fortnight off.
The magic, unsurprisingly, doesn’t work. Instead, our department is full, too full to perform its primary duty of care.
The Emergency Department is the only part of the healthcare system which is completely open access, 24 hours a day. There is an assumption it will cope with anything thrown at it. That assumption is only held by those who don’t work there.
If you did work here, you will wonder how long old people could seriously be asked to use a commode behind a curtain, in an eight-person observation bay, as they wait 16 hours to get to a proper ward and bed. You will wonder how, if there are six patients who need to be placed in the resuscitation room, reserved for those who need the highest levels of care, how they will all fit. You will be angry, because three of them should have been in a ward six hours ago. You will be worried you will end up resuscitating someone on the floor, as it is the only space.
When you arrive in the morning, you’ll find your night shift colleague looking shell shocked, or in tears. You may even give them a hug, before you send them home. You’ll start on the 10 patients who have been waiting overnight and if you’re lucky you’ll spot the mistakes that have been made by overloaded staff and correct them without any harm occurring. Then you’ll hear management declare your department “safe”.
You’ll wonder if the patient who is terminally ill will, in their last hours, get the dignity of a side room to be with their family, or if, as has happened before, it’s going to be in earshot of a drunk brought in by the police, who is swearing..
You will also wonder why there are so few complaints from the patients and their relatives. Possibly there is a misplaced fear of retribution. When they do complain about these inhumane delays, they are often very clear that the staff work like Trojans and are not to be faulted.
The Emergency Department is a place with a finite capacity in space and time. It cannot be allowed to be congested, because the only certainty is that more patients will arrive.
We emergency workers are the “engine fail” light on the dashboard. If we’re in trouble, it’s because the entire health and social care system is failing. If there are patients stuck in our corridors, waiting on a bed, it is usually due to delays elsewhere in the institution.
Caring for acutely unwell patients is a continuous process, occurring all seven days a week with predictable peaks and troughs. Imagine a busy restaurant. The owner turns up at 5pm, tells the dish washers and waiting staff to go home, and asks the chefs to take over because “they’re there anyway”. Of course, there would be an outcry when the plates were dirty and no one could get served.
Unfortunately, though, what is happening in the NHS is more serious than a snappy analogy. It has been proven worldwide that patients in such a badly blocked system will encounter harm, and yes, avoidable mortality.
When a system cannot move a patient from accident and emergency to an in-patient hospital bed, we call it Exit Block. This is hardly unique to the NHS. The causes and consequences of Exit Block have been analysed worldwide and found to be consistent, whether you are in London, Glasgow, Sydney or Baltimore. The problems of long waits and crowding are found all over the UK. The causes are similar and extend beyond party politics, but the degree of system failure has been varied, with Scotland performing better and Northern Ireland being the worst.
In 2010, Robert Francis concluded his first report into the Mid Staffs scandal, prompted by unusually high deaths at the Stafford hospital. He blamed “a chronic shortage of staff”, with concerns on the ground ignored.
This system is like Mid Staffs writ large across the whole UK. The health and social care sector does not have enough resources to perform safely. Yet for some reason, this state of affairs is permitted. To solve it requires facing difficult questions about resources, and working practices. We need to face them, or we are complicit in avoidable harm.
Dr David Chung is the vice president for Scotland of The Royal College of Emergency Medicine.