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A winter's tale

Busy hospital, corridor

Unfair, unsustainable, unsafe – the verdict of frontline doctors, who in a series of interviews with the BMA’s Peter Blackburn, give a harrowing account of providing care during the worst winter crisis in memory

There’s a constant niggle in your head – you come home with your brain ticking over and it’s very hard to get to sleep. There are still patients lying there in that corridor.’

For this emergency medicine consultant, whose voice cracks and breaks just recounting another day at work, the winter pressures crippling the NHS are more than just newspaper headlines or troubling statistics.

‘It’s really scary every day,’ says the doctor, who works in the north west of England. ‘We are frequently in a position of having every cubicle in emergency care full and having a queue of people in the corridor, and they are often very unwell.

‘You can’t examine people there, you can’t really see how they are and you spend a lot of time going up and down that queue trying to make observations and speaking to paramedics.

‘But you never really know how sick someone might be and what you might miss. There are people I thought would be OK and two hours later you get them into a ward and realise they could have arrested.

‘If that was my Nan I would be horrified. And I’m making those decisions. It’s soul-destroying.

‘You’re constantly worrying about what you might miss on the corridor.’

These hospital corridors were not designed to be places of life and death decisions – and these doctors were not trained to work in battlefield-like conditions.

 

Well-being risk

Increasingly, this is the burden placed on frontline staff in the health service, and the unprecedented demands of this winter – the worst on record – have massively exacerbated what were once day-to-day stresses and strains of a very difficult job but now affect the health of doctors and the care given to patients.

As one clinical fellow in emergency medicine in the north east of England puts it: ‘My health has significantly deteriorated. Been trying to work through illness that led me to me being seen in my own emergency department while on shift (and then carrying on working afterwards). Been off work twice in the same month owing to severe health issues, causing more short staffing.’

He adds that he ‘leaves every shift terrified for my registration number, worrying about missing something, doing something wrong, or being blamed for someone else doing something wrong’.

The clinical fellow criticises the lack of senior support and leadership at his trust, believing they would ‘hang me out to dry’ if something went wrong.

It has left him feeling like a ‘clerking machine’, in a system which appears to care little for his well-being. And ever present is the spectre of legal retribution.

‘There’s always a worry about picking the wrong patient and where the fault will be if you get it wrong or someone dies,’ the consultant, who, like many interviewed said, she feared reprisal from her trust if she gave her name, said. ‘Am I going to end up in a police station being interviewed charged with gross negligence or medical manslaughter?

‘There is no way out of this winter – it’s totally engulfing. I’m wondering it this can really be a long-term career choice. I wouldn’t pick this career again knowing what I know now.’

This doctor’s account is harrowing. But this is not a special case. The truth is it’s just one of thousands of similar stories across the country as soaring demand and crippling underfunding hit NHS, and staff, services hard.

 

Unreasonable demands

Samir Lalitcumar, an elderly care specialist doctor at Upton Hospital in Berkshire, is all too familiar with the personal impact working in an ever-tougher healthcare environment can have.

A combination of massive rise in demand – seeing patients with ever more complex and numerous conditions – and significant difficulties filling rota gaps and replacing senior staff left him stressed, burnt out, and unable to cope.

In January, Dr Lalitcumar started having heart palpitations and dizziness and was signed off work with stress until April.

‘It’s taken this to show just how much stress I am under,’ he tells the BMA.

‘I felt all alone – we were working so hard. It’s just not realistic to cope in these conditions. Anything can happen and we are all afraid of what could happen to us – doctors can be made scapegoats.’

Dr Lalitcumar adds: ‘We doctors work and work and never think about stress. But that’s a real problem. You will make mistakes.’

Berkshire Healthcare NHS Foundation Trust, which runs Upton Hospital, was approached for comment, but did not respond.

And Dr Lalitcumar is far from the only doctor concerned about his well-being.

More than 20 of around 160 doctors who provided the BMA with submissions regarding life on the frontline used the word ‘stress’ to describe their daily working life – and several talked about leaving to start a new career.

And these accounts do not just come from hospital doctors seeing the worst of winter, but also from medical students, GPs and staff working in community settings and public health.

The litany of reports point to an unsafe, unsustainable health service being delivered at the cost of its workers’ health.

 

Crumbling down

We also heard from doctors who were working in orthopaedics wards converted to cope with spiralling demand in respiratory medicine, emergency care doctors unable to conduct basic assessments until hours after a patient’s arrival and GPs left holding patients’ hands with no ambulances available and staff working in crumbling buildings which have waited years for maintenance or renovation.

The reports and interviews also included community doctors comforting patients terrified to go to hospital knowing they would face a long wait on a trolley, staff working in hospitals with no beds available anywhere and GPs with vacancies extending to years.

One doctor described the chaos as the ‘constant struggle between resources and treating patients’.

Another simply said: ‘Relentless pressure on appointments, phone calls and home visits. Exhausted.’

Our research also revealed several doctors considering moving to less-than-full-time roles or already reducing hours – and scores of frontline staff living in great fear of losing their registration, or even being pursued in court.

The problems across the frontline raise questions for the future – as well as concerns about the present. Across the country junior doctors have lost training opportunities and increasingly worry about whether they are entering sustainable careers.

One West Midlands core surgery specialty trainee 1 says, owing to rota gaps and massive demand, there was ‘little time for training and feedback. As a surgical trainee I am unable to get to theatre on most days’.

And while patients have noticed a climb in waiting times, an increase in delays and, occasionally, a deterioration of care during recent years of starved resource and climbing demand – the crisis in the NHS is sapping the morale of doctors and claiming their well-being.

An East Midlands GP – who wished to remain anonymous – told BMA News he was one of many who had suffered burn out, and had to take time off from work.

At his surgery each GP looks after more than 2,500 patients and the waiting time to see a doctor is at least four weeks. Patients are frustrated, doctors are managing expectations, and the situation is untenable, he says.

‘I was mentally at a very low ebb at one stage but I recovered from that with a lot of support,’ he says.

‘I feel like a stock market trader stuck in front of the screen, dealing with correspondence, incoming phone calls, scans, emergency cases and organising referrals. I cannot see general practice continuing this way.’

 

Public meltdown

It is a familiar story in general practice. GPs – traditionally the gatekeepers of the health service – are increasingly feeling like they are fighting for survival rather than providing an expert, and knowledgeable, first-point-of-call

A GP from the south west of England says she has already hatched plans for an alternative career because the ‘sheer volume of work no longer feels safe’.

For the experienced doctor, the number of interactions and processes needed every day was too much to cope with – and she has already dropped from nine locum sessions a week to four, to try to keep up.

‘It’s absolutely gutting,’ she told BMA News. ‘We all believe in the NHS but we are all being let down. There was a time when you had the potential to work extra hard if something went wrong; to go into overdrive – but that’s not possible now. It’s all the time.

‘It’s a very claustrophobic, massively pressurised system to be in. You’re doing 40 to 50 triage calls over the phone a day and nobody trained to do that.’

She adds: ‘I just don’t want to do it any more – I could be in jail with a criminal sentence or have to live with the fact that I made a wrong decision because I had complete brain fog. Is it worth the personal cost?

‘We all went into this for the human interaction, to do a bit of good. But now you’re just dealing with people over the phone and those instances of having a good case that makes it all worthwhile are more and more infrequent.’

While hard to hear, the stories are not particularly surprising given this has been a political crisis played out in the public eye.

This year the situation was so drastic that NHS England told hospitals to delay any non-urgent operations for a month – leaving patients frustrated and in pain. In total around 55,000 procedures are thought to have been cancelled. The procedures resumed, with a significant backlog at the beginning of February.

 

Undervalued

In January a survey of BMA members, thousands of doctors across different specialties found that 71 per cent of hospital-based staff had rota gaps in the department where they worked – and only 17 per cent of doctors felt valued by the government and politicians.

And just last week health secretary Jeremy Hunt admitted the situation was ‘unsustainable’ – as new figures revealed hospitals across the country are still operating at unsafe levels with 95 per cent of beds full, on average.

It is often in emergency departments where the strain is particularly apparent.

The latest data for the month of January shows more than two million patients attended emergency departments during the month and 526,000 emergency admissions – the highest number of emergency patients admitted to hospital since records began.

During the month records were also set for trolley waits. In total 81,003 patients were left waiting for four hours on trolleys and 1,043 waiting for 12 hours. And just 85 per cent of patients who attended A&E were seen, admitted or discharged before the four-hour target.

BMA council chair Chaand Nagpaul describes the figures as highlighting the ‘sustained and extreme pressure’ on the NHS.

And NHS Confederation chief executive Niall Dickson adds: ‘The scale of what the system is dealing with is without precedent – hospitals had to deal with more than half a million emergency admissions last month, a record and almost 7 per cent higher than last year.’

‘Toxic,’ is how one emergency medicine consultant describes the situation in his department.

‘We are being asked to work ever-longer hours and just expected to do it. When we were on call we were not just being told to stay in for major trauma calls or things like that but to stay if we weren’t hitting standard performance targets – now everyday problems.’

The consultant says he and colleagues have also felt pressured to ‘fudge’ performance figures. He said he was asked to take ‘rapid handovers’ of patients arriving in the emergency department and urg arrange diagnostics for them or give them prescriptions, without the time and space to make proper assessments.

The consultant says he has also been encouraged to push ‘inadequately reviewed’ patients into a ‘clinical decisions unit’ where the clock for performance targets stops.

Despite raising concerns about these issues – and rota gaps being filled by less qualified staff with no emergency department expertise – with his trust the consultant says he was ignored amidst a culture of ‘bulling, aggression and fear’.

‘The quality of care has not been good,’ he says.

‘You are not doing the right thing, you know it does not feel right, you have scores of patients who really need treatment but you are not given the resources to do it and you aren’t supporting people in the way they need.’

He adds: ‘It makes me feel overwhelmed. You end up taking these feelings home even though you don’t want to.’

 

Workloads unworkable

There are few specialties which have not been touched by the crisis.

A consultant radiologist in the north-west of England said her workload had become ‘untenable’ during the winter and she has even had to take a day off work every week using annual leave to be able to cope.

‘There is a massively increased demand for imaging which we struggle to keep on top of – how do you prioritise what is most urgent for reporting, and you have constant phone calls and colleagues checking things with you. It’s very difficult to keep concentrated and it results in errors being made.’

She adds: ‘I have had good spells and bad spells. I like what I do and I like my sub-specialty interest but when you’re dealing with several things at once because there’s not enough staff to cope it’s not safe. You can’t cover an ultrasound while reporting on three other scans. I do always have an overwhelming sense of impending doom at the moment.

‘It’s very hard work, it’s very tiring.

‘There’s a constant fear of making a mistake.’

 

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