'A&E crisis: 'emergency medicine has become the first port of call'' diff viewer (1/2)

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A&E crisis: 'emergency medicine has become the first port of call'	A&E crisis: 'emergency medicine has become the first port of call'
2013-06-26 01:05:08 UTC	2013-09-22 14:51:31 UTC (3 months later)
It is 8.05am on Monday when Dr Brad Wilson first hears the shrill ringing of the red phone on the wall of the nurses' station. That is the dedicated phone used by Yorkshire Ambulance Service crews to warn the accident and emergency unit at Bradford Royal Infirmary (BRI) that they are bringing in an emergency patient.	It is 8.05am on Monday when Dr Brad Wilson first hears the shrill ringing of the red phone on the wall of the nurses' station. That is the dedicated phone used by Yorkshire Ambulance Service crews to warn the accident and emergency unit at Bradford Royal Infirmary (BRI) that they are bringing in an emergency patient.
"92-year-old woman, query fractured neck of femur in left side," Wilson explains, in the medical shorthand that peppers A&E staff's conversations. Soon after the patient arrives at 8.26 the query becomes fact: she has broken her left hip in a fall. Three hours later she is transferred upstairs to the orthopaedic surgeons who will operate to give her the best chance of regaining mobility as quickly as possible.	"92-year-old woman, query fractured neck of femur in left side," Wilson explains, in the medical shorthand that peppers A&E staff's conversations. Soon after the patient arrives at 8.26 the query becomes fact: she has broken her left hip in a fall. Three hours later she is transferred upstairs to the orthopaedic surgeons who will operate to give her the best chance of regaining mobility as quickly as possible.
She is one of more than 400 patients – 15 of them emergencies heralded by the red phone in Wilson's office – who will pass through the doors in the A&E unit on the day the Guardian is given rare access to a part of the NHS which has been in the headlines for months due to apparently relentless rises in the pressures on services around the country.	She is one of more than 400 patients – 15 of them emergencies heralded by the red phone in Wilson's office – who will pass through the doors in the A&E unit on the day the Guardian is given rare access to a part of the NHS which has been in the headlines for months due to apparently relentless rises in the pressures on services around the country.
The College of Emergency Medicine, the professional body for doctors in A&E units, said recently that they have become "like warzones". The Care Quality Commission, the NHS watchdog, only a little less dramatically says that in many parts of England emergency care is now "out of control".	The College of Emergency Medicine, the professional body for doctors in A&E units, said recently that they have become "like warzones". The Care Quality Commission, the NHS watchdog, only a little less dramatically says that in many parts of England emergency care is now "out of control".
Monday is the busiest day – busier than Friday and Saturday with their drink-related injuries – because some patients who have held off seeking help over the weekend, because they prefer to see their GP, end up getting sent straight to A&E once they have done so.	Monday is the busiest day – busier than Friday and Saturday with their drink-related injuries – because some patients who have held off seeking help over the weekend, because they prefer to see their GP, end up getting sent straight to A&E once they have done so.
As Wilson – a 46-year-old American from Salt Lake City who stays remarkably calm and cheerful despite his responsibilities – prepares to receive his early morning briefing from the night team, colleagues tell him in exasperation about a young woman who turned up at 3.25am complaining of pain coming from under the false nail on her left thumb. Staff gave her a grey cardboard vomit bowl containing acetone nail remover to dislodge it, something she said she had been trying unsuccessfully to do at home.	As Wilson – a 46-year-old American from Salt Lake City who stays remarkably calm and cheerful despite his responsibilities – prepares to receive his early morning briefing from the night team, colleagues tell him in exasperation about a young woman who turned up at 3.25am complaining of pain coming from under the false nail on her left thumb. Staff gave her a grey cardboard vomit bowl containing acetone nail remover to dislodge it, something she said she had been trying unsuccessfully to do at home.
"People have come with period pains, ingrowing toenails and wanting sets of false fingernails removed," said Wilson. "I once even had a young woman arrive – by ambulance – asking for a pregnancy test when she could have just got one in Boots." On this occasion, staff drained pus from under the woman's nail but thought she could and should have waited to see her GP, rung 111 or taken painkillers, and not added to the pressure on A&E.	"People have come with period pains, ingrowing toenails and wanting sets of false fingernails removed," said Wilson. "I once even had a young woman arrive – by ambulance – asking for a pregnancy test when she could have just got one in Boots." On this occasion, staff drained pus from under the woman's nail but thought she could and should have waited to see her GP, rung 111 or taken painkillers, and not added to the pressure on A&E.
The debate about the causes of A&E being overrun has highlighted problems with the 111 telephone advice service which replaced NHS Direct in England in April. The health secretary Jeremy Hunt has also pointed to Labour's 2004 decision to let GPs shed responsibility for providing care out of hours. However, none of the doctors, nurses or managers at the BRI who spoke to the Guardian mentioned either.	The debate about the causes of A&E being overrun has highlighted problems with the 111 telephone advice service which replaced NHS Direct in England in April. The health secretary Jeremy Hunt has also pointed to Labour's 2004 decision to let GPs shed responsibility for providing care out of hours. However, none of the doctors, nurses or managers at the BRI who spoke to the Guardian mentioned either.
Their most common explanation was the large number of patients turning up – in their view – unnecessarily. "At least 20% could be dealt with elsewhere," said Sandy Spencer, the hospital's no-nonsense interim chief operating officer.	Their most common explanation was the large number of patients turning up – in their view – unnecessarily. "At least 20% could be dealt with elsewhere," said Sandy Spencer, the hospital's no-nonsense interim chief operating officer.
Both Wilson and Spencer believe a major generational shift has occurred, with younger people now much more likely to come to A&E the moment they feel ill. As if to prove their point, a 74-year-old man arrives who it turns out broke his left femur three months earlier – the X-ray shows a big chunk of the bone hanging off – but had only now sought treatment, despite having been in considerable pain during that time.	Both Wilson and Spencer believe a major generational shift has occurred, with younger people now much more likely to come to A&E the moment they feel ill. As if to prove their point, a 74-year-old man arrives who it turns out broke his left femur three months earlier – the X-ray shows a big chunk of the bone hanging off – but had only now sought treatment, despite having been in considerable pain during that time.
"I asked him why he'd waited so long before he came here and he said 'I thought I was getting better'," Wilson says. "That's the contrast between his generation, who will put up with things and whose first instinct isn't to come to hospital, and those who seem unwilling to accept any responsibility for their own problems, don't want to wait or don't self-care."	"I asked him why he'd waited so long before he came here and he said 'I thought I was getting better'," Wilson says. "That's the contrast between his generation, who will put up with things and whose first instinct isn't to come to hospital, and those who seem unwilling to accept any responsibility for their own problems, don't want to wait or don't self-care."
Dr Rob Halstead, Wilson's predecessor as head of A&E, puts the proportion of arrivals who do not need emergency care higher than Spencer, arguing 30%-40% could be dealt with in primary care – GPs, 111 or out of hours services.	Dr Rob Halstead, Wilson's predecessor as head of A&E, puts the proportion of arrivals who do not need emergency care higher than Spencer, arguing 30%-40% could be dealt with in primary care – GPs, 111 or out of hours services.
Halstead mentions increased patient expectations which mean that these days "if people are ill, they expect to be seen, like going to McDonald's at midnight to get a burger. It's the same with healthcare. It's the 24/7 expectation of healthcare".	Halstead mentions increased patient expectations which mean that these days "if people are ill, they expect to be seen, like going to McDonald's at midnight to get a burger. It's the same with healthcare. It's the 24/7 expectation of healthcare".
Another incoming patient, George Whilde definitely needed to come to A&E. The 80-year-old retired chemical worker came in from an ambulance lying on a trolley.	Another incoming patient, George Whilde definitely needed to come to A&E. The 80-year-old retired chemical worker came in from an ambulance lying on a trolley.
He had felt poorly the week before when he was on holiday in Tenerife but did nothing more than go to a pharmacy there because he wanted to see his own GP when he got back. That morning he rang the surgery, which gave him an appointment right away – an example of primary care working well.	He had felt poorly the week before when he was on holiday in Tenerife but did nothing more than go to a pharmacy there because he wanted to see his own GP when he got back. That morning he rang the surgery, which gave him an appointment right away – an example of primary care working well.
"The doctor said I had a chest infection and prescribed me antibiotics. I collected them in the chemist just past the surgery and was walking back up to my home when I just collapsed", explained Whilde. "A passerby saw me, told the surgery what had happened, they rang 999 and a couple of the practice nurses brought me inside on a wheelchair and put me on oxygen."	"The doctor said I had a chest infection and prescribed me antibiotics. I collected them in the chemist just past the surgery and was walking back up to my home when I just collapsed", explained Whilde. "A passerby saw me, told the surgery what had happened, they rang 999 and a couple of the practice nurses brought me inside on a wheelchair and put me on oxygen."
Just under four hours after arriving Whilde was transferred from the A&E's three-bed high dependency unit – first to ward three, the hospital's medical assessment unit, and then to the elderly care rehabilitation ward at St Luke's hospital, the BRI's smaller sister hospital. He received textbook NHS care.	Just under four hours after arriving Whilde was transferred from the A&E's three-bed high dependency unit – first to ward three, the hospital's medical assessment unit, and then to the elderly care rehabilitation ward at St Luke's hospital, the BRI's smaller sister hospital. He received textbook NHS care.
Usually mild-mannered, Wilson gets both animated and vexed about patients he believes do not actually need A&E care. "Three hundred and fifty million years of evolution means the human body has learned to deal pretty well with most ailments. Yet no one is willing to give things time to get better. They access emergency practitioners for advice when all they really need is two or three days, or a week, to get better," he adds.	Usually mild-mannered, Wilson gets both animated and vexed about patients he believes do not actually need A&E care. "Three hundred and fifty million years of evolution means the human body has learned to deal pretty well with most ailments. Yet no one is willing to give things time to get better. They access emergency practitioners for advice when all they really need is two or three days, or a week, to get better," he adds.
Bradford A&E is seeing 19% more patients than five years ago, in line with national trends. The four-hour target is partly to blame, he thinks.	Bradford A&E is seeing 19% more patients than five years ago, in line with national trends. The four-hour target is partly to blame, he thinks.
"Before the target came in [in 2004] people used to wait for hours and hours. That was bad, but it made people think they could get their care elsewhere. Nowadays they know they'll be seen within four hours. They bring a book, there's Wi-Fi and coffee machines in the A&E, and it's probably easier than seeing their GP, which can take three or four days," he says. Despite that, both he and Wilson support the four-hour target, though Halstead would like it relaxed for less urgent cases.	"Before the target came in [in 2004] people used to wait for hours and hours. That was bad, but it made people think they could get their care elsewhere. Nowadays they know they'll be seen within four hours. They bring a book, there's Wi-Fi and coffee machines in the A&E, and it's probably easier than seeing their GP, which can take three or four days," he says. Despite that, both he and Wilson support the four-hour target, though Halstead would like it relaxed for less urgent cases.
Wilson says: "People access the emergency department more than they used to because they can. It's free. Some people come here rather than wait a day or two to see their GP because they've sprained their little finger, caught a virus or want cream for their dry skin."	Wilson says: "People access the emergency department more than they used to because they can. It's free. Some people come here rather than wait a day or two to see their GP because they've sprained their little finger, caught a virus or want cream for their dry skin."
Are some patients abusing A&E? Wilson pauses, then replies that "quite a few people, about 3% of our caseload, access our service as their primary care service; they only come to us". Halstead mentions that some people with drug or alcohol problems, who may also be homeless, come once or twice a day, every day. Though few in number, they take up considerable resources as they are usually medically quite complicated.	Are some patients abusing A&E? Wilson pauses, then replies that "quite a few people, about 3% of our caseload, access our service as their primary care service; they only come to us". Halstead mentions that some people with drug or alcohol problems, who may also be homeless, come once or twice a day, every day. Though few in number, they take up considerable resources as they are usually medically quite complicated.
Bradford's A&E was built to handle 110,000 attendances a year. In 2007-08 it had 113,911 but last year that had risen to 135,548. The perceived inadequacy of out of hours care, and the public's unwillingness to use it, is a major factor. "For whatever reason some patients lack confidence in the alternatives to A&E, such as 111, walk-in centres, out of hours services, or GPs if they can't get an appointment instantly. So they come to where the lights are on – here. We never close," says Spencer. The current situation "isn't sustainable", she warns. "We need changes, like GPs being available 24/7," she adds.	Bradford's A&E was built to handle 110,000 attendances a year. In 2007-08 it had 113,911 but last year that had risen to 135,548. The perceived inadequacy of out of hours care, and the public's unwillingness to use it, is a major factor. "For whatever reason some patients lack confidence in the alternatives to A&E, such as 111, walk-in centres, out of hours services, or GPs if they can't get an appointment instantly. So they come to where the lights are on – here. We never close," says Spencer. The current situation "isn't sustainable", she warns. "We need changes, like GPs being available 24/7," she adds.
Wilson says: "What we desperately need is somewhere else to send urgent care patients to, people with things like earache. We do emergency care, not urgent care. Those patients should go to their GP, a walk-in centre, or pharmacist if it's pain relief, or even to their dentist. People come here with bad teeth quite a lot too. The trouble is that emergency medicine has become the first port of call for everything." Halstead wants an urgent care centre sited at the BRI, staffed by GPs, where some people would be sent home and told to self-medicate and others would be advised to see their own GP.	Wilson says: "What we desperately need is somewhere else to send urgent care patients to, people with things like earache. We do emergency care, not urgent care. Those patients should go to their GP, a walk-in centre, or pharmacist if it's pain relief, or even to their dentist. People come here with bad teeth quite a lot too. The trouble is that emergency medicine has become the first port of call for everything." Halstead wants an urgent care centre sited at the BRI, staffed by GPs, where some people would be sent home and told to self-medicate and others would be advised to see their own GP.
Ensuring enough personnel are on duty is a key task for Wilson. "Staffing-wise things are getting worse. Every day we use three or four locum doctors and lots of [emergency departments] rely on them. Some are very good, but locums tend to be less reliable than permanent members of staff. Some are booked but just don't show up – that's extremely frustrating," he says.	Ensuring enough personnel are on duty is a key task for Wilson. "Staffing-wise things are getting worse. Every day we use three or four locum doctors and lots of [emergency departments] rely on them. Some are very good, but locums tend to be less reliable than permanent members of staff. Some are booked but just don't show up – that's extremely frustrating," he says.
When the BRI has an A&E rota-gap they text a group of about 30 local doctors they know – GPs or those in other specialities – to see if anyone can step in. Only after drawing a blank do they ask one of the many agencies which supply temporary NHS staff.	When the BRI has an A&E rota-gap they text a group of about 30 local doctors they know – GPs or those in other specialities – to see if anyone can step in. Only after drawing a blank do they ask one of the many agencies which supply temporary NHS staff.
Wilson is worried that the publicity about emergency medicine and realities of the job mean newly qualified doctors are increasingly shunning it, which could mean a serious staff shortage before too long. "Junior doctors work here as part of their training. They can see staff have high levels of stress, and it puts some off. Some people don't want to work in that environment. The hours – working a lot of weekends, evenings and overnight, because it's a 24-hour service – are pretty deterring. People see that and think: 'Why would I do that when I have other options?'"	Wilson is worried that the publicity about emergency medicine and realities of the job mean newly qualified doctors are increasingly shunning it, which could mean a serious staff shortage before too long. "Junior doctors work here as part of their training. They can see staff have high levels of stress, and it puts some off. Some people don't want to work in that environment. The hours – working a lot of weekends, evenings and overnight, because it's a 24-hour service – are pretty deterring. People see that and think: 'Why would I do that when I have other options?'"
With the pressure on A&E high and rising, there have to be enough beds in the hospital for those who need to be admitted for tests or treatment, as one in five do. Bed managers from across the hospital hold three meetings a day – at 9am, 1pm and 4.30pm – to ensure demand does not outstrip supply. Ann Bannister, the clinical services manager in A&E, stands in front of a massive whiteboard in the department's nerve centre, its patient flow control room, behind the reception desk where non-urgent arrivals queue. She is in charge. Currently just six out of the 216 beds in the BRI's 10 medical wards – where patients who are admitted after examination in A&E usually go – are empty, though five patients are due to be discharged and 12 others are listed as possibles.	With the pressure on A&E high and rising, there have to be enough beds in the hospital for those who need to be admitted for tests or treatment, as one in five do. Bed managers from across the hospital hold three meetings a day – at 9am, 1pm and 4.30pm – to ensure demand does not outstrip supply. Ann Bannister, the clinical services manager in A&E, stands in front of a massive whiteboard in the department's nerve centre, its patient flow control room, behind the reception desk where non-urgent arrivals queue. She is in charge. Currently just six out of the 216 beds in the BRI's 10 medical wards – where patients who are admitted after examination in A&E usually go – are empty, though five patients are due to be discharged and 12 others are listed as possibles.
"That's tight for medicine. That could be a problem if none of these potential discharges happened," explains Bannister. "I've had everywhere full – literally every bed taken. That happens sometimes during winter." She specialises in unblocking bed "bottlenecks" and deals in tight margins.	"That's tight for medicine. That could be a problem if none of these potential discharges happened," explains Bannister. "I've had everywhere full – literally every bed taken. That happens sometimes during winter." She specialises in unblocking bed "bottlenecks" and deals in tight margins.
"It's amazing the difference one or two extra discharges can make to the hospital's ability to cope with what's coming in both through A&E and in direct referrals from GPs."	"It's amazing the difference one or two extra discharges can make to the hospital's ability to cope with what's coming in both through A&E and in direct referrals from GPs."
When there are too few beds in the A&E and medical wards, patients who have been admitted via A&E often end up staying the night in other departments, such as gynaecology or ear, nose and throat, and are sometimes moved as they sleep.	When there are too few beds in the A&E and medical wards, patients who have been admitted via A&E often end up staying the night in other departments, such as gynaecology or ear, nose and throat, and are sometimes moved as they sleep.
In this, again, Bradford simply illustrates how A&E's rising caseload is increasingly affecting the functioning of other parts of hospitals. The NHS regulator Monitor recently reported how this need to house A&E admissions somewhere was leading to planned surgery being cancelled and, in growing number of places, key NHS targets – for treatment within 18 weeks of referral and even urgent cancer treatment – being missed.	In this, again, Bradford simply illustrates how A&E's rising caseload is increasingly affecting the functioning of other parts of hospitals. The NHS regulator Monitor recently reported how this need to house A&E admissions somewhere was leading to planned surgery being cancelled and, in growing number of places, key NHS targets – for treatment within 18 weeks of referral and even urgent cancer treatment – being missed.
"Flow" is Bannister's most-used word. "It gets a bit frantic sometimes. Sometimes when it gets really bad I will act as a porter, or go on wards and make beds, just to keep the flow going. Really bad is when there's patients waiting in A&E for a bed but no flow out of A&E and it comes to a standstill. Sometimes I end up going round the wards saying 'why hasn't your patient been discharged?'"	"Flow" is Bannister's most-used word. "It gets a bit frantic sometimes. Sometimes when it gets really bad I will act as a porter, or go on wards and make beds, just to keep the flow going. Really bad is when there's patients waiting in A&E for a bed but no flow out of A&E and it comes to a standstill. Sometimes I end up going round the wards saying 'why hasn't your patient been discharged?'"
Other tactics she deploys include ringing certain wards over and over again to see if they can discharge any patients and occasionally even asking a consultant to undertake an extra ward round at the end of the day to see if anyone else is fit enough to go home.	Other tactics she deploys include ringing certain wards over and over again to see if they can discharge any patients and occasionally even asking a consultant to undertake an extra ward round at the end of the day to see if anyone else is fit enough to go home.
The ageing population is also affecting A&E. "More patients are more medically complex. People are living longer and therefore older people present with a higher incidence of illness", explains Halstead. "There's now no age discrimination. Previously you'd have said: 'Oh he's 75, that's a good innings, there's nothing more we can do for him.' Whereas these days everybody is treated with whatever is available to relieve their condition, no matter what age they are.	The ageing population is also affecting A&E. "More patients are more medically complex. People are living longer and therefore older people present with a higher incidence of illness", explains Halstead. "There's now no age discrimination. Previously you'd have said: 'Oh he's 75, that's a good innings, there's nothing more we can do for him.' Whereas these days everybody is treated with whatever is available to relieve their condition, no matter what age they are.
"Now an 85-year-old with a heart attack will be transferred to Leeds for a primary angioplasty; that wouldn't have happened in the past. That's a change during my time in medicine. That's a good thing, but doing that is resource intensive."	"Now an 85-year-old with a heart attack will be transferred to Leeds for a primary angioplasty; that wouldn't have happened in the past. That's a change during my time in medicine. That's a good thing, but doing that is resource intensive."
The BRI is doing what it can to reduce attendances, admissions and lengths of stay. For example, when April brought extra pressure, the A&E piloted a "111 triage nurse" who asked anyone arriving with minor complaints between 7am and 8pm if they had rung the new NHS telephone helpline before coming. Those who had not were asked to do so. As a result one potential patient rang the helpline; 20 left voluntarily without calling the helpline or even seeing a doctor, underlining the concern that some may be overusing A&E.	The BRI is doing what it can to reduce attendances, admissions and lengths of stay. For example, when April brought extra pressure, the A&E piloted a "111 triage nurse" who asked anyone arriving with minor complaints between 7am and 8pm if they had rung the new NHS telephone helpline before coming. Those who had not were asked to do so. As a result one potential patient rang the helpline; 20 left voluntarily without calling the helpline or even seeing a doctor, underlining the concern that some may be overusing A&E.
The A&E also has a team of occupational therapists who assess the capabilities of older patients who have had a fall. The team arranges help for as many as are well enough to return home – with visits from carers or physiotherapists – rather than be admitted.	The A&E also has a team of occupational therapists who assess the capabilities of older patients who have had a fall. The team arranges help for as many as are well enough to return home – with visits from carers or physiotherapists – rather than be admitted.