A&E doctors are forced to say ‘I did what I could’ not ‘I did what I should’
Our A&Es aren’t safe. They are distinctly unsafe – patients just don’t realise it.
As a junior doctor, it doesn’t give me any pleasure telling you this, but it’s the truth.
When I read how more than 250 needless deaths occur each week because of long A&E wait times, I wasn’t shocked.
Similarly, it feels like the damning findings from Lord Darzi’s report released today were inevitable. It found that the NHS is in a ‘critical condition’ and is falling short of targets for cancer, A&E and hospital treatments, which has contributed to poor survival rates for cancer and heart disease.
Lord Darzi said: ‘Although I have worked in the NHS for more than 30 years, I have been shocked by what I have found during this investigation – not just in the health service, but in the state of the nation’s health’.
As a junior doctor, this is my reality day in, day out.
In some A&E departments, teams are faced with 13 hour wait times as well as a waiting room full of people with heart attacks, brain bleeds and in agonising pain – all of whom are yet to be seen before shifts have even started.
A recent analysis by the BMA showed that the waiting time is at a crisis point, and the number of patients waiting over 12 hours for an emergency admission in July 2024 was 81 times higher than in July 2019 – a statistic the BMA emphasised was an ‘underestimate’.
Sadly, as other doctors tell me, the state of A&E is horrific across the country – with no sign of it easing.
In 2012, less than 10% of patients waited over four hours in major A&E, now that figure is closer to 50%.
Young women with yet unknown ectopic pregnancies float around waiting rooms for hours, before a set of observations alert clinicians to just how sick they are.
Patients with strokes who have a delayed diagnosis because they weren’t seen quick enough are put outside the ideal treatment window for removing a clot in their brain and instead receive the next best course of action, which is simply to take medication.
Even one young man’s life-saving treatment was delivered on the floor of an emergency department because of a lack of space.
He was fine afterwards. Healthcare staff weren’t.
A&E staff know we’re just not getting to our patients quick enough, and it feels exhausting – especially when we’re fighting just to offer the basic human rights to our patients.
Previously, these excess wait times would have been escalated. Managers would have been in the department; A&Es would have declared a major incident, or asked for an ambulance divert.
Now, there’s nowhere to divert patients to because all other hospitals are in the same position.
A&E staff have got used to saying: ‘I did what I could’, not: ‘I did what I should’.
We’re losing our patients when their deaths could have been entirely prevented – and it’s soul-destroying.
Hospital wards can shut their doors when there are no more beds, A&E has no such luxury.
Instead, staff try to do what they can.
Nurses who should be concentrating on providing emergency care to patients are also doing the work of ward staff for patients sitting in A&E for over 24 hours. They put up with the fact that their patients are put in corridors with no dignity, privacy or regular monitoring.
They apologise time and time again to their patients, relatives, and colleagues, knowing there’s very little they can do. They concentrate on the small wins, like being able to give a cup of tea to a patient who has waited with their mum for seven hours.
They fight to give their patients the basics they deserve.
Patients and their relatives meanwhile are, rightfully, upset and frustrated. They’ve rarely had a positive experience in emergency medicine in recent years and all we can say to that is ‘we’re sorry’.
Recently, one doctor told me: ‘I feel an increasing sense of impending doom, knowing somewhere in the department someone is getting really sick and I can’t guarantee I’ll identify them, that I can protect them, that I can give them the appropriate space to be resuscitated or a conversation for a complex decision or even a space to die in dignity.’
What are the key findings from the Darzi Report?
The report found:
• The health of the nation has deteriorated, with more years spent in ill health.
• Factors affecting health, such as poor quality housing, low income and insecure employment, ‘have moved in the wrong direction over the past 15 years, with the result that the NHS has faced rising demand for healthcare from a society in distress’.
• There has been a ‘surge’ in multiple long-term conditions, including a rise in poor mental health among children and young people. Fewer children get their vaccines and fewer adults now participate in things such as breast cancer screening.
• Waiting times targets are being missed across the board, including for surgery, cancer care, A&E and mental health services. The report says ‘long waits have become normalised’ and ‘A&E is in an awful state’. By April 2024, about one million people were waiting for mental health services. The overall NHS waiting list stands at 7.6 million.
• People are struggling to see their GP. ‘GPs are seeing more patients than ever before, but with the number of fully qualified GPs relative to the population falling, waiting times are rising and patient satisfaction is at its lowest ever level.’
• Cancer care still lags behind other countries and cancer death rates are higher than in other countries. There was ‘no progress whatsoever’ in diagnosing cancer at stage I and II between 2013 and 2021. However, more recent figures show some improvement.
• Progress in cutting death rates from heart disease has stalled while rapid access to treatment has deteriorated. For example, the time for the highest-risk heart attack patients to have a rapid intervention to unblock an artery has risen by 28% from an average of 114 minutes in 2013-14 to 146 minutes in 2022-23.
• The NHS budget ‘is not being spent where it should be’ and too great a share is being ‘spent in hospitals, too little in the community, and productivity is too low’. Too many hospital beds are taken up with people needing social care.
• Between 2009 and 2023 the number of nurses working in the community fell by 5%, while the number of health visitors dropped by nearly 20%.
• At the start of 2024, 2.8 million people were economically inactive due to long-term sickness, with most of the rise since the pandemic down to mental health conditions. The report said ‘being in work is good for wellbeing’ and having more people in work grows the economy. ‘There is therefore a virtuous circle if the NHS can help more people back into work.’
• Raids on capital budgets have left the NHS with crumbling buildings and too many outdated scanners, and ‘parts of the NHS are yet to enter the digital era’. The report says the ‘NHS is in the foothills of digital transformation’.
• The NHS’s resilience ‘was at a low ebb’ when it entered the pandemic owing to a ‘decade of austerity’, high bed occupancy rates and fewer doctors, nurses, beds and capital assets than most other high-income health systems.
• The NHS delayed, cancelled or postponed far more routine care during the pandemic than any comparable health system.
• Too many NHS staff are ‘disengaged’ and there are ‘distressingly high-levels of sickness absence’. The pandemic was ‘exhausting’ for many and the result has been a ‘marked reduction in discretionary effort across all staff groups’.
• Regulatory-type organisations now employ some 7,000 staff, or 35 per NHS provider trust, having doubled in size over the past 20 years.
It’s no wonder that A&E staff have increasing levels of PTSD, anxiety, depression and health problems, with many of my colleagues going part-time for their own sanity.
This wasn’t always the case.
I’ve heard from fellow doctors that, in the early 2000s, A&E care was the ‘jewel in the crown’ of the NHS. Whereas in the 90s, patients were frequently waiting 12 hours or more for care.
There was a realisation that high quality care required efficiency, privacy and personal comfort – so the four hour target parameter (where patients are seen and either admitted or discharged within four hours) was introduced in 2004, and helped shape that.
It’s what makes its decline so heartbreaking. We have seen just how good a service we can provide, and what is possible when we have the opportunity to do things right.
So, what is the answer?
Patients are suffering because of a lack of investment in health. We need investment.
We need to fund our GP services to help keep patients out of A&E whose needs would be better served in the community. We need to provide appropriate and robust primary care for our ageing population that doesn’t cause an annual ‘winter crisis’.
We need to fund social services. Patients ready to leave hospital can’t go home because there’s no aftercare in place. Many attend A&E after they fall, are unable to cope, or don’t take their medications – things that could’ve been prevented with the appropriate social care in place.
Healthcare staff are incredibly resilient, we’ve worked through enormous uncertainty at great personal risk, but we did not sign up to give our patients substandard ‘cowboy’ treatment.
We’re reaching the limit of what we can tolerate.
In a speech today, Keir Starmer is expected to promise ‘the biggest reimagining of the NHS’ since it was formed, with a new 10-year plan published in the coming months. This is a great start, so hopefully it helps where it counts.
The NHS has the potential to be brilliant if the money goes where it’s needed. The system can’t run on the goodwill of healthcare workers alone.
It needs a government who will protect it, who will rebuild it, and invest in, not just health, but all the essential services too.
I want the public to stand alongside the people who care for them. For them to speak out about the importance of keeping essential staff in the service – our politicians need to hear loud and clear just how important the service is, and I want them to listen and support us, too, because everything we do is for our patients.
We need the public and politicians on our side more than ever. Without change, we won’t have an NHS.
Keir Starmer is right, without change, more patients will die – and die unnecessarily.
Do you have a story you’d like to share? Get in touch by emailing James.Besanvalle@metro.co.uk.
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