Accepting the unacceptable? A physician’s perspective on frontline care

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Part of Frontline clinical care in acute hospitals

Elin Roddy is a respiratory and general physician at Royal Shrewsbury Hospital. Here she shares the challenges and pressures of delivering care in a busy hospital, ahead of the publication of a report by The King's Fund on organising care at the NHS front line.

It’s 5.30pm on a winter Monday, already dark outside. On the way back from clinic, I take my customary detour up to the ward via the emergency department and the acute medical unit. If any of my patients are there, I like to know, and I also get to see what’s happening around the hospital.

In the emergency department, four patients wait in the corridor with ambulance crews. The crews look weary, resigned to a wait. These are the same crews that should be responding to 999 calls but instead are trapped in a stuffy corridor waiting to hand over patients to staff who are overloaded and into beds that do not exist.

The emergency department board is a mix of red and black signifying how long patients have waited – red is bad, but black is worse. Many of the annotations read ‘MBR’ – medical bed requested – meaning patients have been seen and assessed, but there are no beds for them. But the waits to see emergency department doctors are also long. The junior doctors here are under pressure, and the senior and middle grade staff in the department are already working a ridiculous rota just to keep things safe. Locums cover gaps in rotas. There’s nothing in the tank.

I cut through resus [resuscitation] to the acute medical unit. There are three patients in resus, one of whom has just had a blood gas sample taken and who looks really sick. The junior doctor assessing him looks flustered and can’t get hold of the medical registrar. There isn’t one on duty until 9pm, I tell him. The day registrar had to go home to sleep in preparation to cover the night shift because the locum dropped out at the last minute. I look at the gas result and give some advice.

Although it is only 5.30pm, the admissions board is almost full, and the second board will need to be started before the night shift come on – a bad sign. Many of the admissions are coming from the overstretched community teams, but there’s also a high number from the emergency department.

The list of patients who have not yet been seen by a doctor is long, as the team is a doctor down today because of a rota gap, as well as missing a registrar. A cardiac arrest on another ward has taken the whole team out of action for the preceding 20 minutes, and they are just discussing how they will catch up. The consultant on call gives me a weary wave. He is trying to teach some medical students but keeps getting interrupted.

Round the corner, at the nurses’ station, a conversation is taking place between the ward co-ordinator and the site manager about which escalation areas to open up overnight, and how they will be staffed. Another nurse is on the phone to my respiratory ward. She’s trying to get hold of a nurse there to hand a patient over in order to free up a bed on the acute medical unit (AMU) for one of the patients in the emergency department. I’d like the man in resus to go straight to my ward, but he hasn’t been waiting long enough.

An occupational therapist is on another phone. ‘I’d like to speak to the duty social worker please, urgently’. We no longer have hospital social workers, so getting non-medical issues sorted is really tricky. There’s a possible safeguarding problem, and urgent care is required for a relative. But home care is almost impossible at the moment, and waits are long, meaning patients are stranded in hospital. A relative approaches the desk: ‘I’ve been waiting here for an hour to talk to someone about my father’. I apologise and find the nurse in that bay to give him an update. She is doing the drug round, and I am not supposed to interrupt her but I do. It might make a medication error more likely, but may avoid a complaint.

Nine or ten patients wait in a cramped ambulatory care reception area. One or two are clearly going to need admitting into beds, but there are no empty beds and they are relatively safe here – at least until the nursing staff finish at 9pm. There is a backlog in assessing these patients because of a lack of rooms, and the doctors keep being bleeped away. There’s nowhere for the staff to write notes, and very little privacy. It’s hot. There’s a sign on the exit door telling people not to use it as a short cut. I take a short cut through it onto the corridor.

Up on the respiratory ward there are two patients waiting for transport. One of their beds is ready for the next patient, but the nurses haven’t had a chance to take handover [share information about a transferred patient]. The other bed space needs cleaning but it’s tea-time and there is no housekeeper today so the health care assistants are giving out the meals first. Four patients of mine are ‘medically fit’ to go home, and would be safer there, but need their care assessments completing first. The form is several pages long, and has to be assessed by an external social worker to see what care and support will be funded.

I call in to see one of my patients in a side room who is dying of lung cancer. He is agitated, his son is upset and I find the nurse looking after him to ask for some more medication. She is in the middle of a drug round and the other nurse is not signed off for controlled drugs yet, so I know there is going to be a delay in him getting the medication. I wonder if a syringe driver might be better, to avoid these delays, but then worry that he would not be alert enough to talk to his daughter who is due to arrive tonight from London.

I sit at the desk on the ward to write up some meds and answer the phone five or six times. Most of the calls are from relatives wanting updates, or from AMU wanting to give handover. I try to stall them on AMU, because I want my patient to get his medication, but I also want the chap in resus to get a bed.

This all takes around 30 minutes. I see many, tiny kindnesses on my travels. I see lots of patients getting good and compassionate care, and I see lots of colleagues bending over backwards to ensure that things get done. I see lots of patients and families waiting patiently, knowing that we are doing our best, thanking the staff for their hard work. And our hospital is not unique. These scenes are being played out up and down the country.

But sometimes we don’t – can’t – notice them. We have made ourselves so used to this new ‘normal’ that noticing it all – the sub-optimal processes, the unnecessary delays, the broken promises – would make it impossible to come to work. They say that ‘the standard you walk past is the standard you accept’. I don’t accept these things that I see – people on trolleys in corridors, patients waiting for vital medication, families in distress. These things are not acceptable. We should not walk past.

But if everybody keeps stopping, who is going to do the work?

This is a shortened version of an article that first appeared as a blog. The full article will appear, alongside perspectives from other clinicians, managers, patients and others, as part of a report to be published by The King’s Fund next week on organising care at the NHS frontline.

Comments

Dr Umesh Prabhu

Position
Was Medical Director for 15 years in NHS,
Organisation
www.bidaonline.co.uk
Comment date
30 April 2017
Dear Elin, Very well said and very well written. Thank you for your honesty. As you know from Twitter, I have been Medical Director of two acute Trusts in UK for 16 years and recently took early retirement. I train a lot about values, value based leadership, culture, governance and patient safety and I travel up and down the country.

You have hit the nail on the head! We doctors (all rest of clinical staff) we all continue to do our best knowing that our patients are suffering every day!

NHS is in crisis because of the silence of many thousands of doctors! Over the years NHS has eroded doctors voice and we have let this happen without objecting!

Today, NHS appoints managers in to leadership position and expect them to inspire doctors and sad reality is most doctors (not all) hate managers because they blame managers for today's crisis! In fact today's NHS crisis is simply because of poor culture, poor policies, targets, financial pressure, silos working, shortage of well trained doctors and nurses (due to poor work force planning), immigration regulation and so on!

NHS has introduced many initiatives like clinical incident reporting, SUI investigation, Never Events, more power to Coroner and so on to protect patients and rightly so! But sadly this has put lot of hard working and sincere doctors and other clinical staff under huge pressure!

In a quest to improve patient safety, sadly NHS has forgotten the importance of caring for its staff! Today staff are under huge pressure, more and more staff are leaving NHS and junior doctors strike is an example as to how badly NHS staff are treated!

Sadly everyone blames poor Mr Jeremy Hunt and Mr Simon Stevens! Sad reality is our own trade Union BMA has failed us our NHS and our patients by failing to show the leadership our patients and our profession deserve! Club culture is very rife in BMA and it is about same old leaders trying to do the same old thing! But some good leaders even in BMA give me hopes!

NHS has some very good leaders and they give me lots of hopes for NHS. NHS needs good leaders from top to bottom with good governance.

NHS must get rid of club culture, old boys network and make sure right leaders are appointed only on merit and there is good governance and accountability and NHS must focus on culture of staff happiness and remove culture of bullying, harassment, victimisation and discrimination based on race, ethnicity, gender or sexual orientation.

NHS needs values based leaders who are kind, caring, compassionate but with courage to say and do the right thing! This is how we transformed Wigan and today 90% reduction in harm to patients and we received 45 awards!

I have now resigned from Wigan but there is lot to do for all of us and NHS needs good leaders and good governance and stop working in silos and make use of excellent IT and transform health and social care!

I am still confident that together we can transform NHS and social care and make both of them the safest and the best in the World! It is NHS wonderful staff who give me the confidence and so is Mr Simon Stevens and also many good leaders of our NHS.

Without accountability for managers and leaders and without good governance, NHS will not be safer or better and patients, staff and NHS will continue to suffer.

My worry is not NHS (because we can sort it out) but Brexit! Brexit is a wake up call for all of us to say 'Our nation is divided' and financial challenge is going to be huge!

But, I am confident that together we can build NHS and make NHS as an example for the nation as to how to build a strong nation and that is by making everyone feel valued, involved and engaged.

Together we can build NHS and together we can build our great nation!

Iain lennon

Position
consultant, emergency medicine,
Organisation
Derby Hospitals FT
Comment date
30 April 2017
The situation described is described by a phrase borrowed from NASA and popularised in healthcare by Diane Vaughn: "the normailsation of deviance"

We should strive at all costs not to accept deterioration in standards. Because they become the new normal. We become habituated, and then the next step down is just around the corner.

Dr TS Hoo

Position
Core Trainee,
Organisation
East Lancashire Hospitals Trust
Comment date
02 May 2017
Great article. Sadly having been in the NHS for only a few years, I know nothing different than the scenarios described above. Dr Roddy, you could also mention that in addition to the present decay over which today's medical leaders are tempted to grow accustomed, there are multiple pairs of eyes which look on and learn the acceptable standards for tomorrow.

Was it due to quiescent/impotent consultant colleagues and healthcare leaders? Or was it due to an insular trade union as has been suggested? Was it a down to a delusional DH or were the roguish bankers to blame? Whatever the cause, for me and a generation of doctors like me, the process of deviance to normalcy is likely already complete.

Pearl Baker

Position
Independent Mental Health Advocate & Advisor/Carer/DWP Appointee/Deputy to COP,
Organisation
Independent
Comment date
04 May 2017
As an Independent Mental Health Advocate and Adviser U may as well be 'invisible', my Registered Charity N.A.R.M.I was well known to many i was consulted by many organisation gave lectures at University, Social Worker and GP Training, and Carer Representative for the MHNSF Trustee of the National Schizophrenia Fellowship and Welfare Benefits Charity, sadly my mistake was to close my Charity when i retired(many years ago) i returned to front line campaigning as an Individual with a wealth of experience, and a Carer.

It is almost impossible 2 make changes when a lone individual despite the knowledge u have consumed over thirty years. It takes passion, time, financial commitment and of course the understanding of a husband who is given little time, because of your 'obsession' to make things better.

As a 'whistle blower' of Neglect. i have continued to be victimized by the LA and GPs responsible for the Health and Social Care of my son. My request from a GP to write a letter of Support to a Tribunal regarding Welfare Benefits remains unanswered.

My one suggestion for others in a similar situation is to gather Case Law, know your subject 'matter' forget the emails, correspondence, you are wasting time and energy. Start your Media Campaign (like i did) U will get some success. The Guardian Newspaper took up my 'Story' placards shown at the Railway Station on the way to London. (with a friend) The result was NEW KITCHENS and BATHROOMS for a one bedroom complex. L & Q Housing Association AGREED not up to their Standards. THIS WAS worth everything to me and those i CARE for.

As a Responsible Persons Representative for DoLS i removed my 99 year old father-in-law from an NHS Hospital, he surely would have died, he is still with us, now in Care. It is clear the CQC Inspections of Residential Homes are NOT 'fit for purpose' I have put together my own 'Care Plan' citing the 12 Descripters in the CHC Checklist, remember if a Self Funder you are in fact employing someone to look after them.

I can only hope lessons can be learnt from my personal experience, and that those organisations such as the CQC start taking note of my Media campaign to make a difference.

The difference between me and others in employment of the STATE i can say it EXACTLY as it is, unlike those who fear for their 'jobs'.

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