As an A&E doctor this is truly upsetting but in no way surprising. Just 30 per cent of those surveyed were very or quite satisfied with A&E services while 40 per cent were very or quite dissatisfied. This is the largest change in dissatisfaction in a single year since the question on A&E services was first asked in 1999.
When I reflect on my recent experiences of working in A&E, these results feel inevitable. I have worked across many departments in the South of England and seen the deterioration in conditions for both patients and staff over the past few years. During September 2022, the time when survey data was being collected, 29 per cent of patients presenting to A&E waited more than 4 hours for admission, discharge or transfer. In February this year 125,505 patients waited 12 hours or more from their arrival at A&E.
Corridor care has become commonplace in A&E. I regularly see upwards of 20 patients in the corridor at any one time on some shifts. For patients this is uncomfortable and undignified as well as prolonging their time to assessment. I cannot fully examine a patient in a corridor where there is no privacy – to do so I then need to find a space somewhere in the department, wheel that patient on their trolley to said space, examine them and complete any bedside investigations and then wheel them back to the corridor.
A&Es are also having to frequently use ‘reverse corridor queuing’. This is a process by which patients who are in a bedspace and have been assessed as needing admission, are moved out into the corridor to provide space for a new patient to be seen. These patients then must wait in the corridor for a ward bed to become available. Again this leaves patients lying in corridors without privacy and dignity, leaves little space for family and friends to support them and is dissatisfying and time-consuming for staff.
The wards are under the same pressures we face in A&E. To facilitate flow through the hospital and allow for more patients to be assessed in A&E some departments have started onboarding – when patients are moved to wards before a bed is available and are then forced to wait in the corridor of those wards.
This all has a knock-on effect on ambulance services. Paramedics wait longer to handover patients in A&E, meaning they are not available to respond to call outs on the road and patients in need wait even longer at home.
Clearly this is not the level of care patients deserve and not the service staff want to provide. These conditions are particularly difficult for older patients who are prone to pressure sores, confusion, dehydration and malnutrition; patients with mental health problems (A&Es are noisy and disorientating, there is no clear distinction between night and day – the lights are always on and meal options are limited); patients with disabilities; people who do not speak English; children and many others.
I find myself apologising continually to patients – for the long waits, for the time in the corridor, for the delays in moving to the ward. It is particularly heart breaking that most patients try to reassure me in return. They tell me how hard they can see everyone working and that they are grateful for our care. My experience is that patients now come to A&E and are not surprised to wait hours on end to receive care.
Constant exposure to these conditions has a huge impact on staff. Staff turnover is high with a reliance on bank and agency staff to fill rotas. Staff sickness and absence levels are increasing in line with an increase in burnout and moral distress. Across health care we have seen different staff groups take strike action – from ambulance workers to nurses and, currently, junior doctors. The second strike dates for junior doctors were the longest in history at 96 hours. We are seeing increasing dissatisfaction among NHS staff that is not just related to pay; in my experience, working conditions are deteriorating and we can no longer rely on the goodwill of staff to go above and beyond what is expected of them.
This is all painting quite a bleak picture of A&Es. We have been in similar positions before with low patient satisfaction towards the end of the 1990s. Then, with sufficient resources and investment, patient care and outcomes improved and this was reflected in a high level of patient satisfaction by 2010. The 2022 BSA survey showed that people still believe in the concept of the NHS but believe it needs more funding and should prioritise staffing, access to GP appointments and A&E wait times amongst others.
I think the situation is salvageable but will take considerable and significant input – focusing on a realistic workforce plan, estate planning, quality data analysis, and long-term prevention and population health planning. It is critical that patients are at the forefront of these improvements. In the meantime, I hope the NHS can keep the amazing staff who are doing their best to provide care to patients who deserve better.