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

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 this week on organising care at the NHS frontline.