CONSUMING PASSIONS - 'In A&E the youngest doctors take care of the sickest patients in the poorest conditions'

A visiting US expert in emergency care and public policy, Professor Gregory Larkin, has recently published a scathing review of our accident and emergency Services.

1This followed a year during which he collected information from key organisations including the NHS Litigation Authority, the General Medical Council and the Faculty of A&E Medicine.More importantly, perhaps, he carried out direct observations in the busiest A&E departments in the UK, as well as focus groups with A&E nurses, doctors and patients.

Professor Larkin' s grim conclusion was that he had uncovered 'the soft white underbelly of a chronically under-resourced A&E operation'.

'With the youngest of doctors taking care of the sickest of patients under the poorest of conditions, UK A&E is a woefully austere frontdoor operation in a health system that was once the envy of the western world'.

He quotes A&E consultants who are ashamed of their units and say that 'the failure to provide proper facilities to enable us to practise safely to the minimum level means that the service we are providing continues to deteriorate and is unacceptable.'

2While I haven't had the luxury of a year in which to study the problems of A& E departments, I did recently undergo a crash course in the types of problem they are facing. I was a member of an external panel of inquiry into the death of a man in A&E:

he died after nine hours without being seen by a doctor.

What our inquiry uncovered was that there had been a series of failures in the management of this patient' s care. No failure in itself was serious enough to result in the final outcome, but all contributed.

The failures occurred when the department was already overstretched, with very ill patients waiting in corridors to be seen because all the cubicles were full.

We heard how, when this patient arrived by ambulance in mid-afternoon, the department had run out of trolleys and linen and the resuscitation room was so full that patients who would normally have been nursed in there were having to be treated in cubicles. These highly dependent patients had to be intensively nursed in the part of the department that has only two or three nurses allocated to care for all the patients in the area.

Although the medical staffing was about average for a department of this size, it was heavily reliant on senior house officers who, particularly in August when this death took place, were likely to be inexperienced and therefore relatively slow in dealing with patients. The most senior doctors were fully occupied in the resuscitation room.

In common with many other hospitals, this A&E department is expected to accommodate all the patients whose GPs had requested an immediate specialty review with a view to admission. Though not seen by A&E doctors, these patients have to be looked after by A&E nurses, further increasing the pressure on the department.

Our conclusions and recommendations were very wide-ranging and included the need for a 'whole-system' approach, not only within the hospital, but also between the hospital and its primary care trusts and local authority social services department.Many of the recommendations related to changes needed in systems within the A&E department itself.

These were all accepted, and are being implemented by the highly dedicated staff who work there.

But there were also wider lessons to be learned.We acknowledged that many of the issues we looked at applied in A&E departments throughout the UK.

For me, one of the main messages was that you can only impose so many 'musts' on a system that remains underresourced.Take the example of trolley waits, where the maximum acceptable time is about to be reduced from 12 to four hours before a patient must be admitted to a ward. It sounds reasonable.No-one should have to wait longer. But what do you do if every bed in the hospital is full and it is night-time?

You can hardly start sending people home in the middle of the night.The blunt truth is that the only way a bed will become free is if someone dies.And patients may well realise this.

In the longer term, the answer is that we almost certainly need more beds.

But beds need space, staffing and, therefore, money - and the biggest 'must' for every trust is to break even financially - so such discussion is not encouraged at board level.

For my part, I would like to see empowered medical and nursing staff joining forces with empowered patients.They should tell the powers that be that if the circle cannot be squared, through no fault of their own, extra resources must be found. l