COMMENTARY

Christmas and New Year in A&E: A Perspective

Dr Dan O'Carroll

Disclosures

December 24, 2018

When asked to write this piece around the Christmas period, I'll admit my mind ran away with fanciful ideas around Dickens' 'A Christmas Carol'. I pictured Jacob Marley dragging Matt Hancock away from his dreams of being the biggest purchaser, worldwide, of refrigeration units (as part of Brexit medicines contingency planning) and being forced to view the ghosts of Christmases past, present, and future of poor Ed (ED or Emergency Departments). I paused, and reflected on this idea, and wanted to write about Ed's redemption rather than Scrooge's.

   

Dr Dan O'Carroll

Emergency Medicine is still a specialty in its, relative, infancy. The changes have been far reaching and profound since it was first established as Casualty in the 1950s. In the early 1970s the first 30 consultant posts were established as an experimental pilot and were filled by many consultants with 'unconventional medical careers' from returning missionaries to the clichéd 'failed' surgeon. The presentations were mainly surgical in nature, including fractures, lacerations, and head injuries. Casualty traditionally didn't interfere with 'medical problems'.

A&E Over the Years

The specialty, and demand for it, grew and grew, but it remained somewhat neglected. I have first-hand experience of working in huge A&Es in the late 1990s, staffed entirely by junior doctors (SHOs) overnight, with no shop floor senior presence and the middle grade doctors being tucked up safely in bed (NOT TO BE DISTURBED!). This is unthinkable now, and those same departments will have many more senior doctors covering the full 24-hour period. It coincided with very poor patient experiences, many news agencies reported (now) unimaginable waits for beds, extending into days rather than hours and occasional disasters such as patients being found dead on corridors whilst waiting for ward beds to become available.

It couldn't continue like that, and the introduction of the 'A&E 4-hour target’ brought focus to the emergency pathways. Huge increases in funding, staffing and attention completely changed the landscape and patient expectations. The initial target was 98% and was introduced in 2004, and surprisingly it was broadly met. These were halcyon days for the specialty. With the formation of the College of Emergency Medicine in 2006, training number applications increased, and the consultant workforce was expanding. Many of us remember these days as being fun!

It was a short-lived golden summer and by the winter of 2012-13 performance against the target began to suffer.  We, the ED, became the victim of circumstances. Patient numbers and expectation continued to increase: "why wait a few days to be seen by your GP when you can be in and out in 4 hours?”.

It seemed that focus was lost. It was the A&E target rather than hospital target, and it was A&E’s problem to sort out. This is, of course, impossible, as the vast majority of breeches occur due to flow problems due to lack of bed availability. The numbers continued to rise, the staffing levels failed to keep up with this, and the (relative) funding dropped. This coincided with increasing problems with social and primary care and an increasingly dependent frail population. Clinician productivity has dropped off significantly, one of the main reasons behind this is the increasing complexity of these frail patients.

It does feel that we're at the tipping point, we can't continue as we are. One would hope that the ghost of Christmas yet to come could awaken the country from its current sleep walk into a disaster for poor Ed.

Not All About Trauma

The country would be shown that given the correct resources these incredibly dedicated people who chose to practise in emergency departments can make a difference. The specialty continues to attract bright, caring and dedicated individuals, who chose one of the hardest career pathways. Despite popular perception, trauma isn't a big part of the role, so it's not for the 'adrenaline or resus junkies'. The mainstay of our patient demographic is the frail complex elderly medical patients. Mostly the rotating junior doctors comment on how much they have enjoyed their placement, and the most frequent reason for this is because of the teamwork. I often tell them that in their time in the ED, 'they will work in the closest team of their entire careers'. Despite the almost intolerable current pressures staff remain focused on doing the best they can, from providing advanced resuscitation skills, to holding hands and ensuring that final moments are spent in peace with family rather than unnecessary intervention. All the team pulling together from clerical to domestic staff, from porters to security. All striving to do the best they can.

New Year Resolutions?

What can be done to allow these teams across the country to function at their best and provide the highest quality care that they all aspire to?

The future needs to show an increase in funding across the whole system, including: increasing social care funding to ensure that the 'back door' of the hospital remains clear, increasing the bed capacity, particularly in the winter months so that the bed capacity can include a 'buffer' for ED referrals.

Staffing needs to be increased further, we need to further embrace the advancement of skills of the non-traditional work force, nursing staff and others taking up roles that were traditionally carried out by doctors, with appropriate training, competence-based assessment, and support.

We need closer integration of urgent and emergency care and that may mean co-location of services, and we need our primary care colleagues to be supported and to help them to improve accessibility - from the outside this looks very much like a supply and demand issue.

We desperately need honest discussions with patients, families, and other professionals, about advanced care planning, end of life pathways and DNACPR decisions. It's becoming increasingly frequent that we are over-treating patients for no obvious gains.

We need the public to play a role. Too often we see 'abuses' of the system. For too many, because it's free at the point of access, there is no perceived cost. Whether that be from the relatively frequent use of ambulances as 'taxis' or the worried well attending 'just in case' and insisting on expensive investigation.

Most of this goes back to the finances. We need an honest discussion between those in power and the public and recognition that we either all have to pay more taxes, or we have to accept that the current standards are going to slip. Unfortunately, I don't believe with 5-year parliamentary election cycles politicians will be in a position to provide meaningful long-term strategic guidance or costings.

The extraordinary ED teams in the country have previously shown that they can make these improvements in care and patient experience. I believe that they can do it again, if the external support and will is there.

References:

J R Soc Med. 2005 Jun; 98(6): 255–258. Emergency medicine: past, present, and future.
Parliament.uk/House of Commons Library Feb 2017: Accident and Emergency Statistics: Demand, Performance and Pressure.

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