A&E Perspective: Aggression in EDs, Worst Ever Performance Data

Remember those halcyon days of the Thursday night clap for carers, when the nation came together to show its appreciation for the NHS and the frontline carers who were struggling to deal with COVID-19? Remember those days when it was suggested that around 20,000 deaths would be a good outcome for the UK?

They say that a week is a long time in politics, but even given this much longer timeframe,

it is alarming to see the reversal of support towards healthcare providers and how the now apparent indifference to the skyrocketing death toll has become the new norm.

Strains

It is very clear that the NHS was under considerable strain before the pandemic hit the world, seemingly facing an almost continuous period of winter pressures with demand exceeding supply across the board. The BMA reported how research has shown the decade of austerity had left the NHS 'extremely fragile' with more than 4 in 5 English hospitals operating with 'dangerously low' spare capacity. The same article reports that 35% of doctors were suffering from stress, anxiety, depression, or burnout that worsened during the pandemic.

This matters not to England's new Heath Secretary, Sajid Javid, or to some parts of the media, who seem to have placed GP colleagues in the firing line, colleagues who are being blamed for the surge in emergency department attendances, which is translating into record poor performance. There is no doubt that our GP colleagues are providing more patient contact, and it is true that the number of face-to-face consultations provided is lower than before the pandemic. This does not mean that this is a poorer service for most patients. Most GPs can safely triage patients via telephone consultations and arrange to see patients that need a physical assessment in a timely fashion. Many primary care problems, and decisions, like much of medicine, can be made on the patient's history alone and just increasing the number of face-to-face appointments is not going to improve the situation.

The Daily Mail has taken it upon itself to claim a victory with Sajid Javid's commitment of an extra £250 million for GPs to improve access - a minuscule increase in funding for the number of patients concerned - and a commitment to name and shame surgeries that are not performing with the publication of league tables. I'm sure this will further boost morale in our beleaguered colleagues…. It’s safe to say that the new package has not been greeted with any enthusiasm from the profession. It will not address the decreasing numbers of GPs and it will do nothing towards the Government's commitment of an extra 6000 GPs in 2016.

In a Twitter thread, the previous Health Secretary, Jeremy Hunt, seems to think the current measures will be inadequate, and the new plan seems to be little more than extra GP locums.

I'm inclined to agree with him and that this is yet another sticking plaster.

It does seem ironic that during the current castigation and criticism of GPs, particularly regarding face-to-face consultations, that Sajid Javid pulled out of an appearance at the Royal College of GPs' annual conference.

Violence

This on-going criticism of the NHS by some parts of the media is causing a rise in incidents of violence, aggression, and abuse of NHS staff, so much so that the Academy of Medical Royal Colleges felt it necessary to put out a statement reiterating that verbal or physical abuse of staff is completely unacceptable. Recruitment and retention of staff in primary care is said to be suffering due to the ongoing abuse, and a well-publicised episode of a serious assault against a GP.

There is no doubt that a contributor to the current problem is patient expectation and demand. There appears to be little appetite for any attempts at self-care or seeking advice from alternative sources eg, pharmacists or NHS 111. The current crisis facing ambulance trusts is also exacerbated by inappropriate use of the service, which seems to be finding it difficult to concentrate on genuine emergencies versus people who need non-emergency medical assessment or treatment. Many emergency departments have huge problems in unloading patients and releasing ambulance staff in a timely fashion, with obvious potentially dire consequences. One does wonder how many other departments would be deemed to 'require improvement' during the current pressures?

Patient Expectations

Managing the patient expectation presents difficulties to the increasingly overburdened EDs. We are often dealing with patients that have tried (or claim to have tried) on multiple occasions to contact there GP and been unsuccessful. This is often someone seeking reassurances, X-rays, or blood tests for their non-emergency problem. Whilst having sympathy for the patient’s predicament, it still increases the ED workload and means that the patient is not being seen by the appropriate clinician and directing patients like this to other providers can often result in friction and disappointment.

On a daily basis we are dealing with patients complaining about waits to be seen, whether that is to be seen by an ED clinician, a speciality (in particular mental health) or waiting for a bed to be admitted in to (again, in particular, mental health). These complaints are understandable, and sometimes frustration and being worried about one’s relative can boil over into inappropriate behaviour with abuse or aggression, this though, is always inappropriate and needs to be recognised as such and probably more than anything else, its directed at the wrong person. When these episodes do happen its usually at a member of staff who is working flat out and doing their level best rather than at the policy makers who have led us to this position!

As we move towards winter, the worst ever 4-hour performance data has been released today with the longest number of 12-hour stays. This puts us in a spectacularly bleak position going further into winter. I have no doubt that episodes of violence and aggression towards staff are likely to increase in frequency as frustrations boil over.

Still, at least we had our claps.

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