I was sitting in a slightly
uncomfortable high-backed chair watching what had been an extremely busy
department tip over into a near chaotic one, and I couldn’t blame the nurses
and clinicians in front of me for it. They were in an impossible position and
no one was helping them.
It had been a struggle to get to the
hospital that morning. I had spoken to my GP first thing in the morning and she
advised me to attend hospital. She said that the aggravation of my asthma,
which was stopping me from working and had left me barely able to climb the
stairs, could no longer be managed at home and I needed to attend hospital. So
at 9.30 that morning, I set off for hospital, arriving a little before 10.00.
The short bus journey had left me very breathless and I had to use my reliever
inhaler just to walk through the entrance.
The triage nurse, after a quick
assessment and a lot of coughing from me, called a doctor. The doctor wasn’t
happy with the wheeze in my breathing and both of them agreed I needed
admitting to the emergency department. But there was a problem; the emergency
department was already full, at 10.30 on a weekday morning. The triage nurse
said I could be a “chair patient”, did I mind?
I wanted to say, “I don’t mind, I just
want my breathing to get better.” My asthma had other ideas and all I could say
was, “I don’t … mind…” my coughing taking away the other words.
A “chair patient” was exactly that.
Instead of sitting on a trolley I was sat on a chair, one of the high-backed,
red vinyl-covered chairs that populate the hospital wards and NHS waiting rooms
where I was treated. They had taken two beds out of a double side room and
replaced them with six chairs. There the less critically ill patients, who
still needed medical treatment, could sit and be treated. When I arrived, there
were five patients being treated there; when I left, there were eleven.
In charge of this chair area was one
nurse, he was being supported by a woman I took to be a healthcare assistant,
an auxiliary nurse, but later I found out she was a ward housekeeper. She was
doing her best, but above basic paperwork and putting ID bracelets on patients,
there were not many clinical activities she could do, she couldn’t even check
patients’ temperatures and blood pressure. Therefore, all the clinical work
there fell onto one nurse.
I was clinically unwell, but in that
situation I should have been the most unwell person in that chair area, but I
wasn’t. The emergency department was already full and yet more ambulances and
more patients were arriving, ill patients needing treatment. People who were
more ill than I was were sitting in that chair area—a woman with chest pains, a
man with a suspected deep vein thrombosis, a woman needing admitting to
hospital whenever a bed became available. The nurse there was rushing around
with so many things to do.
At lunchtime, when a senior manager
visited the chair area, I learnt that the emergency department was down six
nurses due to illness (COVID-19) and the failure of the nursing agencies to
provide extra staff. The nurse in the chair area asked the senior nurse for
some help; there were already eight patients in there and another one was on
the way. The senior nurse told him there were no extra nurses available. When
he complained about the severe workload he was under, she replied, “You’ll just
have to cope.”
I had been in his situation before, when
I worked on hospital wards, and I had to bite my tongue when I heard her reply.
I’d been told the same thing many times in the past and I knew how frustrating
and unsupportive it was. A senior nurse telling me to cope, even when I was
raising concerns to them.
I watched that nurse and the housekeeper
with him trying to cope as the workload carried on increasing, but then, by
mid-afternoon, I saw the worst thing happen. The nurse was so busy and so
overworked that he stopped prioritising the work and clinical need and just started
to deal with each task as it came along. An important task, such as monitoring
a patient’s vital signs or giving them medication, would be pushed back in
favour of a lesser task, like a doctor not being able to find something on the
department’s computer system.
I didn’t blame that nurse for what he
was doing, he was so stressed and overworked that he could only deal with each
task as it was thrown at him. I have been in the same situation as he was in. I
know how stressful and overwhelming it is, the workload becomes too much and
you can only survive by going from one task to another; you’re too stressed to
step back and prioritise because in the time it takes to do that more tasks are
thrown at you.
Unfortunately, this is when things get
forgotten and clinical errors happen.
I do blame that senior nurse for not
seeing what was happening, especially when the concern was raised to her, and
not doing anything to help manage the incredibly high workload those nurses
were under. She didn’t even offer to escalate the situation. It is senior
management’s responsibility to manage situations like this, but there is so
much pressure on hospital to “cope” and treat all the patients that are brought
to them. However, there is a physical limit to how many patients can be
treated.
In March 2022, 1 in 22 patients waited
over 12 hours in an A&E department before they were admitted to hospital
(1). That’s 33 times higher than March 2021 and 68 times higher than March 2019
(1). In February 2022, 7,200 patients waited over 60 minutes in an ambulance
before they could be handed over to an emergency department; that’s 8.5% of all
ambulance handovers that month. In January 2022, over 15,000 patients waited in
ambulances for over 120 minutes, four times higher than in January 2021 (2).
The NHS standard for this says that handovers from ambulance to emergency
department should only take 15 minutes and shouldn’t exceed 30 minutes (3).
In the three months leading up to
January 2022, an average of 42,000 people visited A&E departments in
England; this is 15% higher than it was in the same period in 2012. Of these
patients, 37.7% waited longer than four hours to be seen in January 2022, which
is an increase of 28.9% in January 2020 and an increase of 8.7% compared to
January 2015 (4).
The data shows that A&E departments
are under pressure, but why are patients waiting so long? The NHS simply does
not have enough staff to manage this increase in demand.
The first week of January (2022) saw a
13% increase of staff off work, from 71,000 to 80,000; 44% of them had COVID-19
(5). But this only added to a large pre-existing shortage of NHS staff. The NHS
has an uncomfortably high level of vacancies. 10.3% of NHS nursing posts, 5.8%
doctors’ posts and 8.3% of all NHS posts are empty (6). This is a chronic
situation and we have seen no change since 2018.
We are also seeing a high degree of
stress and burnout amongst the staff working for the NHS. In a recent survey,
57% of nursing staff said they were thinking of or actively planning to leave
the NHS (7). Another survey found that a third of GPs are considering leaving
their roles (8).
We are looking at a perfect storm,
increasing demand on the NHS, continuing high vacancy rates within the NHS and
higher numbers of staff considering leaving the NHS. But we know that poor
staffing levels have a direct effect on patient care. A simple survey found
that 53% of nurses surveyed found their recent shift unsafe because of lack of
nurses on duty and 67% admitted that they observed basic nursing care, such as
personal care and pressure area care, was missed as a trade-off due to lack of
staff and pressure of workload (9). But poor staffing levels can have a severe
effect on patient care.
The
Shrewsbury and Telford Hospital maternity scandal saw over 300 babies die or be
left brain-damaged between 2000 and 2019 (10). In her report, Donna Ockenden,
an expert midwife who led the enquiry into this, found that one of the causes
of this scandal was poor staffing levels (11). She called for national minimum
staffing levels; these should reflect local demands and include allowances for
sickness, training and annual leave, and if they were not achieved on a day-to-day
basis it should be escalated to the service’s senior management, the service’s
medical leads, the chief nurse, the medical director, and patient safety
champion (11). She recommended this for maternity services but her
recommendations should be rolled out right across the NHS; however, I doubt
they will even be implemented nationally for maternity services.
“The true barrier to tackling this
crisis is political unwillingness. The current situation is breaking the
workforce and breaking our hearts,” said Dr Katherine Henderson, the
president of the Royal College of Emergency Medicine (12).
The
government wants to reduce the “COVID backlog” because the NHS was dedicated to
the COVID-19 pandemic, but their plan does not address the problem at the heart
of the NHS. In an oral statement to parliament, Sajid Javid, Health and Social
Care Secretary, said there will be £2 billion of funding for new IT, £6 billion
towards capital investment and £9 million for extra tests and procedures by
2025 (13). He did not announce one penny for workforce planning and
recruitment. He promised a 30% increase in community diagnostic centres within
the next three years (13). He also said, “No one will wait longer than two
years [for treatment] by July this year,” and he also added, “Our aim is that
we will get back to 95% [for patients receiving diagnostic tests] by March
2025.” Yet without any investment in staff, and trained clinical staff, will he
be able to achieve any of this?
Pat
Cullen, RCN General Secretary and Chief Executive, said, “Ministers say
supporting the NHS to clear the COVID-19 backlog in England is one of their key
priorities—but without the workforce to do it these are hollow words.” (14)
And she is so right.
But
Sajid Javid summed up the government’s lack of concern or priority over NHS
staffing when he falsely claimed, “We now have more doctors and nurses
working in the NHS than ever before.” (13) How can he claim this when there
are 10.3% of nursing posts and 5.8% of doctors’ posts empty in the NHS (6)? The
Nursing and Midwifery Council (NMC), the body that registers nurses and
midwifes, reported that between 1st April and 30th
September 2021, the number of registered nurses on their register only
increased by 1.7% (15). How will this address the huge shortage of nurses in
the NHS?
This
government seems unconcerned about and unwilling to address this shortage of
NHS staff. In April, the government rejected legislation that would have
required them to publish an independent assessment of the health and social
care workforce every two years. This was voted down by Conservative MPs (16).
This amendment would not have required the government to do anything more than
just assess the state of the workforce every two years; there wasn’t even a requirement
to address any shortfall in staffing, just to look for it, but even this small
step seems to be beneath this government. How committed are they to addressing
the huge holes in NHS staffing when they won’t even look to see how big the
holes are?
But
how committed is this government to the NHS? When conservative MP Michael
Fabricant falsely claimed nurses had drinks parties after work during the COVID
lockdowns (17), no one in the government condemned him or even contradicted his
claims. He later apologised for his appalling comments (18) but he has not
received any censure from the Conversative party and no one in the government
even criticised him for making the comments. If he’d made the same comments
about police officers or army generals, would members of the government have
remained so silent?
I
wasn’t admitted into hospital that day in January, I finally left the emergency
department at eight o’clock at night. The doctor had wanted to admit me, she
wanted me observed and to receive regular nebulisers, but I could see that
there were far more clinically unwell people there, people who needed to be
admitted to hospital far more than I did. I managed to make a deal with the
doctor. I am a nurse and so is my husband, he could keep a watch on me and bring
me back if I deteriorated. If she prescribed me nebulisers then I would take
them at home with the nebuliser I had there (the last part was slightly untrue,
but by the next morning I had one, thank you Amazon next-day-delivery). I was
able to return home, where I always feel happier.
There
was no clinical incident in that chair area that day. No patient was harmed
because of a missed intervention or observation, but it so easily could have been
with the impossibly high workload that nurse was put under. And if there had
been an incident then they would have blamed that nurse and only him. They
wouldn’t have blamed the senior manager who offered no help. They wouldn’t have
blamed the Trust’s chief executive for not raising concerns over the unsafe
staffing levels and closed the emergency department to admissions to allow the
staff to safely care for the high number of patients already there. They
wouldn’t have blamed the chief executive of NHS England for not having a
strategy to manage the chronic under-staffing in the NHS. They certainly
wouldn’t have blamed the health and social care secretary and the prime
minister for allowing the NHS to be so chronically under-staffed for so long
and having done nothing to address it.
I
know who I blame, and it will never be that overworked nurse.
Drew Payne
