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.