One Day in January (2022)

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 1^st April and 30^th 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

The Healthcare Professional Will See You in Four Hours Plus

Two years ago I had pneumonia. After three weeks of antibiotics and resting at home my symptoms had not improved. I staggered to see my GP, that Friday morning, and he advised me that I needed to be treated in hospital, there was no more he could do for me and I wasn’t getting any better. Reluctantly I agreed with him and my husband took me to your local A&E. We arrived at 12.00 noon, at 1 o’clock in the morning I received my first dose of antibiotics.

At the time I was so angry and demoralised to be treated like this, as if they didn’t really believe I was that ill, but later I came to realise what had happened, after talking to other people and checking some facts. The whole hospital, not just the A&E Department, were short staffed and having to cope with a large increase in demand. Is it any wonder that the system cracked?

On Monday 28th January, the Government took a step that will make my experience happen more often and to more patients, they announced that they will scrap the four-hour waiting target for A&E treatment (1). The Chief Executive of NHS England, Simon Stevens, announced it the Health and Social Care Committee meeting, on the 28th (2). Matt Hancock, Secretary of State for Health and Social Care, was also giving evidence to the committee at the same time. Simon Stevens said the four-hour target would be significantly altered, political language for scrapped (1).

This has certainly come as a surprise to everyone working in the NHS because no one had been consulting on this, neither the Royal College of Nursing (RCN) or the Royal College of Emergency Medicine (RCEM) were consulted about this (3), the Government just dropped it on us. This isn’t a new idea from this Government, in January 2018 Jeremy Hunted had hinted at this, in the face of the winter pressures on the NHS (4). It seems that the Government is using Brexit, and all the chaos we are facing because of it, to push through something they have been wanting to do for a while.

The four-hour A&E target has been a thorn in the side of this Government for so long. The target is that 95% of patients are treated within four hours in A&E, but in December only 86.4% of patients were treated within this target, and since July 2015 the target has not been met once (3). This has been a constant indicator of how poorly this Government is resourcing and managing the NHS.

The four-hour target was not reached by plucking a number out of the air, but is evidence based (5). It was introduced in 2004, following extensive consultation by the then Labour Government, as a response to overcrowded A&E Departments were patients were faced with long waits for treatment (5). Yet now, when we are again being faced with overcrowded A&E Departments and patients facing long waits, this Government plans to scrap the four-hour A&E target. What is the logic in this?

Targets, when evidence based, have proved very useful in measuring healthcare outcomes and help improve the quality of care. The RCEM, in a report supporting the four-hour target, have found extensive worldwide evidence that time-based targets help improve performance and were associated with reductions in morality (5). This target has also proved useful in highlighting places that are under pressure and strain, but now what it is doing is repeatedly showing how much strain the whole NHS is under, month after month, and embarrassing the Government, month after month.

A&E Departments are under stress for a lot of reasons, not just an increase in demand, but since 2011 there has been 8.8% raise in people attending A&E, this is 23.4million more A&E attendances, or 5,100 more patients a day (6). These increases in demand have not been matched with an increase in resources, which have stagnated since 2010, but there are also other factors putting huge strain on A&E Departments, such as:

- Staff shortages. 10.9% of nursing posts (7) and 7% of doctors’ posts (8) in the NHS are currently empty. These figures are for across the NHS, but this does mean there are far less nurses and doctors available to work A&E Departments. Shortage of staff has been directly linked to poor care. 45% of NHS staff, involved in patient care, have reported that they are too short staffed to deliver safe, dignified and compassionate care (9), and A&E Departments are not immune to this.

- Loss of hospital beds. In the last 30 years the NHS has lost half of its in-patient beds, right across the broad, including medical, surgical, maternity and mental health beds (10). Since 2016/2017, hospital bed occupancy has been running above 90% and regularly exceeds 95% during the winter months (10), which is far higher than the recommended safe limit of 85% (11). The less hospital beds available, the less availability there is to admit new patients, the harder it is to admit patients from A&E, therefore the longer patients have to wait in A&E to be admitted and the four hour target is routinely broken.

- Underfunding of social care. Since 2010 social care budgets have been cut by £7bn and between 2018-2019 they will be cut by a further £700 million, 5% of the whole budget (12). This directly affects patient’s ability to be discharged, because there is less money for home carers, less money for care home funding, less money to adapt patients’ homes and therefore less support for patients living in the community. When there isn’t the social care support then those patients cannot be discharged, becoming delayed transfer of care (DToC) patients, and DToC’s caused by social care problems have increased 130% since 2014 (13). And if hospital beds are being occupied by DToC patients, how can new patients be admitted from A&E?

- Not being able to get a GP appointment. Currently we are short of 15% of the GPs we need, 6,000 GPs (14), and there is a huge difference in the availability of GPs across the country (14). In some areas there is three times the number of patients for each GP (14), making getting a GP appointment far more difficult. The BBC found that only 40% of patients could get a same day appointment (15), 60% were not, while 27% of patients were able to get an appointment within that week. Not all of those who cannot get a same-day appointment will have urgent health needs, but many will, and where can they go when they cannot get a GP appointment? 40% of NHS Walk-In Centres have closed since 2010 (16).

There are a lot of factors that have caused the increase in A&E waiting times and there isn’t one, easy fix to it. Like so much else in healthcare, there are a lot of interconnected factors.

Different NHS Trusts and Social Care Providers around the country are introducing strategies and services to try and reduce A&E attendance. Doncaster has set up a multidisciplinary rapid response team to treat patients in their own homes (17); in Dorset an advanced nurse practitioner acts as a “gatekeeper” to A&E, redirect non-urgent A&E patients to other services where they can be seen (18); at the Chesterfield Royal Hospital nurses have been placed in charge of assessing patients at the children and young people’s assessment unit, therefore streamlining the service and reducing unnecessary admissions (19). But these are only local changes, none of them are national strategies, and it could be even argued that they are only tinkering around the edges. None of them are trying to tackle the reasons behind the increase in A&E demand.

What we need are national strategies to tackle this problem. We need more community services that people can access near to their home when they have an urgent care need (An infection, a wound, a sprain, etc…), which are not just open Monday to Friday, nine-to-five. We need services that enable people to stay in their homes when they are ill or have a long-term health condition, not just social care but much more healthcare being delivered in or near to patients’ homes. I am a Community Nurse, and many of my housebound patients still struggle to get to and from hospital outpatient appointments because there is no alternative. We need to move to a more community-based healthcare system. When I was a student nurse (nearly thirty years ago now) there was a lot of talk about moving us to a community-based healthcare system, and since then that is all there has been, talk. There are some local-based initiatives, but that has been no national policy or political will to achieve this.

In their new NHS Long Term Plan, the Government has promised, by 2023, an extra £20bn in NHS funding, but only £6.9bn will be spent in the community (17). How the are we expected to develop all these new services to reduce hospital admissions with only 34% of the funding? I would say this is a joke but it isn’t funny.

A&E Departments are not coping with the rise demand for their services, which is caused by a lot of factors, and yet this Government’s sole response has been the scrap the A&E treatment target, and therefore remove the one thing that has highlighted the problems in A&E Departments. Do they think that by hiding the problem it will somehow go away? Because this seems all they have done about it.

Managing Brexit is not the only thing this Government seems incapable of doing.

Drew Payne

When You Just Don’t Understand the Situation

“If you can keep your head, while all around you others are losing theirs, believe you me you don’t understand the situation.”

I don’t know who said it but I do like this quote, except when it comes true. Jane Cummings, NHS England’s chief nurse, has recently shown that she is a living example of this.

The crisis in nursing has further deepened, last week figures from NHS Digital were released that showed last year (2016 to 2017) more nurses left the NHS than joined it (1). Last year 33,500 nurses left the NHS (about 10% of the nursing workforce), 3,000 more than joined, and 20% higher than left in 2012-2013 (1). Some of these nurses have moved into the private sector, to work for nursing agencies and private companies and private hospitals, but an alarming number of nurses have left the profession altogether. Last year saw 1,678 more nurses leave the NMC register than joined it, 35,363 nurses left the register, 27% less nurses joined the register than left it (You have to be registered with the NMC to practice as a Registered Nurse, therefore if you leave it you cannot work as a Registered Nurse) (2).

A closer look at these statistics makes an even more uncomfortable read.

3,000 more nurses left the NHS than joined it (3). This is the biggest gap but not the first, for the last three years more nurses have left than joined the NHS, but last year saw the biggest gap. There’s no evidence that this trend isn’t going to carry on.

The largest percentage of those nurses leaving, 51%, were nurses under 40 (3). These are nurses at the beginning of their career. Traditionally, the largest percentage of nurses leaving had been over 55, nurses retiring. This has been a concern because of the drain of skills and experience from losing these nurses. Last year we saw the largest percentage of nurses leaving were ones at the beginning of their careers. Nursing is now so stressful and undervalued that it is driving away nurses at the beginning of their careers.

"We are haemorrhaging nurses at precisely the time when demand has never been higher,” Royal College of Nursing head Janet Davies said: "The government must lift the NHS out of this dangerous and downward spiral.” (3) She added that the government needs to address nurses’ poor pay and lack of support to start filling the huge number of empty nursing posts (3). She hit the nail on the head, unlike our Chief Nurse.

Jane Cummings told the BBC: "We do lose people that need to be encouraged. We're in the process of bringing in lots of nurse ambassadors that are going to be able to talk about what a great role it is, to be able to tell their story, so we can really encourage people to enter the profession and for those in the profession, to stay in it," (3).

She is the professional lead for nursing and midwifery in England (4) and yet she makes a comment as crass and patronising as this one. Nurses are the backbone of healthcare, we are the ones who actually carry out the vast majority of patient care, and the NHS is haemorrhaging nurses. Yet all Jane Cummings can say, in the face of this of all, is that she’s introducing “nurse ambassadors” who will tell everyone what a “great role” nursing is. She plainly ignores all the factors that are stripping the NHS of nurses, and instead she announces a pie-in-the-sky project. As if all we need are people to go around saying how great nursing is and nurses will stop leaving the NHS. What planet is this woman on?

If a “nurse ambassador” turned up at my workplace and told me it was great to be a nurse, I’d reply asking them what they were going to do about our ever increasing workload, all the empty posts in our team (let alone we need more nurses to manage our increasing workload) and what where they going to about the fact that my pay has decreased, in real terms, by 14% since 2010 (5)? If they answer nothing then I’ll demand to know what good are they? But let’s cut out the middle people, if this is all Jane Cummings can offer then I want to know what good is she?

According to NHS England, Jane Cummings was appointed National Lead for emergency care in 2004 and she had been working in management for many years before then (4). It is safe to say that it is many, many years since she worked on the clinical coalface of nursing, and it shows how her patronising response to this latest crisis is. Why is she in such an important role when she cannot offer the leadership needed?

In 2012, Jane Cummings’ salary was £165,000pa (6), and I am sure she has not seen her salary fall the way the clinical nurses have seen our salaries fall, in real terms.

How has Jeremy Hunt reacted to this latest nursing crisis? He is the Minister for Health and Social Care, he is the politician responsible for the NHS.

He has shown his typical complete lack of knowledge about the situation. In reply to the fall in the number of NHS nurses, Hunt said that he will increase student nurses places by 25%, training 5,000 Associate Nurses this year and 7,250 next year, make it easier for Associate Nurses to re-train as Registered Nurses and give nurses first refusal on any “affordable” housing built on former NHS land (7).

At first this may sound great but a quick glance at the figures shows how hollow they are. It takes three years to train a Registered Nurse and two years to train an Associate Nurse, so any extra training places will not give us more nurses now. In three years times how many more nurses will be leaving the NHS than joining it? There seems no evidence that the NHS will stop losing nurses. This Government has abolished bursaries for Student Nurse training, since then there has been a 23% fall in the number of people applying for nurse training (8). Will they be able to find enough appropriate people to fill these extra training posts? Associate Nurses are not a replacement for Registered Nurses, as yet there are no plans for Associate Nurses to be able to give IV drugs.

As for first “dibs” on “affordable” housing, well only on the ones built on former NHS land. You still need a mortgage for an “affordable” home, it’s not social housing, and with nurses’ pay falling in real terms who can we get a mortgage from? And how many “affordable” homes will be built this way? Certainly not enough to house all the nurses, and their families, who need them. This is another patronising and meaningless “bone” thrown at us by Hunt, which does nothing to ease all the problems faced by nurses.

Nursing is in crisis, we are haemorrhaging nurses from the NHS, yet this has been a problem for years and no one in leadership is doing anything meaningful about it. I want to scream “You’ll miss us when you’re gone, when there’s no nurses left you’ll be in trouble!” But with the leadership styles of Jane Cummings and Jeremy Hunt, I don’t think anyone will notice or will they even care, and that makes me so sad.

Drew Payne