Has Jeremy Hunt ever actually been to the Emergency Department?
I think I need to stop reading the news because all it seems to do is annoy me these days. The article that has set me off today is one on the BBC which says that Jeremy Hunt wants all hospitals in England (so I guess the rest of us will follow suit) to get back to hitting the famous 95% A&E target.
The 95% target states that 95% of people who present to A&E should be seen and either treated or discharged within four hours and it is completely unrealistic. The reason it is so unrealistic is simply because of the many nonsense reasons that millions of people turn up at A&E combined with the number of genuine cases.
I actually wonder if Jeremy Hunt has ever stepped foot inside an Emergency Department in the first place? The man whose job it is to run the NHS doesn't seem to have a clue what actually goes on within it. He clearly doesn't understand the volume of patients A&E sees, how many of them are super complex or how many of them just shouldn't be there in the first place.
Lets make up an example - Wee Betty (who is clearly not real, I am making her up). Wee Betty is a 94 year old lady who lives alone, she has carers who visit her four times a day to provide personal care, meal prep and medication prompts, she also has a falls alarm which she wears on her wrist. Betty actually manages quite well at home and does a lot of her own cleaning and small bits of shopping. Tonight Wee Betty had a fall at home.
Betty had been doing her dishes after her carer left for the evening, Betty doesn't let the carers help her to bed because their final visit of the day is 8pm and she doesn't want to go to bed that early only to have to wait till the first visit of the day at around 10am before she can get up again when they come in the morning. She was heading towards the toilet when she either tripped or slipped and fell, injuring her hip. The problem was that she had removed her falls alarm to do the dishes so she could not alert anyone to help her.
Betty lay on the floor in pain for a while, she is not sure how long but knowing she needed help she managed to pull herself across the floor, reach for the phone and dial 999. The ambulance was with her within 10 minutes and quickly conveyed her to hospital where she was taken to the busy majors department at her local A&E .
Betty was seen by an experienced nurse who was immediately concerned for her hip - suspecting a fracture. The nurse was also concerned that Betty may have hit her head, she seems confused and the fact that she is known to live alone suggests that this is probably not Betty's normal state. The problem is that the nurse cannot order an x-ray of Betty's hip or even give her pain relief without the Doctor seeing her. The nurse places Betty in the queue to be seen urgently and actually goes to tell the doctor about her. The doctors however are all busy right now, there has been a two car accident and the four occupants of the cars are being brought in - one is going straight to resus but the others are coming to majors. Taking the advice of the nurse, the doctor quickly writes up some painkillers and the nurse gives them to Betty.
An hour later Betty is seen by a junior doctor who is concerned not only about her hip and her head injury but about the length of time Betty may have been on the floor. We know the carer left around 8.30pm but betty didn't arrive in the department till almost midnight - this is nearly three and a half hours unaccounted for, we do not know when she fell so we have to assume she could have been on the floor the whole time. Lying on the floor after a fall for that length of time can actually do some bad things to you, certain compounds can build up in your blood that can actually make you really unwell. The doctor orders an urgent hip x-ray and does some blood tests before returning to see his other patients.
We are now in hour two of Betty's stay in the department and she has had her x-ray because they were quiet enough to fit her in quickly. It's bad news, betty has a hip fracture - it will likely need surgery but Betty has other health problems that complicate surgery, including an irregular heart rhythm making it very risky, her age is also a factor. The orthopaedic registrar is called to review her and takes a further hour to arrive in the department due to her dealing with something else on the main wards at the time.
By the time the ortho reg arrives, the results of Betty's blood tests are back and she also requires treatment for acidosis which is caused by that compound in her blood we spoke of earlier. The ortho reg cant do anything for her hip until that is corrected, surgery is a no-go for now. The medics decide to admit Betty under medicine first, then transfer her to ortho once she is more stable, they go to tell her and become more worried about her apparently increasing confusion, a CT scan of her brain is ordered and an hour later she goes for that. It's now well into hour four and although we know that Betty will absolutely be admitted to the hospital, there is still way more to do before we can do that. We need the CT scan, and we need the results - perhaps Betty has had a stroke and that is what caused her fall? If so we need the stroke registrar on call to see her and decide if she should be admitted to one of the specialist stroke units, although it is unlikely this would happen due to us not knowing the time of the fall in the first place and already being in hour four post admission, maybe neurology need to see her for her head injury? That will take hours to happen. Betty will likely end up in Acute Medical Receiving while we try to figure it out, but they are full just now and there are no beds up in the wards for them to move anyone to in order to create a bed for Betty - she has to stay in A&E for now there is simply nowhere else for her to go.
So my question is: What can we do to speed this up Jeremy? Now there are in fact several things that could have been done here to speed things up, but they are all outwith A&E 's control - the nurse could have been able to order the x-ray, but its not something we are allowed to do, I assume because they worry we would order too many unnecessary ones and it really takes a doctor to know someone needs one (yeah right) so they order less and that costs less. There could have been more doctors in the department and Betty could have been seen quicker, but as it happens the department was actually fully staffed that night with the 'correct' amount of people according to whoever decides these things. There could have been less people in the department but we cannot control the car accident, the three people with chest pain, the other lady that fell that night or the 25 people who presented that night with minor ailments that could have waited to see a GP.
The single most important thing we could have done here? Prevent Betty coming in to the department in the first place. Had Betty had a care package that actually suited her she probably wouldn't be in A&E right now. Because the carers come so early in the evening and then so late the next morning, Betty will not allow them to help her to bed. She does not want to go to bed at 8pm and who could blame her, she knows if she did it would be 14 hours before anyone appeared to help her get back up and she doesn't want that. Despite her 94 years of age, Betty is all there mentally and has every right to make these decisions, they are in fact decisions I would make myself.
The saddest part of this story? Betty is unlikely to survive this event, statistically 70% of elderly people who fracture a hip die within a year, Betty is not able to have surgery due to the risks so she will stay in hospital to wait for a nursing home placement, one where they have the correct people with the correct skills to look after the now bedbound 94 year old who just yesterday was popping to the shops for a loaf of bread.
Let me spell it out for Jeremy Hunt: THE PROBLEM IS NOT IN A&E ! The problem is the system as a whole, it's the social care system being far from adequate, it's staffing levels being ridiculously low, it is the number of A&E departments you have closed putting even more pressure on the ones that remain open and it is the fact that people present to A&E for so many reasons they shouldn't, often because they are unable to get a GP appointment or simply because they know A&E has to see them and they want and expect that to happen immediately rather than waiting a while to see the appropriate professional. In short: YOU are the problem Jeremy and it is high time you resigned and gave the job to someone who perhaps has some health care experience?