As the pressures on the NHS intensify to a point that would have once seemed unthinkable, it’s clearer than ever that the preservation of this sanctified institution became too reliant on varying degrees of self-sacrifice from its staff. How much is too much to ask of people? And how late is too late to rectify this? For many nurses and doctors these tipping points have passed, as they pursue alternative career options, early retirement, or make plans to leave.
The situation in acute and emergency medicine across the country has grown steadily more desperate, but no one can say that those working in these services have not given enough. During the covid-19 pandemic, the whole health service collectively responded to the challenges posed by a novel virus. Since those first few waves, many people working in acute and emergency medicine have had no release valve, no chance to reflect, and no let-up in the burden of care placed upon them. Many still bear the damage to their own physical and mental health from working during the pandemic, and yet have had to shoulder a sense of inevitability about the mounting pressures that have unfolded in emergency departments and assessment units around the country.
The current crisis was an inevitability that has been signposted for close to 10 years. As far back as 2013, the Royal College of Emergency Medicine and senior NHS managers were warning that patients in emergency departments were at risk from a combination of “toxic overcrowding” and “institutional exhaustion.”12 Such warnings went unheeded, swept aside to focus on more positive local narratives, hospital trusts’ financial performance, and inspection reports from the Care Quality Commission.
For those of us working at or close to the front door of emergency care, we have been operating under the shadow of a slow moving catastrophe for years. Those of us old enough to remember the energy it took to achieve the four hour emergency access target mourn the loss of such standards and how far removed and incapable we are of achieving them today. It must be harder for those who haven’t had a chance to witness what a functioning system looks like—their only experience is of the hopelessness that accompanies a continuous slide in standards of care.
While the health secretary Steve Barclay can apportion blame to “a combination of very high rates of flu, persistent and high levels of covid, and continuing concerns particularly among many parents around Strep A,”3 the more longstanding causes of the current pressures have been highlighted by the Royal College of Emergency Medicine’s Winter Flow Project reports.4 Even before “winter” and seasonal viral outbreaks set in, 12 hour stays in emergency departments were at their highest level on record, with the percentage of patients meeting the four hour target at its lowest.5
Stretched to their limit
It takes energy, tears, physical illness, mental illness, and burnout to work in a dysfunctional system, but even when this toll has been exacted, the challenge before staff is still more than their hard work alone can overcome. As a result, we’re seeing ambulance response times that are measured in hours rather than minutes, trolley waits measured in days not hours, and lengths of stay in hospital measured in weeks not days. The “crunch” is being felt by all team members in emergency departments and, to a similar degree, in assessment units. Yet still the expectation persists that people working in those areas will “cope.”
The lack of rapid solutions to system-wide problems perpetuates the expectation that there is no solution other than to pile more and more pressure at the front door of emergency services where patients are being housed in corridors, on hard waiting room chairs, or on floors without any modicum of dignity. This expectation sees staff go home in tears at what they have witnessed. It also assumes that the emergency department will keep expanding and its staff will keep stretching themselves, but eventually both will snap.
That is the unwritten part of this steadily unfolding catastrophe. Industrial action can go some way towards challenging the pay, terms and conditions, and working environments of staff. Scenarios that have become worryingly commonplace—a nurse having to attend a foodbank at the end of a 12 hour shift or a doctor struggling to find affordable rental accommodation at the start of another geographical change for their rotational post—are worth pushing back against by unions and workers. Yet striking can’t fully mitigate the growing personal toll that many members of nursing, clinical, and operational teams experience on a daily basis.
The NHS doesn’t need heroes. It needs royal colleges and local, regional, and national leaders to support their teams and sway the government for change. It needs those bodies and individuals to counter any false narrative that the current crisis was caused by seasonal viruses or that it can be cured solely by extra funding. It needs the government to listen. Solving this crisis will require wholesale reform of the social care system; a standardised process that matches in-hospital capacity against local populations and sets targets of occupancy to promote flow through local systems; and a cross-party initiative to develop a coherent workforce strategy and transform the NHS.
The NHS doesn’t need heroes. It needs a sustainable working environment upon which more people are trained to provide better care, a workforce who are looked after and taught self-preservation rather than self-sacrifice, and staff who are given the time to care for the people they serve.
Competing interests: none declared.
The views expressed in this article are the author’s and do not represent any of the organisations they’re affiliated with.
Provenance and peer review: commissioned; not externally peer reviewed.
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