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Diary of an FY1 – NHS Winter Crisis

July 12, 2015

You may have read recently that the NHS is in a little bit of a crisis lately.  The news has been difficult to get away from. It was first reported as an A&E crisis with the percentage of patients being admitted or discharged within four hours slipping across the country. Doctors and commentators cleverer than me have pointed out that this isn’t a problem intrinsic to the A&E department – that hospitals are stretched to their limit and this pressure on staff and service delivery, seldom seen, is backing up and venting itself visibly in A&E.

But I don’t know about any of that. My ward is up in a chilly eyrie of the hospital, as far removed from A&E as possible. What I’ve gleaned from sneaking in to use the blood gas machine wouldn’t even fill up a matchbook. And all I know of other wards is parsed and passaged gossip from the hospital grapevine. With a fixed number of beds, and thus patients, I can’t say I’ve noticed my ward get much busier.

That is probably because we are always busy – How would we notice the difference? But our patients are complex – in one respect, their pneumonias and infective exacerbations are their easiest problems. A whiff of nebulised beta-agonist with a chaser of intravenous antibiotics usually does the job. But as well as making a battlefield of their lungs, illness has weakened the patients, or made explicit how fragile their lives had covertly been before we met them.

That is when we must offer them up to the trinity of physiotherapy, occupational therapy and social services to transfigure our patients with exercises, gadgets and underpaid visitors so they can return to living their lives in a meaningful way. It is perhaps here, at this link in the chain, that things start to back up. It’s so easy to write “PT/OT/SS” in the notes but there just aren’t enough of these therapists to go around. If only we could discharge patients within a four hour target.

Thus, I am visited daily by the discharge co-ordinator, the ghost of a Christmas on-call yet-to-come, asked why my patients aren’t going home. Since this isn’t a problem I can solve with senna or Sando-K, I am at a loss. Meanwhile, whispers that operations are being cancelled and elective wards are being filled with newly admitted inpatients. This is my experience of the NHS in crisis if you want to call it that: too few people, of all professions, with too much work to do.

The other phenotype of this crisis that I have seen is a lack of beds at other hospitals. As I’ve previously said, St Elsewhere’s is a mostly charming district general hospital. It can handle most things that come through the doors but for a few conditions, like acute stroke, we rightly refer on to the nearest tertiary hospital with the facilities to provide the best care. But. But when those hospitals don’t have beds, the patients are left at St Elsewhere’s. This has been a mercifully rare occurrence, and the big boss London hospitals have found beds after only a short delay, but this shouldn’t even be happening at all.

Why does nobody have any beds? Where have they all gone? In the past ten years, the UK has lost around 50,000 hospital beds. Hospitals across the country have closed and what have we got in return? Answers on a postcard. My consultant broods on ward rounds; she wishes she could scoop up all the little old ladies of our ward and take them home with her. There, she could keep them safe while the knots and creases of stair assessments and community commodes are ironed out.

Japan have around one and a half million hospital beds. That’s around one for every three angsty-teen-fuelled mecha robots. But even if we had that many beds, it would do us no good without people of all professions needed to staff them. Physiotherapists don’t just grow on trees – they’re really good at climbing them, but they don’t grow on them.

I would dearly love to get up on my soapbox, clear my throat with a declarative cough and proclaim boldly my manifesto for fixing the NHS. But I’m afraid that would amount to little more than hot air (still, enough to be a minister for health!). This is such a momentous problem and I am just so close to it, and so small, it would be like making confident assertions on the identity of a jigsaw puzzle with only one piece.

On an unrelated note, I wish I didn’t have to spend my lunchtimes in the bereavement office. It’s been an unavoidable fact of life on the ward that not all patients get better but, lately, it’s been getting me down. Death follows me around like a stink. My consultant has reassured me that our patients really are that sick but it’s a cold comfort.

But I don’t resent it. In death as in life, they are still my patients – filling in their posthumous papers is the last thing I can do for them so I should do it right. In the GMC’s guidance that the care of the patient is my first concern, nowhere is it mentioned that a pulse is requisite. But I wish I didn’t have to schedule my lunch breaks (precious illusions that they are) between the bereavement office and the mortuary.

Maybe it’s because these patients remind me that the power of medicine is not absolute. That patients aren’t there to be fixed or saved by dashing and heroic doctors. They’re people, sick and vulnerable and we might be able to make them better. Might. Maybe. Perhaps. Perhaps not. Every one of these patients is my own memento mori.

God, January is such a miserable time of year.

Written January 2015

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