A Week in A&E: Condition Critical? Panorama

Accident & Emergency - the NHS's ever-open door.

-Who the

-BLEEP

-do you think you're talking to?

It's a more stressful place to work than it once was.

The pressure upon A&E just won't stop building.

-When the hospital's full, we cannot win.

-Ready, steady, slide.

-You need to wake up then, sweetheart.

-PHONE RINGS

Hello, A&E?

Not everyone is prepared to go on taking it.

A&E is a sinking ship and unless things change dramatically,

it will sink.

Tonight, the real emergency that's threatening A&E.

INDISTINCT TANNOY ANNOUNCEMENT

If we don't do something, you will turn up in an ambulance to

an emergency department and there will be no doctors there to see you.

SIREN WAILS

The University Hospital of North Tees in Stockton treated nearly

90,000 patients in its accident and emergency department last year.

Nothing special about that.

Yet they let us film for seven days in theirs...

But A&E's always politically sensitive.

You just lay still, mate.

More than 100 hospitals wouldn't.

Three initially said yes only to say no later.

It's 1.30am.

It's quiet in A&E when a 28-year-old man checks in,

escorted by police for his own safety.

Vodka and Lucozade.

He has deliberately cut himself - and badly.

Basically, I was having a quiet night in with my girlfriend

and she told me that she didn't want to continue the relationship.

Er, so I was upset.

And I couldn't find the words to tell her, so I got a knife and...

What we're going to do is take the dressings off

and have a look at your wounds.

SUCKS IN BREATH

-It takes a lot to surprise A&E staff.

-That's the deepest one.

Compared to all the others.

What we'll need to do is

we'll need to close it by using stitches, yeah?

The numbers turning up in A&E just go on rising nationally.

No pain, no gain, they say, though, don't they?

A million more patients in England since 2010.

We set out to discover why.

A&E staff say the initials really stand for "Anything and Everything".

All human life is here.

INDISTINCT

This morning I was in my van towards my job

and my left ear was itching like mad.

I always carry my pencil behind my lug.

I scratched it, realised there was no rubber on the end,

so it's gone in my ear.

Had to seek medical advice.

Certainly over the 25 years that

I've been in A&E things have changed.

It's higher volume, harder workload,

we get patients in who are possibly more demanding.

It's a more stressful place to work than it once was.

If I allowed my staff to behave like this,

they'd be out.

A patient is brought in, for some reason bitterly complaining

about the NHS.

-We'll get you on the bed, mate, right?

-Yes.

But his medical diagnosis turns out to be quite simple.

Diabetic. He's fallen, his sugars might have been a bit low...

He's laid on the floor until somebody's found him,

five, six hours.

So, here we are.

-We'll sort you out, son.

-OK.

-Have you had anything to eat today?

-No.

-No?

You know you should do, don't you?

Well... I was on the floor!

The hospital on Teesside in the north-east of England

serves an area of once-thriving heavy industry.

The monuments to its past are all around.

Its A&E is ruled by a government target -

patients must be seen and treated or admitted within four hours.

So I understand you had high blood pressure because you take...

In England, Wales and Northern Ireland,

95% have to be dealt with within this time limit.

In Scotland, the figure is even higher - 98%.

-He was pre-alerted through... Diverted.

-So they've got the stroke team?

-Yeah.

-The nurses' station is the nerve station of Stockton's A&E.

Red on the computer screen warns staff that they may

be at risk in the jargon of breaching the four-hour limit.

Failure means fines and ultimately naming

and shaming for the hospital's management.

TANNOY: 'Anyone free for a handover in majors, please.'

Stockton's been meeting its targets.

It has a Patient Process Facilitator, dedicated to the task.

-Meet Pam Dove.

-Jack of all trades.

PHONE RINGS

Hello, can I help you?

There's a female patient who's getting close to breaching the limit.

The lady is on 220 minutes

and they have to be out the department in 239

otherwise it's classed as a breach.

She hasn't got long, now - she's got 15 minutes.

-So you've got about 15 minutes left...

-Yes.

-With the clock ticking...

-Yes.

-To avoid a breach.

-To avoid a breach.

Right, OK - how long will it be?

Right, five minutes and we can set off.

Lovely.

-This is like a Target Olympics.

-Yes.

-Like a race. It's a sprint.

-Definitely a sprint.

Throughout our seven days in A&E,

we saw the reality of working within this target culture.

Everyone we spoke to had something to say about trying to keep to

the targets in a department under continuous pressure.

PHONE RINGS

Hello, A&E, staff nurse.

I feel the breach thing is...

It's a bit of a mixed blessing.

We do need some pressure to make us work efficiently,

but at the same time, it can be infuriating

when all you want to do is look after your patient and you've got somebody

or multiple people telling you that this person is coming up to breach.

-Consultants were critical, too.

-We're working harder and harder

towards targets that are sometimes unachievable.

No matter how hard you try, you can't win?

We can't win when the hospital is full. We cannot win.

'But Pam on this occasion had a mini victory.'

Did you win, Pam?

-Yes, we did.

-How many minutes did you have left?

-Four minutes.

And Pam goes off shift and passes the baton over to the next

competitor in the Target Olympics.

You're about to hand all this over to Becky - good luck!

-Thank you!

-She'll need it!

-I know!

But the targets weren't designed to make life easier for the staff -

they're meant to benefit patients.

Patients come first. We need to do the best for patients.

What you have to remember is behind every target is a patient.

We don't want people to wait four hours in the A&E.

If you and I were going to the A&E department,

we'd want to be seen quickly,

so although we have that target,

it's not the be-all and end-all.

A&E is busy. There's a backlog of patients.

Brought in by her daughter,

73-year-old Marion Knaggs has bad stomach pain.

She needs tests to find out what's wrong. But these take time.

Eventually, the tests are completed

and a bed is found for her in a ward. But there's a problem.

When we got up there, there was about four or five people waiting in

front of her and we waited there

for about 10 or 15 minutes

to be told we had to come back to the accident and emergency unit

cos there were no beds.

There's a traffic jam in the rest of the hospital.

There's no beds.

Everybody's trying. The manager on call is aware.

So it's just basically down to bed managers to help get some

patients moved out onto the base wards.

It's unfair to the patients - they're getting moved,

getting shunted from pillar to post. It's frustrating to us.

And finally, second time round, Mrs Knaggs is admitted.

Do you want to sit in the chair?

But having had a six-hour wait, she's breached the limit

and become a negative statistic.

I feel like the staff are trying their best to work with every

single patient and treat them as an individual, not just

a patient number, but they don't seem to have enough staff and enough

resources to deal with the amount of people coming through the doors.

Did you think that before today?

-Or is that something you've learned today?

-Something I've learned today.

Peter Hawes, the diabetic,

had had his blood sugar levels checked,

he's rested and now the hospital wants to get him out

before he breaches the four-hour rule as well.

I think I've been well looked after.

But I'm glad to be going home!

See ya!

And Peter goes off with 16 minutes to spare.

But in the rush to get him home,

no-one notices that he's being discharged with a cannula -

the tube for an intravenous drip - still in place,

which upsets the nurse who'd looked after him earlier.

It annoyed me, put it that way.

You try to have

that continuation of care.

The stresses and strains of the job are such that you're trying to

strive to meet those targets, you're pushed to the limits.

So, do the targets need reforming?

We asked the Department of Health for an interview,

but they declined and referred us to NHS England.

Their A&E chief admits they do.

What was intended to be something to ensure patient safety

and improve patient experience,

that has been translated down to something that feels like a target

culture and that's one very important reason why we need to review it.

And do you accept that the four-hour 95% target as it currently applies

-is too crude a measure?

-It's too crude.

I think now things have moved on.

When it came in, it was highly effective. Now, it's too blunt.

It's really been a powerful weapon for change within A&E

departments, so it's not going to be got rid of without there

being something that is better.

It's the end of the day.

There are fewer staff, but difficult new patients.

Drug abuse happens around the clock -

this hospital deals with three to four overdoses a day.

This woman is admitted unconscious.

The first priority, to bring her round.

All right. All right.

Can you speak to us, how are you doing?

You need to wake up then, sweetheart.

-Sharp scratch.

-My name's Jenny.

-Try your very best.

Just about to do a sharp blood test, OK?

A test reveals a long list of drugs in her system.

Diazapines, opiates...

Well, it's got methadone and morphine have tested positive,

so that's basically heroin or sort of heroin replacement medication.

Cocaine, obviously.

For a while, this patient consumed resources -

everything else had to wait.

Later, she was admitted to a ward, but by morning,

she'd discharged herself.

Are you all right there, darling?

The constant pressure upon A&E means that it's always

in the political front line.

Before this winter, a crisis was predicted and the government

announced that £400 million more was going into A&E in England.

But Stockton Hospital didn't qualify for any of this

because of its above-average performance.

Last couple of months it's been horrendous.

Beds are emptied and then straightaway,

patients go back in again, so...

We're constantly chasing our tails.

And that day, the hospital simply ran out of beds.

So at one of their twice-daily bed management meetings,

they responded.

Because we have trigger points, we have an escalation policy

and a programme of trigger points that we look at.

BLEEPER

Sorry. That's a call to say that they're escalating another bed meeting because of pressures.

So it's likely to be that either A&E or the emergency assessment unit

are under pressure.

Anyway, I want to knock myself clean off. BLEEP!

-Just relax.

-Otherwise, I'll BLEEP.

Listen, Michael...

Staff in A&E are attending to Michael Alfwaite.

He's had far too much to drink and he's threatened suicide.

The paramedics said you wanted to kill yourself, slit your wrists?

-You going to do it?

-I suppose so.

The most common drug of abuse arriving in the department

is alcohol, which comes on a daily basis.

-How much have you had to drink today?

-Well...quite a lot.

There are more than a million alcohol-related hospital admissions

in England each year.

-I'm

-BLEEP

-sick to

-BLEEP

-death of these

-BLEEP.

He is fighting. He has not really got the strength to actually...

Do you know what I mean?

They're managing to hold him fine and I think he's just all bravado.

In the cubicle just opposite, they've had quite enough of him.

The nurses and doctors shouldn't have to put up with him swearing

and threatening to bite and kill them.

It's scandalous. Something should be done.

If they get in that state, they should be chucked out

and let themselves get sorted.

Now he's briefly become violent and fallen over.

-Who the

-BLEEP

-do you think you're talking to?

Michael, what are you doing, sweetheart?

Many A&E staff seem to have the patience of saints.

If you all just understand what...

It's becoming less attractive as a career.

The job is stressful and it is hard work.

My work/life balance hasn't been good in recent weeks.

Myself, I'm sure many of my colleagues,

we all take work home with us.

It isn't a balance?

-I have a lot of work on my plate.

-Not life?

No.

Recruiting enough A&E staff and keeping them in their jobs

is now a national problem.

Their champion says accident and emergency departments

won't work properly at this rate.

For the last three years, we have recruited only 50%

of the registrars into emergency medicine.

This means there is a lack of about 350-375 registrars

around the country.

That equates to three quarters of a million patient consultations

per year that can't happen because those doctors don't exist.

They're one consultant, a registrar and two nurses short

in Stockton's A&E, and fill up some gaps in staffing with hired temps.

They're called locums in the trade.

The one on shift admits it's not quite the same

as having someone permanent.

You can have good locums and you can have bad locums.

Quite a lot at the moment are perceived as being bad,

they sort of come in, don't care about the job.

They come in to do the work, get paid and go.

So stressed out A&E doctors have been voting with their feet.

That's the house we often stay in when we go down there.

-You rent this place?

-Yeah, rent it down there for very little.

John Thompson trained in Stockton

and he's worked as an A&E consultant there too.

But he has left the NHS behind to live and work in Fremantle,

in Australia.

We met him when he was here visiting relations and old friends.

-There are kangaroos, there you go. Stalking kangaroos.

-Oh, my word!

The pressures are less in Australia

and the emphasis primarily for my working day

is on patient care.

The pressures from the four-hour rule and from up above

have taken so much away from the job in the NHS in the UK

that it's just...

It's too hard.

The number of UK medical graduates

working in Australian emergency departments has gone up

by over 60% in the last four years.

That looks a lot better, doesn't it? It's still quite dry.

Alex Muirhead quit, as well.

She didn't leave the country

but she left the specialism she had originally chosen for good.

She was an A&E consultant at Stockton Hospital until last December.

Now she is a local GP instead.

It was quite sad, really, because I used to love working in A&E

but it got to the stage where I just didn't enjoy my job

and I didn't want to spend another 20 years working as an A&E consultant.

As an A&E department I don't think you get

an awful lot of respect from the rest of the hospital.

To some extent, A&E's now seen as everyone's dumping ground.

All medical staff for the boardroom.

It would help if far fewer of us turned up in A&E in the first place.

According to official figures,

40% of patients don't need to go to accident and emergency at all.

For some, it's a safe haven.

Every week. I get admitted every week.

-You come here every week?

-Every week, mate.

-Are they good and kind to you when you come here?

-Some of them are.

The ones who know me personally, they're all right,

but other people think he is in and out, he is an idiot.

In the last month, I think he's attended six times.

Is he the only one or is there...?

No, no, we have quite a few, what we class as regulars.

Peter is admitted to a ward.

There are plenty of others who shouldn't be here at all

but they turn up in A&E all the same.

We had a gentleman who came in and he had a splinter in his finger.

At that point we were on a three-and-a-half hour wait.

A lot of sore throats come in, and coughs.

I am talking just little coughs.

One reason we heard for coming to A&E

is because it's difficult to get an appointment with a GP.

I was involved in a road traffic accident last night.

Woke up this morning with pain across my shoulders.

Went to the local doctor's but they couldn't book me in

so I couldn't really wait until Monday.

I don't want to waste these people's time,

I am sure there's more deserving people than me.

Besides GPs, the NHS offers a whole host of alternatives

to accident and emergency.

But lots of us still say "Thanks, but no thanks, I'll stick to A&E."

We have been in a nightclub, me and my partner.

A guy has tried to provocatively dance with me.

He has obviously had too much to drink, went for him

and I've got caught in the middle of it and been punched in the face.

-Had you any doubt about whether to come here?

-No.

I think I'm just being a bit vain, I am panicking in case I broke my nose.

Even the professionals admit part of the reason some patients still go

to A&E is that the alternatives are a bit of a maze.

It's very difficult to understand.

We've had lots of different things, NHS Direct, the 111 system.

They don't really know what all that means.

Minor injuries unit, urgent care centre...

I agree entirely. I think there is a confusion around the names.

You want me to know where to go and I can only just make head or tail

of these titles and I've been working hard at it.

-Did you lose consciousness when you fell?

-No.

Bu quite a lot of patients in Stockton wish they were being

treated in a hospital nearer home.

I was walking my dog and she was on a lead

and then another dog come chasing up to her

and I fell flat on my face.

I was in shock.

I knew my face was all bleeding

and you know what women are like,

we like to have our pretty faces.

On top of that, Christine Johnson had to travel to be treated.

In 2011, the A&E department in Hartlepool, 15 miles away,

was shut and services were concentrated in Stockton Hospital instead.

And here, as in other places, the closure of a local A&E still hurts.

-Where would you like to have been taken?

-Hartlepool.

For you and your husband, getting here to Stockton is a palaver?

-It is.

-Have you told anybody that?

-No, it was... Who can I tell?

I'm just a little person, aren't I?

I think right across the country,

people want all the services that they can as local as possible,

and whilst we try to achieve that,

if you go in for a local service,

it's got to be of the highest quality.

And bringing the two services together was the right thing to do.

Can I have a look at you, sir, is that OK?

What was striking about our time in A&E was the number of elderly,

frail patients they dealt with day and night.

The number of over-65s attending major A&E departments

in England has gone up by around 190,000 in the last year alone.

Admitted in the small hours of the morning,

it was Bill Galloway's 100th birthday.

# Happy birthday to you Happy birthday to you... #

What is the most challenging in the middle of the night

is complex medical patients.

Elderly patients, just doing simple things at 4am,

interpreting a chest X-ray,

trying to get clear information at that time of the morning

and when you have a department full of those type of patients,

it's absolutely exhausting.

If they're admitted on to a ward,

the elderly may affect A&E departments in a different way.

It's Sunday.

78-year-old Dot Bromilow has been medically fit to be discharged

for two days, but she's still taking up an acute hospital bed.

Why are you still up here in the ward?

Well, bureaucracy.

She relies on home help

which is organised by her council's social services department.

It was stopped as soon as she was admitted into hospital.

That's standard practice.

But it can't be rearranged until after the weekend.

For the moment, until your care package is sorted...

I'm stuck.

Today as we speak, we have eight of those patients

that are sitting in a hospital bed

that are waiting for a process to be completed.

If they don't leave the hospital it clogs up the system

and causes problems back in A&E and you can't get them out?

No.

Using official figures, we have calculated that in total,

delays involving social care packages are costing

the NHS in England about £100 million a year.

And cuts in local authority budgets are making things worse.

There's bound to be a consequence.

Social care and local authorities have taken a significant reduction.

We need to join the services up and one of the key things we have to do

is to bring the doctors, the nurses, the social workers back together.

Because it's expensive for the NHS and embarrassing for the Government?

It's expensive for the NHS.

It's wrong for patients to keep them in high acuity health care

environments when they would be much better off at home

being supported in their own environments.

We spent seven days in A&E.

Alex Muirhead, now a GP, originally looked forward to many more

years there, but decided enough was enough.

There's a tiny part of me that feels guilty for jumping

from a sinking ship, but for me,

I don't haven't a single regret about leaving.

-A sinking ship?

-Yeah.

The A&E is a sinking ship and unless things change dramatically,

it will sink because it's not a popular place to work now.

I don't think we're going to go down like the Titanic

in a matter of hours, we're going to slowly sink.

It will be on a daily, weekly, monthly basis, there will be

an imperceptible reduction in the capacity of emergency medicine.

Stockton remains a good and safe hospital

but the man who represents A&E doctors nationally

warns of the risks unless action is taken.

This is about a call to arms to address the real problems that

we have in accident and emergency departments up and down the country.

-You feel it pushing?

-Yeah.

My real fear if we don't do something about recruitment

and retention in emergency medicine,

is that you will turn up in an ambulance to an emergency department

and there will be no doctors there to see you.

There will never be no doctor, that won't happen.

We may have a situation where emergency medicine

doctors are insufficient.

What we will have to do in the short-term is to look

at how we use the wider skills that are available

in the hospital, to look at the extended role of nurses,

of paramedics, of physician's assistants.

Working to crude and blunt targets with serious shortages of staff,

treating patients who shouldn't be there at all.

111 can give you medical advice...

Remember what the initials A&E are short for?

They can stand for "Anything and Everything",

or "Always and Everyone".

They stand for that because we are always open,

we are open 24 hours a day, seven days a week.

Anyone can drop in at any time.

There certainly is an expectation from the public they come to A&E

and they get seen and sorted.

It's a difficult thing, if we provide a good service,

you almost make a rod for your own back.

Some people, working in this environment is what draws them.

Bu for some people, they don't want to be struggling with difficulties

like having no beds and trying to maintain the safety

and comfort of your patients.

We didn't just see flashing blue lights at accident and emergency,

there are political warning lights, as well.

This most visible part of the NHS is under heavy stress

and in need of urgent treatment.