Cold Comfort: So-Called ‘Tough Decisions’ Are Putting Patients at Risk

by Dr J

4 January 2018

Chris Sampson/Flickr

This is part two of Cold Comfort, a regular series covering the NHS winter crisis from within A&E.

Waking up intermittently in my ‘days’ between night shifts in the emergency department, I flick between news outlets and read the daily statistics on the winter crisis in the NHS. Patients waiting over 12 hours on trolleys, all non-urgent operations cancelled, 100,000 staff vacancies, 14,000 fewer hospital beds, 21 trusts on black alert. It makes for a depressing read.

The health secretary, Jeremy Hunt, defended the situation this week by saying it was not technically a crisis, since they “have a plan”. Maybe somebody should have given him a dictionary for Christmas. Meanwhile Theresa May praised NHS staff for their hard work.

To a disillusioned workforce, the praise of the health secretary and prime minister is an empty gesture. It’s like being hit in the face, and then being thanked for not getting blood on their carpet as you try to stem the flow. The situation the workforce and the public now face is the result of years of underfunding within the NHS and social care, and the government pretending the cancellation of patients’ operations and appointments was ‘planned’ is unlikely to ease the pressure for long.

The tweet of Dr Richard Fawcett, an A&E consultant in Stoke, in which he apologised for “the third world conditions of the department due to overcrowding” echo conversations among colleagues. One friend tells me the horror story of a patient having a heart attack in the corridor, picked up by chance by a passing nurse who noticed he looked pale. Unable to provide him with the high-dependency bed he required whilst waiting to be taken by ambulance to the nearest heart centre, he was left waiting in the corridor. “It was at least the corridor outside of resus,” (where the high dependency beds are located) my friend tells me. You’ve got to have a sense of humour.

Every day is challenging. Patients line the corridor daily, cubicles double up and the department runs out of physical trolleys to put people on. Patients ask for simple things like food and a hot drink. I understand their pain; I haven’t eaten for seven hours either. Unfortunately, I have to explain, it’s a short-stay waiting room so there is no food available here, and all I can do is apologise for the fact the patient has been here for over six hours already, and may have to stay longer.

These situations inherently affect patient safety; they delay assessment, treatment, and over-stretch clinical staff, meaning they are not reviewed as often as they should be. An example is patients who have sepsis, where the response to an infection has started to compromise organ function. These patients need antibiotics within an hour, as evidence has shown this decreases mortality significantly. I see this target not being met regularly. As research published in the BMJ Open journal in November has shown: austerity causes deaths.

What I find overly concerning in all of this is the changing rhetoric: “The NHS needs to make some difficult choices about what it can afford,” says Simon Stevens, chief exec of the NHS. “It’s a challenge we need to face up to as a society to find more resources,” says Jeremy Hunt.

What worries me is the more that we hear it, the more it normalises the idea that the NHS is ‘unfundable’. Drowned out by the continued distraction that is Brexit, it is easy to forget/ignore/turn a blind eye to the systematic, politically-driven underfunding that has been going on for the past decade in the name of austerity. The chancellor putting £1.6bn extra into the NHS this year – not even half the £4bn asked for by Stevens – is nothing other than a plaster over the haemorrhaging femoral artery of the NHS.

The idea that some people will need to pay is already being normalised within the NHS, by first inflicting these rushed-through rules on those least able to defend themselves: refused asylum seekers, undocumented migrants, non-EU migrants. As the chronic underfunding keeps the NHS failing to meet targets in the headlines, it’s easy for the government to target their next group. Those applying for UK visas are already being forced to pay an up-front ‘health surcharge’ (per person per year) before their visa is granted. These changes, brought in to ‘save the NHS’, unfairly utilise people’s idea of fairness, and in fact do the opposite by destroying the fundamental dictum: universal healthcare, free at the point of use.

Other ‘tough decisions’ announced over the Christmas period include cutting access to some ‘basic’ medications available over the counter such as lice shampoo and eczema emollient. Again, no substantial analysis has been done, with the poorest and most vulnerable set to suffer the most from these changes.

These so-called ‘savings’ are politically motivated, unfounded and unproven to save money, while destroying core NHS principles by denying patient care. Meanwhile, legally endorsed corruption through PFI (private finance initiative) contracts continues to go unchecked. Barts Health Trust, based in east London, is an example of how PFI deals are destroying the NHS, with a £1.1bn rebuilds costing £7.1bn due to the scandalous contract with Innisfree and Skanka. Its recent rebuild of the entrance of the emergency department which should have cost something in the tens of thousands has ended up costing in the region of £750k due to Innisfree holding the contract and being able to charge the trust extortionate prices. As patients are told we can no longer afford to prescribe them basic painkillers, how do atrocities like this go unchallenged?

As shown by the paradise papers, many PFI contracts are held in offshore trusts. So we are all being doubly ripped off, tied into open-ended blank chequebooks, with extortionate amounts being paid by near-bankrupt health authorities to companies that pay no UK tax. The health authorities are unable to employ locum staff to support the unfortunates working on the wards, meaning everyone is overstretched. No wonder austerity has likely resulted in 45,000 extra deaths in the NHS since austerity was introduced in 2010, as the BMJ Open study estimates.

To me the ‘tough decision’ seems an obvious one: bring PFIs in-house and fund the NHS properly. As I prepare myself for another night on the front line, I glance at my phone and see a message from a friend saying she didn’t get a formal break in her 12 hour shift, but was told to have a “quick drink of water and stretch her legs.” The situation is unsustainable.

Dr J is a medical doctor working in A&E in one of London’s major trauma centres.

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