A doctor shortage at heart of A&E crisis ... but how did it ever come to this?
The casualty unit at the Royal Victoria Hospital was likened to a ‘war-zone’ this week. But the crisis in our A&E units runs even deeper. And it’s all down to a shortage of junior doctors
The diagnosis of the ills facing Northern Ireland's accident and emergency departments hasn't been good for years now. But the prognosis for the future is even worse. Critical, in fact.
And while some critics have said that this week's "night of hell" in the A&E department at the Royal Victoria Hospital in Belfast was an accident waiting to happen, no one's disputing that emergency measures on a wider scale are needed to treat the service's ailments.
On Wednesday night health officials in Belfast had to call in extra staff to implement a major incident plan to tackle a huge backlog of patients seeking help in the Royal where, at one point, 42 people were waiting on trolleys and where tearful nurses likened their department to a war-zone.
But it's clear that the problems go much deeper than one horrendous night in the RVH and the health union Unison has said there's a province-wide crisis which was foreshadowed in a report late last year from the College of Emergency Medicine, which warned that excessive pressure on A&E consultants had the potential to put patients at risk.
It's just seven days since the emergency departments at the Downe Hospital in Downpatrick and the Lagan Valley in Lisburn were closed for the weekend for the first time in what is supposed to be a temporary shutdown forced upon the South Eastern Health Trust, they say, by a shortage of middle-grade doctors.
Politicians and health professionals, however, are divided over the move, with the former claiming that not enough has been done to recruit more medics and the latter countering that they'd done all they could but had failed to entice the right people.
In Downpatrick, the local MP, Margaret Ritchie of the SDLP, is furious. "I don't think the authorities have been robust enough about managing this issue. I want to know where they've advertised for doctors."
The story's the same in Lisburn, where DUP Assemblyman Paul Givan said the closures must be short-term. "What we must have is have 24/7 front-door access to the emergency department. And that's what the trust and the Health and Social Care Board have assured us they're working to achieve.
"But that's what they said two years ago, when the A&E department closed at night during the week. I believe they want to do it, but I'm not sure that they can deliver."
The dilemmas facing emergency departments aren't peculiar to Northern Ireland. Across the UK, there's a 50% shortage of medical staff in A&E units.
Several factors have exacerbated the difficulties and medical experts say they're not going away. "There's no magic wand. You can't go into the cupboard and produce a blow-up doctor," said one.
Dr Sean McGovern, a consultant in emergency medicine and the vice-chair of the College of Emergency Medicine in Northern Ireland, said that emergency departments were struggling to provide the level of service needed.
"The catalyst is very clearly a junior doctor shortage regionally and UK-wide. There's probably no department in Northern Ireland that has the correct number of consultants."
The recent Transforming Your Care strategic document from the Department of Health identified the need for between five and seven A&E units for Northern Ireland into the future, a reduction on the 10 currently operating across the province.
"A minimum of 10 doctors are needed for every department. Yet we have only approximately 55 consultants in emergency medicine right across Northern Ireland, so it doesn't take a genius to do the maths," said Dr McGovern, who pointed out that the number of consultants was only half of the total of MLAs in the province.
In a survey last year, all but a handful of the consultants here took part in a UK-wide survey by the College of Emergency Medicine – 78% of them said they thought their jobs were unsustainable due to staff shortages and workload pressures. Dr McGovern, who's based at the Ulster Hospital, said a number of factors had contributed to the problems. "The European Working Time Directive has been one. When I was in training, it wasn't unusual for me to do 70 hours-plus per week but now under the directive, no doctor will be working more than 48 hours. So if you want the same cover, you need more doctors."
Dr McGovern doesn't believe there's a quick fix. "Placing endless adverts for doctors when they just aren't there isn't going to work. We have to get the infrastructure right first."
The fact that, in many centres, more women than men are now training to become doctors has had an influence on the shortfall.
One observer said: "Women will obviously eventually take time off to have children. Then they may want to go into part-time work and the unsocial hours and the pressures of emergency medicine aren't attractive to women."
Many younger A&E doctors also want to work in the bigger and more challenging acute hospitals, like the Royal and the Ulster, instead of smaller hospitals.
One source said: "They want the experience and to keep up their skills, instead of working Saturdays in somewhere like the Downe, where they might be stitching up patients' broken lips while people with major traumas, or cardiac problems, are going straight to Belfast anyway.
"So the reliance in the smaller hospitals has been more on locums to do the weekend shifts, but there aren't enough anymore."
Surveys have also shown that working in A&E departments has the highest rate of burn-out in the health service and few doctors work beyond the age of 60.
Dr McGovern said: "The pension age for doctors has been raised to 68. So, if you're a junior doctor and you have a choice to make – of going into a career in high-intensity emergency medicine and working unsocial hours before burning out at the age of 60 and getting a low pension – it's hardly a very attractive proposition, is it?"
What is becoming more and more appealing to junior doctors from the British Isles is the lure of Australia.
A significant proportion of newly-qualified medics are heading Down Under with the initial aim of staying for a couple of years to sample a different life and a different working environment. But many of them don't come back. It's been estimated that up to 25% of senior emergency doctors in Australia have trained in the UK.
Insiders say salaries are twice as big and, even though the cost of living is higher, the British and Irish doctors are still quids in.
But it's not just the money and the sunshine which makes them stay. The infrastructure in the Australian health service is said to be vastly superior to the UK.
"They have the correct number of doctors. They're not hunting round for locums and they can get on with doing their job. The work-life balance is right and their families will have settled," said one commentator.
One medical student, who plans to stay in Northern Ireland, told me his heart told him to go into emergency medicine, but his head was making him think twice.
The man, who didn't want to be identified, said: "I know it's a very rewarding area to work in, but I just don't want to do it for the rest of my life in the current circumstances.
"I don't relish the prospect of having to work at nights and at weekends in emergency departments where it's a tough job in every respect.
"I know people at the top are taking the problems more seriously and there are working groups in place and, hopefully, they'll recommend an increase in the number of senior medical consultants, which would make the career path more attractive for junior doctors like me."
The chief executive of the Health and Social Services Board, John Compton, has said he understands the concerns of people surrounding A&E services, but he has denied union claims that the service isn't working, or that last weekend's closures had caused any major problems.
Seamus McGoran, director of hospital services at the South Eastern Trust, said earlier this week the closures were a regrettable necessity in the interests of sustaining emergency services in Lisburn and Downpatrick.
The fear in Lisburn and Downpatrick is that the temporary weekend closures will be permanent and are part and parcel of the overall Government plan to centralise A&E services in Belfast and other acute hospitals throughout Northern Ireland.
One observer called it "closure by stealth".
"The shutdown at the City Hospital in Belfast was supposed to be a stop-gap measure, but it hasn't re-opened," he said.
But Mr McGoran has insisted the future of hospitals like the Downe, which only opened at a cost of £64m in June 2009, is not under threat.
"There are many more day-surgery services, outpatient and diagnostic services than there were. We have cataract surgery, fracture surgery, sexual health services and bowel cancer screening has been centralised in the Downe for the Trust area."
In the meantime, politicians are stepping up their campaigns to have the Downe and Lagan Valley hospitals' emergency departments up and running again as a matter of urgency.
Paul Givan plans to raise the issue in the Assembly, while Margaret Ritchie has tabled a question in the House of Commons on Wednesday.
DUP MP Jeffrey Donaldson said he warned that the Downe and Lagan Valley closures would create difficulties at the Royal. He said he wanted to see a speeding up of plans to integrate out of hours GPs services with A&E to alleviate the local problems in Lisburn and Downpatrick.
He also said that radical new thinking could be needed to tackle the UK-wide shortages in emergency departments and with consideration given to making it compulsory for medical staff to serve some time in an A&E unit and not just during their training. "If we are continually in this situation of understaffing, then that needs to be looked at."
But Mr Donaldson has defended his party colleague and Health Minister, Edwin Poots (left), from criticism from other politicians and from representatives of medical staff.
The Royal College of Nursing and the health union Unison have said they've never seen the situation so bad at the Royal. The depth of anger was demonstrated as Mr Poots was booed as he arrived at the RVH on Thursday.
But just as health officials had done earlier, he gave media interviews to say "exceptional" problems at the Royal had been a "one-off", which had been turned around within three hours.
But privately there's a sense of dread among some Stormont advisers that Mr Poots' attempt to give the A&E units a clean bill of health could come back to haunt him in the cold winter months which lie ahead.