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Mike Nesbitt: Night I saw relentless pressure on A&E staff, they deserve better from politicians

By Mike Nesbitt

Published 13/10/2016

Mike Nesbitt outside the A&E department of the Ulster Hospital in Dundonald
Mike Nesbitt outside the A&E department of the Ulster Hospital in Dundonald
Mike Nesbitt chats to some of the busy staff

A close relative of mine was an emergency admission to the Ulster Hospital recently. It was a Monday night and while it would be wrong and overly sensational to describe the scene in the emergency department as "bedlam", it was certainly busy - busier than either staff or patients would have liked.

I was told this is common for a Monday night. People do not like to attend the hospital at the weekends if they can avoid it, and GPs refer many during the course of the opening day of the working week.

Busy means there were far too many patients for the available space, leaving my relative on a trolley, in an open space, for a long time.

Busy also means too busy for staff to knock off work just because their shift was over.

My relative's primary carer was a young nurse who was being encouraged to go home by her colleagues. It turned out she was an hour and a half over her shift. I asked if she was off tomorrow? No, she told me, she was back in at 7.30am.

So, I decided to ask to spend a Monday night in the emergency department (ED).

May I begin by thanking the staff who made me welcome from the moment I reported for my night shift as an observer. What I saw was relentless demand, met by an infinite supply of calm, assured professionalism.

The emergency department at the Ulster Hospital was designed to cater for 25,000 cases a year.

Today, the figure is around 95,000, but lesson one is that you cannot understand the nature of the problem by looking at those figures alone.

On the plus side, the hospital has increased the emergency department's capacity, but those responsible for managing our local health service openly acknowledge that there is a constantly widening gap between funded capacity and patient demand.

It is inevitable that the longer the problem is ignored, the more acutely the consequences will be felt.

On the down side, the Ulster Hospital staff know their patients and unfortunately for the pressure on services, a disproportionate number of those patients represent the elderly.

Strangford and North Down, for example, are home to significantly more over-65s and over-85s than the Northern Ireland average.

That means they are more likely to need the services of an acute hospital and often present with multiple problems.

While many patients continue to have a very positive experience of the health service, a frightening range of specialties are all reporting building pressures and worsening service provision.

These include trauma, general surgery, urology, ENT and pain management.

It is inhumane to expect people to wait in agony for over 100 weeks for orthopaedic surgery, yet that is exactly what is happening in many circumstances.

This means patients are attending the emergency department because their conditions have deteriorated in a way they would not have, if they had been seen in a timely manner.

The cruel reality for some others is despite having paid all their lives into the NHS, many are resorting to using hard-earned savings to pay private clinics thousands of pounds just to get back some quality of life. Lesson two is the way the hospital characterises so-called "inappropriate attendances".

In a sentence, emergency department leaders do not see this as an issue. In fact, they express sympathy for some who attend the ED when their issue is not what you or I might call an emergency.

Like the self-employed tradesman who hurts a finger on a Sunday afternoon. Why should he lose a day's pay by queuing at his GP surgery on a Monday?

The ED is the obvious place to go on a Sunday and the Ulster management are content they have a triage system in place that filters off the non-emergency patients, treats them promptly, and gets them back to work without becoming a blockage to the flow.

That said, the night shift staff who let me observe did express frustration at the loss of valuable resources, dealing with people who just do not seem interested in, or in real need of medical help. Like those who arrive by ambulance, abscond in a taxi for home, only to reappear later in the shift in a second ambulance, still the worse for wear.

Emergency departments have been dealing with alcohol related issues since the dawn of time.

What is new is the epidemic of patients presenting with mental health problems. The facilities and depth of expertise within our NHS is insufficient and inappropriate.

The answer has to be a multi-agency approach. It makes no sense for the PSNI to lift someone and hold them in a cell, if their real issue is mental health.

The same goes for EDs; the model needs changed, for their sake and for the sake of the ED staff who fight a constant battle to maintain the flow. The real block is not so much the numbers entering ED, but the lack of beds at the far end.

I spent the entire night watching the nurse in charge of intake take brief after brief from Northern Ireland Ambulance Service staff, who just kept on coming, with older people suffering cardiac issues or bumped heads from falls; infants with itchy, inflamed skin; and all ages in between, looking for oxygen, pain relief, strapping, and maybe most of all, sympathy and a sense of community.

I marvelled at the nurse's ability to take the paramedic's brief, ask a few simple follow-up questions, and make an instant assessment of need.

That is the trick in ED: you make more decisions, more quickly, on less concrete evidence, than in any other part of the hospital.

The bigger challenge is getting the patient admitted. Can they sit in a chair? That's easier than finding a trolley, which is itself more likely than finding an empty bed.

So, if the patient cannot sit, there is often no choice on a Monday night but to keep them on the trolley they arrived on, meaning the ambulance and crew are grounded for the duration.

Lesson three - the paramedics understand and have patience unlimited, happily assisting the ED staff by keeping an eye on the incoming patients with kindness and wit.

They contribute much more than I ever imagined on their long days and nights. Plus, the nurse who stayed late for my relative was the rule, not the exception.

On Monday night, I saw a doctor work 45 minutes over his shift, because he wanted to see the result of some tests. Two nurses also worked over hours, unpaid. Why? Because they would not sleep easy abandoning a patient midway through a procedure they had started, without knowing the outcome. It is properly inspiring.

The Ulster Hospital's ED is the most challenging of environments, but the staff love their job.

Whatever people try to tell you otherwise, I met consultants, doctors, nurses and ancillaries who work in the emergency department of the Ulster Hospital because they want to.

They love ED at the Ulster, it's what fulfils them, and there is no way I could imagine them ever dropping their standards.

It was my privilege to watch them in action. I thank them for the opportunity. As politicians, we owe them better and I hope the publication of the Bengoa report later this month is the start of real reform of the NHS and respect for its wonderful staff.

Belfast Telegraph

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