When Saturday Comes: Politics, Health and Football

The NHS is political football, whatever David Cameron says. Healthcare policy is realised through relentless, tribal warfare of deep-seated ideologies and the fierce factional loyalties of rival die-hard supporters. Like Rangers v Celtic, Real Madrid v Barcelona, in the Healthcare Championship, there is an historic struggle of ideas and identity going on, but with vested financial and political interests manipulating the conflict in the background. The players on the pitch, the NHS staff, want to put in a shift, score goals and defend well, but the refereeing is inconsistent and frankly a little suspect.

Over recent weeks, many grudge matches have been played out over the UK A&E overcrowding crisis. Every lobby group jumps in to the tackles with their own theory as to the cause. According to them, it is variously the fault of the public for attending with trivial hang-nails, the GPs for not liking being out in the dark or working weekends, the A&E staff for being risk averse and admitting everybody, the closure of local hospitals by cynical politicians, the global financial crisis, the Barnet formula in Scotland, the elderly population, collapse of social care, insufficient district nursing and so on. Every side sets out to secure maximum points and their win bonuses, but no one gets shown a yellow card if the play was unsporting or goals should have been clearly disallowed. Maybe the game could be massively improved if referees looked to reliable data and reproducible evidence rather than the shrill appeals for penalties from the partisan stands or players on the pitch.

In Scotland (using Auditor General data), the numbers of emergency attendances have been going up, but only gradually and slowly (15% in 10 years). On the other hand, the number of elective (planned) admissions has risen rapidly (36%) to meet crowd-pleasing treatment guarantees. The length of stay has dropped in keeping with a degree of modernisation, but this has been way offset by a substantial reduction in bed numbers (7%). The net effect of these changes is increased occupancy, and progressively fewer beds to put emergency patients in. Once a crucial hospital occupancy tipping point is reached, the system collapses because patients are admitted here, there and everywhere, get poorer care and stay longer thus compounding the bed problem exponentially. The Emergency Department then becomes a holding warehouse for new admissions, the staff get burnt out and irritable, and the occasional patient who wanders in with a minor complaint (even though international evidence clearly shows that this group do not ever cause overcrowding) gets the blame for the whole debacle. Losing every week like this has been enough to cause some staff to quit their NHS club and look for an overseas team.

The use of impartial evidence focusing on capacity and occupancy could therefore be the match-winning strategy to resolve the issue of A&E overcrowding. Globally though, the biggest healthcare game is between the self-reliance, competition and market forces of the private sector versus the equity, co-operation and cost-effectiveness of publicly provided services. Here too, use of scores from fairly conducted matches rather than the opinion of pundits may improve the sport for everyone. In a recent properly refereed international play-off, for example, the Commonwealth Fund reported the UK NHS to have been the most cost-effective and equitable healthcare system in the world. Some heavily sponsored teams setting out to take on the NHS may indeed find a level playing field difficult to manage. In fact one such team, Circle United in Cambridge, recently suffered such a humiliating defeat that they voluntarily dropped out of the entire league and are now restricting themselves to playing Rounders.

When Saturday comes, the NHS staff will boot-up and trot onto the pitch. Their long-term performance in the league will crucially depend on their manager, the board of the club but also critically, the backing of the fans.

Never Mind the Bollocks: 10 Things Emergency Medicine Consultants Can Do Now to Help the NHS Stay the Best Healthcare system in the World

Scotland has a serious politics hangover, and now the party conferences have started up in earnest. The NHS is front and centre as usual, wheeled out like a beat up old Jag that mostly still goes like a dream, but has had some very unfortunate internal modifications over the years, and is currently towing a caravan full of improvement specialists. It needs some expensive work done, but the garage report says its well worth saving and is definitely much better value than using rental cars.

We know that politicians mostly talk bollocks about the NHS, influenced by which lobby group or vested interest has their ear at the time. We in Emergency Medicine on the other hand can have some real influence on whether we stay at the top of the healthcare global charts in spite of them. Here's my 10 point check for us EM consultants to do our bit, divided into DCC and SPA activities.

On the Floor: Speed, Safety, Cost-effectiveness

1.     Make clear disposition decisions based on risk, and only admit patients who really need it. Think: “If not me, then who better to be gatekeeper?”

2.     Use robust evidence-based guidelines combined with experience to assess risks and standardise treatments in the right context. Science and art of medicine.

3.     Ensure important time-critical things happen quickly. Early resuscitation, sepsis care, pain-relief, revascularisation and haemorrhage control improve quality, outcomes, patient experience and length of stay.

4.     Consider early DNR and end-of-life care when treatment futile and simply prolonging inevitable death. What would we want for ourselves?

5.     Avoid confusion and duplication by clear communications with in-patient team, GP and patient/family. What needs to happen next and by whom?

In the Meeting Rooms: Focus, Clarity, Candour

1.    Say at the start of every meeting; “This meeting will have been a success if we achieve what outcome?” If no clear answer given, leave and go do something useful for patient care instead.

2.    Do not tolerate the cruelty, danger and inefficiency of ED overcrowding. Make everyone’s life hell until they fix it - the more senior the better.

3.    Talk up the importance of EM senior cover at every opportunity, and plan how to stretch cover across as much of the day as possible. We are the answer, now what was the question?

4.    Take every opportunity to analyse, critique and evaluate EM service performance. Seek to improve every small pixel that makes up the picture. No one looks good with their head up their own ass.

5.     Teach, support and inspire trainees, med students, ambulance staff and nursing colleagues to understand the key role of EM in turning chaos into order. We are the NHS.

Our Wee Bit Hill and Glen

After the flag waving and songs, the bluster of economic pseudoscience, the bogus arguments about cultural differences, the dirty tricks of the financial establishment, and the genuine angst of people reluctantly empowered, we will on Friday 19^th September 2014 still have emergency departments in Scotland to run. And with either outcome, there may be trouble ahead in our NHS.

   If we wake up in the world’s newest nation state, we will surely enter a period of intense turmoil and uncertainty. It is very difficult to imagine that this will not lead to some damaging caution in health spending, at least until the financial industry takes stock and reboots itself. Of course, if the pessimists are right and the economy collapses, health funding might remain constrained for a very long time. Doctors may themselves begin to consider relocating to other areas of the world to avoid the turmoil and the distinct possibility of higher taxes. This drain of talent may continue indefinitely, as it is highly likely that the accreditation of specialists will continue to be recognised on either side of the border (such as now occurs between Australia and New Zealand), thus allowing easy economic migration in search of better wages and/or conditions in England.

  If alternatively, we wake to the confirmation of remaining in the UK, we have the distinct prospect of taking a hit in public spending following proposed

austerity-focused cuts in the rest of the UK through the Barnett Formula. Furthermore, the enactment of the TTIP could force the Scottish devolved NHS to open itself to overseas private competition, thus driving a parallel destructive orgy of privatisation to that of England. This scenario ends with a US style market driven health service that provides expensive, defensive mediocrity and gross inequity of provision. The loss of Scotland carrying the beacon for the retention of the NHS in its original and highly successful form, may also then consign the whole egalitarian principle to history; a casualty of the voracious appetite of global capital to make quick money without conscience.

   In either scenario, I worry about the grassroots effect of this political frenzy on running our departments, particularly in the urgent need to continue to fund improvement and recruit and retain excellent staff. Furthermore, I worry about the distraction from the very real world current problems of roster vacancies and overcrowding that are damaging patients and the reputation of our healthcare system.

   So, as a plea to both camps: come Friday morning, Scotland will have come through a major crossroads. As the dust settles, we still need to receive adequate continuity of funding to provide a level of healthcare as befitting this wealthy nation we are told we live in, whoever will be in charge. But also, perhaps given that health is an already devolved issue, and the government will continue to have tax raising powers whatever, how about taking advantage of all the talk from both sides about social justice and the importance and value of the NHS? Simply immediately put forward measures to increase top rate income tax by 1p in pound, remove the discretionary points system for consultants and use the resultant income to fund the expansion in rest home care places, chronic disease programmes, hospice care and 24/7 acute services necessary to banish overcrowding, bed blocking and boarding.

  It would be nice to have something concrete to show from what may be prove to be a very brief window of political engagement to improve the way we run things on our particular piece of ground.

Competition, Co-operation and the W*nker Theory.

The pervading wisdom is that public health services, designed on co-operative interaction, need to be exposed to “market realities” by introducing competitive forces to make them more efficient. In fact, we already have this tension of ideas on the trading floor of the emergency department.

If the ED tone is too friendly, accommodating and conflict-averse, patients risk being stacking up, denied access to any specialty guarded by a territorial, overstressed or inflexible registrar. Such patients may then end up in poor old Gen Med for days longer than necessary, awaiting the specialty input it was obvious they required from the start, or worse, inappropriately discharged and coming to harm. However, if the ED tone is too stroppy, hectoring and directive, patients risk being hurriedly bundled into pressurised specialty beds causing stress, animosity and unseen down stream pressures for that service - not least the admitting registrar being castigated on the post take round for being “too soft”. Indeed, such is the nature of the balance between collegiality and high-handed siege mentality for the duty ED consultant, that if during the course of a busy shift in the emergency department there is not at least one annoying w*nker from the in-patient services to patiently manage, the annoying w*nker might indeed be yourself.

Emergency registrar slain for absent CRP

The whole referral game can sometimes deteriorate into competitive set pieces, in which move and counter move is anticipated and blocked. ED docs playing the game with experience and seniority roll out their moves with skill and confidence, playing key bits of information like ace cards to force the opposing player to fold early. Juniors, new to the arena, apologise and squirm as the weary specialist dances round their rambling referral like a matador, weakening it with a series of well practised weary requests for irrelevant absent information. More tests and the gathering of multiple other opinions are suggested.  It is intimated that the referrer has lost either their faculties or their bollocks, and thus any ability to make a reasonable decision. The overall quality of referrals of this nature from the ED in general is questioned. Finally the killer blow of “no beds anyway” may finally finish off the sorry spectacle, and leave the referrer thinking twice before re-entering that arena for the rest of the shift.

Of course, most of the time those on shift in the hospital realise they are working to a common purpose and co-operate together seamlessly and good-naturedly to the patient’s benefit.  But if referral were always dead easy for the ED, would we fall into the trap of not earning our corn as a specialty ourselves? Emergency Medicine’s greatest contributions to health outcomes and economics are generally the early input of time-sensitive treatments to minimise morbidity and mortality (e.g. antibiotics in sepsis), and the safe discharge of patients who do not require in-patient care (e.g. PERC negative patients with pleuritic pain). Once an ED referral is accepted by an admitting team though, the EM doc is relieved of the responsibility of finessing the diagnosis and the worry of discharging the patient home. This creates a very strong temptation to glibly, even sloppily, “buff and turf”. This behaviour becomes closer and closer to routine operating practice when the department is overrun with new patients, overcrowded due to access block or staffed by inexperienced or burnt-out docs. Such practice may then undermine the value the specialty adds to those most important of health indicators: outcomes and costs.

Chilean Mine Rescue: no w*nkers

It may just be possible however, to have a highly functioning referral system that utilises both co-operation and competition to produce great results. How? Give the ED direct admitting rights to all specialties, selecting the most cost-effective and safe disposition for their patient using evidence-based practice, senior supervision on the floor and clear pre-agreed referral points (e.g. pre or post CT for stroke). Then simultaneously exploit the competitive egos of the ED consultants by presenting them with detailed performance feedback benchmarked against colleagues from both within and outside their department. Furnish them with a list of not only admission percentages, did not waits, critical incident and lengths of ED stay on their watch, but also collated in-patient mortality, length of stay, and regular feedback from all specialties on patients they admit.

Arguably human behaviour is equally influenced by the desire to co-operate and the urge to compete. Facilitating co-operation and trust on the shop floor, but yet encouraging healthy competition for excellence between senior practitioners may tap into this very effectively. Then nobody has to be a w*nker at work.

Death in a Crowd

Overcrowded emergency departments kill people and the other departments of our hospitals appear largely ambivalent to this fact. Have we lost the point here or is what happens in emergency departments simply unimportant in the "bigger picture"?

What IS the ultimate goal? Maybe: "Everyone should have a long, productive and happy life with only brief episodes of non-disabling, non-preventable illness or injury, culminating in a dignified pain-free death surrounded by loved ones". To get there, sure, the really big gains are likely to be found in public health with immunisation, screening, and measures to tackle violence, smoking and alcohol. Or in chronic disease management with secondary prevention and early interventions for diabetes for example. Or perhaps most importantly, using social and economic policy to drastically reduce the inequality, relative poverty and social exclusion that drag down the health of entire communities.

Emergency medicine, however, has two vital supporting roles in the fight. Firstly, providing aggressive treatment of bad stuff such as sepsis, trauma and acute coronary syndrome prevents those inevitable blips of acute illness or injury from becoming life-limiting. Secondly, allowing expert evidence-based management of low yield, high risk acute presentations without over-investigation or unnecessary hospitalisation prevents those recurring "groundhog day disasters", such as mis-diagnosing migraine in sub arachnoid haemorrhage, dyspepsia in acute coronary syndrome, intoxication in serious head injury or viral illness in septicaemia.

To do this bit effectively though, there are three required, evidence-based structural components: senior input (for experienced heuristics and "fast thinking"), check lists and protocols (for error trapping and "slow thinking") and the absence of overcrowding.



Overcrowding is the single biggest threat facing emergency departments this winter. Once our departments get overcrowded, all sorts of bad stuff starts to happen. Most bad shifts in the emergency department, like a major accident producing a heavy multiple trauma load, or staff sickness causing crucial roster gaps, are surmountable, mostly, with hard work, multi-tasking, leadership, experience and team work. However, start a shift with patients on trolleys and no prospect of in-patient beds and it will be a shift of frustration, impotence, poor care and staff burn-out, completely resistant to the most talented or heroic of efforts.


In overcrowded departments, treatments get missed or delayed. Errors happen with mixed-up blood samples and wrong medication. Critical incidents occur with patient falls, violence to staff and unnoticed deteriorations. Both patients and staff feel the place they are in is frankly a bit crap. All of these small, and occasionally big, levers operate to produce the eye-watering mortality increases associated with overcrowding: more than 30% additional deaths in admitted patients and more than 70% in discharged patients. It is nearly always an overcrowded hospital that causes emergency departments to become terminally constipated. Overcrowded hospitals have either insufficient beds for their workload, or inappropriately long length of stay due to inefficient work practices.

Ward staff and specialists don't care too much about emergency department overcrowding as it doesn't really affect them. The solution may lie in reversing that through overcapacity protocols. Using these, when the emergency department becomes dangerously overcrowded, the wards share the risk and the pain by also taking patients in their corridors. Where this has been done around the world, the bed fairy has quickly gotten busy with her special magic.

John Snow, the father of epidemiology, would never have tolerated the proven damage caused by ED overcrowding. He would have removed the handle on this particular pump, possibly by personally pushing gridlocked patients into less dangerous areas of the hospital than the corridors of an emergency department. We need systems, seniors and space in our emergency departments to achieve our potential impact in the "bigger picture". Perhaps a little direct action of our own is required this winter to give us some of the latter by using overcapacity protocols. Maybe then "whole of hospital solution" will actually mean something?

Ninjas not Nanas

Ninjas not Nanas

What is the point of Emergency Medicine? Heroic life saving? Round the clock universal medical care? Gatekeepers to hospital beds? Traffic wardens for patients within complex health system? Initial surrogates for expert care? Specialists in vague but risky symptoms? Safety net for a caring society?

Probably all of the above, often in one shift. We are, however, allegedly in “crisis”. Victims of a "failing" NHS acute care system, in a specialty no-one apparently wants to do, trapped, burnt out, powerless at the bottom of the medical heap. We have become pitied, weak, frail and in need of rescue, broken down at the side of the health highway.

However, although sometimes it is quite nice for people to empathise with our difficult job, the big money is now being quietly loaded into trucks to be driven away from the perceived embarrassing train wreck of “A&E” and given to others who confidently declare (without supporting evidence) they have the answer to the acute care problem.

At this point, however, before it is too late, it is time to tell the emperor he is naked and may have received some poor tailoring advice. The truth is that emergency medicine one of the most successful, least dysfunctional part of the entire system. It is simply the visible bulge in the balloon caused by pressure on all sides.

On one side, primary care is seriously hampered by vast variations in practice. Some GPs are outstandingly dedicated, provide excellent patient-centred care and make superb timely referrals. Others appear to be too risk-averse, possibly lacking interest or experience in acute care, or have insufficient access to either simple "rule-out" investigations or chronic care plans for their complex patients to mitigate hospital referrals. As a result, some of the most so-called “inappropriate attenders” at an emergency department are there because the GP sent them in: patients who need a simple blood test like d dimer, or an x-ray or non-urgent scan, or elderly person with a social care crisis. In the absence of community alternatives, the latter group will get admitted for a prolonged hospital stay, perhaps for minimal benefit other than simply accessing services.

On the other side, the in-patient specialists frequently provide the emergency team with a complex array of referral arrangements seemingly designed to protect them from interference with their special interest, elective and sometimes private work. They have layers of junior staff who can be astonishingly dismissive of legitimate emergency referrals through either fear of admitting the “wrong type of patient” and wearing it from the boss on the ward round, or simply through their own inexperience and overwork. “Selling patients” becomes a core skill for the emergency department, with some shifts feeling like a long day cold calling for double-glazing telesales. Furthermore, whatever the bed state of the hospital, the in-patient specialty teams continue to admit electives. Each day seems to bring the same surprise that a number of emergency patients have turned up who also require care. Delays to in-patient review and admission are the major cause of emergency department overcrowding and stress.

So, in addition to emergency medicine doing its own core work of sorting out and resuscitating acute undifferentiated illness and injury, it is picking up the deficiencies of its neighbours. This is undoubtedly straining an otherwise highly successful model of care. Emergency medicine consultants have been shown to improve survival in critical illness and injury and to reduce admission to in-patient beds. An enormous number of patients are still appropriately treated in a very timely manner by international standards to a high level of satisfaction. A&E remains one of the most successful brands ever, in terms of popularity with the public, and local departments are fiercely defended by their communities. Arguably, along with the system of holistic general practice and free-at-point-of-care access, UK emergency medicine plays a major part in keeping the NHS consistently one of the most cost-effective and equitable health care systems in the world. The current “crisis in A&E” is like a highly-functioning airport becoming overloaded during an air traffic dispute. Once the planes take enough passengers away again through departures, the airport works perfectly well.

So, rather than look for alternatives to emergency medicine to solve the current crisis, we should do the exact opposite and give emergency medicine more control of its immediate pressure points:

Telephone advice and support to GPs from emergency medicine consultants backed up with rapid access to community lab, x-ray access and outreach home care teams. Direct admission rights to all in-patient specialty beds without hindrance or delay, together with simple contact arrangements for senior members of duty specialty teams. The emergency department as the hub of operational management for the hospital with the ability to cancel electives during critical occupancy periods and to mandate the redistribution of medical staff from non-urgent duties during activity peaks or critical roster gaps. 

As emergency physicians, we need to stop feeling less like nanas, be more like ninjas, and retake control.