We interviewed a friend who worked in A&E. It is a first step to share experiences wherever we work and find common grounds to change things. If you want to talk to us about your situation, get in touch!

You said working in A&E was pretty stressful. Can you explain a bit more?

I was in an inner city A&E, and the kind of thing that people think of when they imagine people coming into A&E; stabbings, gunshots, car crashes, falling off ladders etc is a tiny fraction of the actual workload. Huge amounts of people through the door are suffering from mismanaged chronic illness, which is related to poverty and on some level education, and housing, and work, and family situations and all sorts of other, really complicated things. The cliché is that most people suffer from “shit-life-syndrome”, smoking and drinking long term, living in poor housing, stress, mental health, infections, poor diet, lack of exercise. And all these things are layered on top of each other, so it’s very rarely just one thing. People might present with an isolated singular problem, but more often than not there are underlying multiple causes.

To be honest, when I started my training as a paramedic, and started going into medicine, I felt like I had been shown some secret truth of society. Basically, poorer people get sick. Obviously reasonably well-off people get sick as well, but just not in the same way. It’s really obvious but really eye opening, that when you peek behind the curtain a bit you see that society is just structured to make people who are poorer or live in worse conditions much sicker.

You can see that in A&E. As things get harder for people, and as people struggle more in other areas of their lives, A&E is one of the first places that you see it. Mostly, wherever you are in the country, you can call 999 and you will get an ambulance. You’ll probably get taken to hospital. For most people it’s an emergency lifeline to getting some level of care, whether it is the care that they need or actually want is another question but for most people it is their only immediate option.

Was the stress that you were confronted with symptoms and situations that you can’t deal with?

Part of the reason that I found it so stressful is that I went into working in A&E a lot older than most people who work there, having not worked full-time in a while. It’s a really fast paced setting of really multitasked work with a high level of decision making and juggling multiple things at the same time. Assessing a patient, diagnosing, ordering tests, understanding test results, forming a plan, giving medication – and doing this for several patients all at different stages of this process at the same time. I felt old and tired and just like “Fuck this. This is horrible”. Of course this experience was exacerbated by the fact that more and more people are getting sicker, the health service is struggling in various ways, more people are coming to A&E because they can’t get a GP appointment or coming to A&E because they’re seriously mentally unwell.

Can you speak a little bit to the pressures that might be brought about by these management solutions that we hear about cause? Something like the 4 hour target from admission to discharge either from the hospital or to a ward? Was this heavily enforced? 

I think they might have got rid of the target. I was only in A&E for a year, and the whole thing was in such a state that nobody even bothered talking about it. I remember talking to some people who’d been there longer and they spoke about it in a way that suggests it was just a bullshit thing that people had to get around by moving people to wards or shuffling them about so it looks like the target had been hit even when patients were still there hours later. So, I don’t know whether the target was still there when I was working in A&E, or whether they’d decided to just get rid of it. To some extent though, it was probably something that was introduced with the best intentions but in reality just became something that workers had to get around or fiddle by moving someone to a different department, getting someone discharged on the books but they’re still there waiting for transport or social care arrangements to be sorted out. I didn’t really come across it as an issue. 

I can remember some of the worst days during the winter where I would go home at 6pm with patients in bed in A&E, and come in at 7am and the same patients would be in the same place. Sometimes they’d still be there when I would leave again in the evening. You’d do handovers where you talked about patients who had been there for 30-40 hours. There’s all sorts of research which shows that every hour people of a certain age spend in a hospital bed shortens their life by a certain amount, so I think that’s one of the problems with the focus on acute medicine in the health service. You’re saving people in the immediate term, but they die 3 months later because they have such shit healthcare early on in the process. They don’t die then, but you probably cause them to fall over and break their hip because they’ve been in a bed for like 2 weeks.

Was the main reason for this stagnation that the wards were full, or was it that the work that you were doing couldn’t be done for other reasons? The normal idea is that A&E would work fine if the rest of the hospital wasn’t so full up.

I’ve tried to do a lot of reading and talking to people to understand this. I think it’s a really complicated, multi-factoral (as they say) problem. I think it’s something that is impossible to confront without a widespread and radical reshaping of how people live and work. I think probably all of the reasons that people give have some element of truth to it. You know, the classic one is that it’s an underfunded workforce that is tired and stressed. People are leaving, hospitals are out of date and you have an aging population which brings about a series of chronic conditions that go with that. These are all definitely factors, but I don’t know how much we can put down all of the problems that the NHS has to them. There is an element of truth to the fact that people’s health is getting worse, people’s mental health especially is getting worse. At the same time other areas of the health system are in disarray. For instance look at dental care, which previously people wouldn’t have had trouble accessing. There is an issue with health education, people having very little understanding of their own health. This goes hand in hand with an increase in anxiety and depression, where it seems that there is this level of health anxiety now that wasn’t there before. There are issues around cultural and religious understanding of how health systems work. The isolation of people from wider social networks is another massive factor. Maybe 30-40 years ago, people would live close by to family relations who could reassure and offer some level of care. With this gone, and people being more isolated they tend to worry more, and so you have this loss of a multi-generational knowledge to refer to. It’s hard to unpick any one of these things from everything else though.

Work gets done in A&E, it just only gets done because people work harder than they necessarily should have to. This is especially true for nurses and HCAs. The level of responsibility and speed that these people work at is incredible. Obviously this is true for doctors etc. as well, but these guys are really bearing the brunt of it. 

I think that if you doubled the staffing in A&E, the work would definitely get done faster, but the bottlenecks aren’t really to do with people not being able to keep up with the work. The barriers are more around things like discharge towards or discharge to home. When you start looking at discharge to home you have to start looking at the ambulance service who previously, if someone wasn’t fit to walk or make their own way home, an ambulance or patient transport service would sort them out. A lot of these patient transport services have been contracted out of the NHS now, and the ambulance service is entirely overrun and overworked – in fact they probably struggle as much, if not more than anyone in the health service. So I think that the biggest bottleneck is definitely around discharge, with some caveats concerning test results and understaffing 

Could you describe the situation in the A&E regarding the relationships between doctors, physician associates and advanced clinical practitioners? Were there clashes of competency between these professional groups? Was there stress around it?

There weren’t clashes in the A&E that I worked in, but I imagine that it varies from hospital to hospital. Where I worked was good, there was no stress between the different roles, and because of the structure of A&E it tends to be much more of a horizontal structure than situations like on wards. In A&E there tends to be a much more collaborative environment between the various professions, so it is a much easier place to get on in a role like mine even though the pace is faster and there’s more time-critical decisions, sicker patients etc. Nurses there tend to be much more experienced and are doing things that nurses wouldn’t do in other areas of the hospital. It’s also a place where newer doctors tend to do a rotation, and you often have the situation where there’s an A&E nurse who’s been working there for maybe 15 years showing the doctors what to do and explaining how things work – even to the point of double checking what the doctors are doing. So in a way because of the nature of the workload you have this more flat structure which seems different to other areas. The cliché is that surgical wards are particularly hierarchical, and my experience of PAs in hospitals is that PAs on surgical wards are basically the doctor’s dog’s body.

This happens all over the place though. In the same way that there is this growing space in medical care for diagnosis and examination between registered workers like nurses or paramedics and doctors, you now have Health Care Assistants and other medical workers doing jobs that only nurses would do traditionally. So everything’s kind of upscaled a bit in terms of scope of practice and responsibility.

Was there any sort of collective discussion between doctors, nurses etc. around the situation that workers in ED have to face? Was there any sort of common understanding of how these problems could be overcome?

One of the things that is quite depressing about working in the NHS is that everyone knows that it is in an absolute state, and there is some kind of collective understanding about what needs to happen amongst workers. I don’t think that it’s a particularly difficult set of solutions to come up with. The problem is a lack of political ability or power to implement the solutions, or even before that to believe that the implementation of those solutions is even possible. My feeling is that everyone knows that it’s broken, everyone knows how we could fix it – nobody believes it’s going to happen. Whether that would be through some kind of worker-led transformation, or even through some kind of parliamentary solution. This is, I think, one of the main reasons that people leave. Not so much because it is necessarily broken, but more because people can’t imagine it getting fixed.