A&E in Crisis

[Sheilbh]

This is a great piece explaining the NHS crisis:

A&E in crisis: a special report
As the NHS faces its worst winter in years, Robert Colvile provides an in-depth, first-hand account of the pressures facing the health service
Robert Colvile By Robert Colvile8:00AM GMT 02 Jan 2015 Comments1428 Comments

If you want to tell the story of the NHS, there are a million places to start. You could start with the politics – Labour attempting to "weaponise" the issue ahead of the election, the Tories to defuse it.

You could start with the money – the struggles over scarce resources, the debates over how many more billions will be needed as the population ages.

Or you could start with the individual stories – with the people passing through the lobby of the Queen Elizabeth Hospital in Birmingham, one cold December morning. The girlfriend feeding crisps to a paralysed young man. The white-haired lady lingering over her tea, complaining as she stands up. The young family, sitting together, heads bowed. The little girl, horizontal in a wheelchair, breath mask clamped to her face, being wheeled out by her father.

But here's where I'm going to start: in a small green-painted room off one of the main corridors of that same hospital, where 10 women and two men are studying the spreadsheet projected on the walls and firing jargon back and forth.

"Four in urology with a decision to admit." "306 is gone, 728 still waiting." "With all that agreed, does that give you any ITU capacity?" "They're desperate to bring the liver over from Worcester." "Time to be seen is at 1hr 54."

This is the "Ops Centre" of one of the country's biggest hospitals, where I am spending the week as a fly on the wall. At this and other daily bed meetings, the senior nurses and managers get together to work out who is in the hospital, and where they need to go next.

They go through, ward by ward, listing spare beds and allocating them to the people in A&E. They can see who's been waiting longest, where the pressure points are, and what needs to be done to resolve them.

This, then, is the story about the NHS that I want to tell. It's the story of the NHS as a system – a system that takes millions of patients through from the GP surgery and A&E department to treatment, recovery and discharge.

It's the story of how that system is starting to creak and increasingly crack under the strain. And hopefully, it might also be the story of how we can fix it.


Ambulances lined up outside Accident Emergency. (Photo: Andrew Fox/The Telegraph)

PART ONE: THE LONGEST NIGHT

The Queen Elizabeth Hospital is what we all want the NHS to be. Opened in 2010, this gleaming, £545 million building houses one of Britain's newest and best-performing hospitals. It has the biggest renal unit in Europe, a laboratory the size of a football pitch, a pharmacy manned by robots.

This the hospital where we send our wounded servicemen, the place where a young Malala Yousafzai came for rehabilitation after being shot in the head by the Taliban. It even has a working IT system: if enough patients say they dislike the food, the catering staff are automatically summoned to explain themselves.

When I arranged to spend the week before Christmas at the QEH, I wanted to learn about the real state of the NHS from the doctors and nurses, patients and managers at one of its flagship hospitals. Instead, I found myself with a front-row seat for the worst night in the hospital's history.

It starts at 7.30pm on Tuesday, with another meeting in the Ops Centre – this one the handover between the day and the night shift. Normally, hospitals like this aim to have 85 per cent of their beds in use.

But the past week has seen packed A&Es across Birmingham and the West Midlands. Trust after trust is "running hot", with occupancy rates at 95 per cent or higher. What that means is that patients are streaming in through the front door – but there is no place to put them.

The result? The system breaks. The QEH and other hospitals measure the pressure they are under via their EMS level (EMS standing for "Escalation Management System"). EMS 1 is normal, EMS 2 is tight, EMS 3 is a crisis, and EMS 4, in the words of one senior executive, is "Armageddon".

Nicky Bartlett, the senior manager on site, opens the meeting by announcing that as of 6.54pm, for the first time in its history, the QEH has gone to Level 4. In other words, there are no beds. Anywhere. The chief executive has called a crisis meeting in the morning, but it is already apparent that some patients will have to bed down in the Emergency Department (A&E, to you and me). The question is: how many?

The staff study the list of patients projected on the wall. There are more than 40 in ED at the moment: their complaints include "palpitations", "painful shoulder", "headache", retention (of urine)", "deliberate self harm", "cellulitis, toe, left" and "generally unwell".

They are ranked and colour-coded according to arrival time: those who have been waiting for longer than the four-hour national treatment target are picked out in bright red. Already, there are six such names: the longest has been here for 7 hrs 41 min.

The team go through the wards, hunting for empty beds: "623, full. 624, full. 625, full." Every few minutes, the emergency beeper will go off, summoning someone to the phone – usually to be told that a particular bed isn't free after all. Then they go through the staffing levels, trying to jiggle things round to free up some extra capacity. There isn't much.

I follow Anne Adams, the night shift manager (and, like all the others, a highly experienced nurse), as she makes the rounds. She spends almost two hours circling the Emergency Department, getting a picture of each team's needs, constantly borrowing phones to call other wards, juggling patients and manipulating capacity so as to conjure up beds.

Meanwhile, patients are stacking up in ED – and more keep arriving. The ambulance service are asked whether they can deliver to other hospitals, but they are even worse off. And the delays are cascading across the system.

An old man, lying on a bed in ED, tells me he fell over at 12pm, suffering a hairline fracture. He was still on the floor until 3.20pm: the paramedics they sent kept being diverted to more urgent cases.

I study the patients. There are no bleeding head wounds tonight, few drunks or drug users. The QEH is a couple of miles out of town, so the city-centre revellers tend to end up elsewhere – another reason its A&E can usually just about cope.

There is a jogger in skimpy, Day-Glo shorts nursing his wrist; a man in his fifties, clutching his chest and wheezing; a younger man, with what I take to be a bandaged finger. On talking to him, I realise it's a heart monitor: he suddenly developed tachycardia earlier today, for no rhyme or reason he's aware of.

Mostly, though, the patients are frail and elderly. Some moan or writhe, but most lie still on the trolleys in the ED bays: the only motion is the steady beep of the heart monitor. The lucky ones have relatives beside them, tired and worried. The unlucky ones don't.

It's 9pm. We're up to 12 patients in the red now, and the ambulance screen shows two more cases en route. "They're not going to be able to go anywhere, you know," says Anne. But still, the siren wails, the doors open, and a woman in her seventies is wheeled past, glaring at the world. "If you think this is bad, it's only December," one ambulanceman tells me. "January and February are insane."

At 9.45pm, the senior staff gather back in the Ops Centre for their final meeting. On the way back, we get a stroke of good news: there's been an "RIP" upstairs. It's not good news for the family, of course. But tonight, the managers will take any space they can get. The mourning relatives won't be disturbed, but the moment they leave, the bed will be deep-cleaned and pressed back into service.

We go through the spreadsheets again. There's an emergency winter pressure ward that was due to open later on, but there aren't enough staff on duty tonight to man it: across the site, QEH is down 15 trained nurses. Make that 16: one of the sisters upstairs has developed diarrhoea and been sent home.

By now, there are 52 people in ED – 13 of them in the red. A male patient is arriving with testicular torsion – I wince – and will need to be operated on right away. The lists are shuffled to make room.

There are so many breaches of the treatment targets developing that the two senior staff, Anne and Nicky, have to spend almost half an hour listing them on the spreadsheet. At 10.30pm, they finish their calculations. Nicky announces grimly: "As a site, then, we are at minus 36 beds."

There are some final pieces of juggling to do, but the rest of the night will be about making life as comfortable as possible for those stuck in ED, while somehow keeping capacity open to treat new patients. As a regional trauma centre, the QEH will receive any stabbings or car accidents or other disaster victims from across the whole region, no matter how busy it is.

Blessedly, the night turns out to be accident-free – but still, other patients keep arriving, keep thinking they're going to get beds. Shortly before midnight, I count 25 people in reception; not all of them will need to stay overnight, but some certainly will.

I spend the rest of the night haunting the emergency rooms, notebook in hand. Some people are willing to talk to me, most are tired and drained and uncertain, waiting for treatment, or results, or even just some information about what is happening. The atmosphere feels slightly dreamlike: patients appear and reappear, now sitting, now lying, now being wheeled past with mysterious devices attached.

Nicky and Anne and their colleagues keep chipping away, organising beds, keeping space clear, arranging tea and sandwiches for the early hours. Nicky, I learn, started her shift at 7.30am but has stayed to help in the face of this disaster. The bleeper keeps summoning Anne to the phone for the latest piece of bad news, but she still manages to make a joke about it. At one point, I try to work out how far she and I have walked, in our endless circuits around the wards. It stretches into the miles.

The night rolls on. The old man in Bay 16, his legs stick thin, has kicked off his blanket. No one seems to notice. Another patient in white surgical stockings spends minutes trying to stand, then trying to put on his jumper, before slumping back, half-naked, in failure.

The man in Bay 2 is still curled up on his trolley, as he has been since the early evening. The jogger in the neon yellow short shorts now has a cast and sling on his wrist. He might be out of here soon: another space freed up. Cheery, upbeat messages about this initiative or that play on the monitors' screensavers. "Are you aware of the risks of fraud?" "Started exercise? Picked up an injury?"

Out in reception, past midnight, the crowd has started to thin. A middle-aged, middle-class couple I noticed earlier are still there, sitting together: she seemed defeated by the world, but in fact, she has simply sprained her wrist, and is bent over to cushion it. A spectral figure in a jet-black parka, hood pulled down and utterly immobile, turns out to be a young student with a splitting migraine.

In the early hours, the emergency beds appear from where they have been stockpiled: the ED is becoming a makeshift dormitory. The beds are ugly, unsophisticated, wooden things. One by one, the curtains on the bays are drawn and the patients transferred.

There is a periodic howling noise. It turns out to be coming from a woman in her thirties or forties, lying on her stomach clutching her side. She is part of a queue of trolleys that has started to form in the corridor, for patients who cannot get beds. One of the ambulance staff is tasked with looking after it.

"How are you doing?" he asks one 93-year-old, her eyes and skin almost milky white. "A bit fed up, really," she responds, tartly.

The night has started to blur into an endless sequence: buzzers beep, patients groan, there is a sudden cold draft as the doors swish open and the ambulance crews deposit another patient, and another, and another. They don't know, out there in the city, that there's no room at the inn.

I spend hours on the wards, and I do not see a single incident of dangerous care: the doctors and nurses still follow the guidelines, the ambulancemen still swab down each trolley carefully. Everyone who needs urgent attention, or is in extreme pain, is attended to. Despite the pressures, a solitary bed is still keep free in case of disaster.

The staff tell me this is a great hospital, that they're never known it this bad, that whatever the night throws at them, they'll cope with it somehow.

Still. What I am witnessing is a health system that's been stretched to its limits and beyond. Ultimately, 28 patients – most of them frail, elderly and alone – will spend the night in this cold, bright, noisy, draughty, busy place, while doctors and nurses somehow try to keep an A&E running around them. Even as they do their best to cope, everyone here is aware that this is something that simply shouldn't be happening.

This is one of the most efficient hospitals in the country, one that prides itself on its ability to handle pressures that would cause others to seize up. And tonight, for the very first time, it's lost that fight.

When the day shift arrive at 7.30am, someone takes a picture of the patient list – by now a wall of solid red – and emails it to a colleague in amazement. The unspoken message: what the hell happened here? And how do we stop it happening again?

PART TWO: THE RISING TIDE

For more than a decade, the NHS has been told that less needs to happen in hospitals, and more needs to happen in the community. It's a policy that makes perfect sense. Keeping people in hospital beds is a hugely expensive business. Far better to treat them as close to their own homes as possible – or, better still, to prevent them needing treatment in the first place.

Jeremy Hunt's big idea, the £3 billion Better Care Fund, is only the latest variant on this idea: at its most basic, to spend a few hundred pounds fitting a handrail in an elderly person's home rather than a few thousand replacing a hip.

This is a doctrine that the Queen Elizabeth Hospital has embraced. Since moving from its old building in 2010, it has made sure that the only people staying in hospital beds are those who absolutely, definitely need them.

That, indeed, was the story that I was originally invited to Birmingham to tell – about a hospital that was doing imaginative, innovative things to deliver quality health care, despite the pressures that it faced.

On the morning after the night shift from hell, for example, I stood in surgical scrubs in the Ambulatory Care department, watching a patient's thumb being repaired: he was a demolition worker who had had it crushed between two pieces of machinery. The operation took just 25 minutes, measured by the big red clock on the wall.

It was not completely trouble-free: as the blood rushed back after the tourniquet was removed at the end of the operation, the patient began writhing in pain, prompting me to fear that the anaesthetic had worn off. But by the time I had returned to the ward, his sling had been fitted and the next patient was being readied.

The idea of Ambulatory Care is to treat people as day cases – to get them in and out – rather than force them to stay in the hospital. It treats 37,000 patients a year, carrying out biopsies or hernia repairs, removing varicose veins, wisdom teeth, gall bladders, even testicles.

Many of these would once have been overnight stays, with the operation carried out under general anaesthetic; now, the patients are given iPads to distract them from the surgery under local anaesthetic, or else chat to Colin, one of the surgical team whose job is to keep the patients calm and still.

The same principle applies in A&E. Those patients needing surgery will end up in the Surgical Assessment Unit upstairs – a new ward that serves as a halfway house between A&E and operating theatres. But there is also the Clinical Decisions Unit, to take care of cases that are medical rather than surgical – and the Acute Medical Clinic, which takes in the emergency cases that, like those in Ambulatory Care, can get in and out without taking up a bed.

Liz Miller, the matron in charge of A&E – and one of the legion of friendly, chatty, vastly experienced nurses who are the backbone of the QEH's operation – gives the example of a low-risk pulmonary embolism. Five years ago, it would have seen you in hospital for five days minimum. "Today we can visualise the clot, see whether you need oxygen and heparin injections, set you on a course of anticoagulants and send you home in six hours."

The problem is that all these systems and structures amount, in the end, to an effort to swim against the tide. When the hospital was built, for example, politicians and planners pronounced that it should be smaller than the old QEH it replaced, because more would be done in the community.

"The 'experts' said we're going to be providing care outside of hospital, so you don't need to be as big," recalls Dame Julie Moore, the hospital's formidably impressive chief executive (and another former front line nurse).

They told her to "shell" three wards – to build them as empty spaces, ready to be kitted out in a decade or so if demand required it. "The minute we signed the deal," she says, "we unshelled them. And then we found the space for three more wards in the attic, so we opened that."

That meant that the hospital opened with 1,213 beds, rather than the planned 1,013 – but even that wasn't enough to cope with demand. The hospital was soon forced to reopen wards in the grubby, low-ceilinged, Thirties building it had so eagerly abandoned, to house elderly patients suffering from dementia and other long-term conditions.

Partly, the QEH's problem is that it is a very good hospital, so both the GPs who are commissioning services and the patients themselves vote with their feet: it estimates that between a quarter and a third of those it treats are from outside its catchment area. But there's also a wider trend, one which affects the QEH just as it does every other hospital: too many people are needing treatment.

In the week of Dec 8-14, 440,428 people were admitted to A&E departments across England. In the equivalent week in 2011, that figure was 398,930. Over the week of my stay in Birmingham, West Midlands Ambulance Service has the second, third and fourth busiest days in its history.

On that Tuesday night, the hospitals they were taking the patients too just couldn't take any more. As Liz Miller tells me, "It wasn't one ward that fell over, or one department, or one hospital. It was the whole health economy of the West Midlands."

Why is this happening now? Well, it is a colder winter than last year – flu is more widespread, and norovirus too. In the run-up to Christmas, GP surgeries are often booked up by patients needing prescriptions for medication to see them through the new year.

It is also what one A&E nurse refers to as "granny dump season", when people drop their elderly relatives in hospital to give themselves a break, or because they have other family members visiting and cannot act as both hosts and carers.

But what's really frightening is that, even though the papers are full of stories of A&E crisis and ambulance services in meltdown, we haven't actually yet reached the worst time of year. events on that Tuesday night. The ambulances were hugely busy, but in terms of raw numbers coming through A&E, the total was fairly standard for this time of year – 83, compared to an all-time high of 113 on New Year's Eve 2013/4.

The real winter pressures tend to kick in around January or February, when temperatures are at their coldest and older patients with flu are turning up at A&E in their droves. And the thought of what happens then, admit some of the staff, is "terrifying".

The most obvious solution to the A&E crisis, and the one most often mentioned in the papers, would be to stop people coming to A&E – especially those who aren't genuinely sick, but who are treating the NHS, in Liz Miller's words, "as a second opinion to Google".

Already, patients are being urged only to seek emergency treatment if absolutely necessary. As for the drunks clogging up A&E departments at weekends (and on New Year's Eve), the president of Britain's association of emergency doctors, Dr Cliff Mann, has called for them to face arrest.

The problem is that all these people coming to A&E are actually behaving quite sensibly. They know they may have to wait days or weeks for a GP appointment – whereas A&E departments are legally bound to try to treat 95 per cent of patients coming through their doors within four hours.

"If you're ill, where would you go?" asks Tim Jones, the QEH's director of delivery. "Somewhere you can be guaranteed to be seen within four hours, that has the backup of full diagnostics, that will treat you and get you out in time? Or a GP who may well refer you to A&E in any case? Fundamentally, you know that if you get to A&E you'll be treated quickly, then you'll get out and get on with your busy life." Even the Health Secretary, Jeremy Hunt, has confessed to taking his own child to A&E, rather than waiting for the GP.

The NHS has tried to develop alternatives – walk-in centres, polyclinics, helplines – but they haven't stuck. The QEH's surveys of the patients arriving in A&E show that 84 per cent have never even heard of NHS 111, the phone line that is meant to be their first port of call.

The fact is that people will keep coming to A&E as long as a) it works and b) it has to stay open even when everyone else has closed their doors. "Either the health system runs a 24/7 service or it doesn't," says Jones. "You can't have a system in which one part runs 24/7 and the rest of it switches off at 5pm."

But that only solves part of the problem. Because the patients that Julie Moore and her senior colleagues are really worried about are the ones who don't have a choice about coming to A&E – the ones who aren't walking through the doors, but being wheeled in on trolley.

On that Tuesday night, for example, dozens of people were (eventually) treated. But most of them – the jogger with the sprained wrist, the student with the migraine – were also sent home. Of the 28 people who bedded down for the night, every single one was over the age of 75. That's the reality of life in A&E, says Liz Miller: it's not the "sexy, Gucci stuff that you see on 'Casualty' on Saturday night" – it's "patients just getting sicker, older and less able".

And here's the sting in the tail – the one that makes what's happening this winter in Birmingham, and everywhere else, not an A&E crisis, but an NHS crisis full stop. It turns out that the only thing harder than stopping patients coming in is getting them out again.

PART THREE: THE BLOCKED PIPE

It is the morning after the night before. In the wake of the Level 4 alert, the Queen Elizabeth Hospital has gone on to a war footing. Briefings have been cancelled, training delayed, elective operations – scheduled procedures which patients have been expecting for weeks or months – cancelled.

But the priority – the urgent need – is not to treat patients. Or at least, not exactly. It is to get them through the system – to shift patients from beds to the Discharge Lounge; to browbeat transport and social services into taking people home, or finding them space in the right programme; to get them their pills and their food while they wait; and finally to move patients along from A&E into the beds that have been vacated, creating space for new arrivals.

On top of this, there are all the regular patients to be treated – including three stabbings, two cardiac arrests and one trauma alert (the blessing being that they didn't happen the night before).

At the end of the day, I return to the Ops Centre, to find out what all this frantic effort has achieved. There is a certain black humour in the air, coupled with a lingering sense of shock and amazement at the scale of what the hospital has confronted.

In all, 53 patients have been shuttled through the Discharge Lounge, and the winter pressure ward brought into service far earlier than expected. But when the screen comes up, it shows more than 50 new patients in ED – some ticking into that now familiar red colour which notes that they have been there for more than four hours.

"Better than yesterday!" says someone, mock-hopefully. "You don't know how much that doesn't make me feel better," shoots back one of their colleagues. The hospital is still short six beds – though enough space is subsequently freed up that the boxy wooden beds stay out of A&E.

Contemplating the pressures to come, everyone is aware that it is not a reprieve, but a stay of execution: you can't stay on a war footing, with no training and no elective operations, for ever.

Why does it take so much effort to free up a bed? Because patients are becoming more elderly. And many of them can't simply go back to their homes; they need places at nursing homes, or rehabilitation programmes, or other packages of care. Keeping that flow going is what keeps a hospital alive – but they have absolutely no control over it.

Social care isn't run by the NHS – it's handled by social services, who answer to councils with very different priorities and whose own budgets have been slashed even as the health service's has been ring-fenced.

Even when the money's there, the organisation often isn't. Everyone might be agreed on what should happen with a particular patient, but they still need to wait for the nursing home to decide that it's got a bed free, to come and assess the patient, to agree that it can cope with their particular needs – and for the family to sign off on it. If the stars don't align, a perfectly healthy patient may spend weeks or even months clogging up a desperately needed bed.

"In my first few years as chief executive," says Julie Moore, "we had about 18 delayed discharges a week. That's now in the fifties, and it's been as high as the seventies."

Three times a week, Andrew McKirgan and colleagues from the hospital and social services hold meetings to chase up the cases of these bed-blockers (although the hospital itself prefers not to use that word) – medically fit patients who should be on the pathway out of hospital, but aren't.

On my final day at the hospital, he talks me through some of the 100 patients on his list (while taking care to keep their identities hidden). It is a litany of minds changed, beds that appear and disappear, endless little delays at every stage building up into weeks or months of stasis.

In desperation, some hospital trusts have resorted to providing recovery beds of their own. But that capacity soon becomes filled and blocked itself – as well as taking space and staff away from the nursing home sector.

Also, if you're like the QEH, and attracting patients from outside your own catchment area, you have to liaise with whole new sets of social services officials, many of whom will understandably (though wrongly) prioritise patients at their own hospitals. For example, the average length of stay in the QEH for patients from the Birmingham area is 12 days – for those from outside it, it's 20.

As a result of all this, what is happening in Birmingham – and elsewhere – is that the pipe is getting blocked. Patients are taking too long to get out of hospital. That means they either get "warehoused" in overflow wards, or sit there in beds that are needed by others.

The more pressure there is in the system, the more problems cascade across it. For example, it was decided a few years ago – for the best medical reasons – to concentrate particularly tricky surgical procedures in centres of excellence.

In the West Midlands, if you've sprained your ankle, you'll be treated by your local hospital – but if you need brain surgery, you'll be passed up to the QEH before being sent back to your area to recover.

Yet this "hub and spoke" model is starting to break down. The QEH has already had to ban GPs from outside its catchment area from referring certain routine operations – those sprained ankles and the like – because it takes up capacity needed for complicated, delicate, specialist work like liver transplants.

"What happens is you start filling your major trauma beds with non-major trauma, because you can't move those patients out," says Andrew McKirgan.

"Then you get someone admitted to our A&E who needs access to our specialists, and to a specialist trauma bed, but can't get one because we've got six patients who we can't move out to their local district hospital. And those hospitals are getting equally upset because they've got patients who urgently need, say, our specialist neurosurgery, and we can't take them because we've got patients waiting for the right rehabilitation facility."

As the pressure mounts, each area looks to its own interests first. Local hospital managers, says McKirgan, "will take one look out the window at the ambulances on the deck and say, 'Oh, crikey, we're going to really struggle – let's just tell Birmingham that we just can't take those three patients back today.' In periods of pressure, everybody gets quite parochial. The hub and spoke starts to disintegrate because everyone's retrenching to their own local boundaries."

PART FOUR: UNEXPECTED CONSEQUENCES

One of the first things you learn in hospital is that bad things happen – and that they can break your heart. I start up a conversation, at random, with a 77-year-old waiting in the lobby. She is in near-constant pain from spinal problems that took months to diagnose: she shows me the box of almost 100 pills she has to take every week, and tells me calmly but certainly that she often thinks about taking an overdose to end the pain, because there's no one there to miss her.

Sometimes, the bad things are the doctors' fault, and sometimes they aren't. In February 2009, Rachel Bradshaw, an 18-year-old mother, died after QEH surgeons drilled a pressure bolt too far into her brain: they were attempting to deal with the complications caused by liver failure after a paracetamol overdose. The one consolation is that the error only hastened her death, rather than causing it. (Her family's claim for compensation for nervous shock was this month rejected by a judge.)

In other cases, it's harder to apportion blame. Michael Thomas is a 63-year-old chef from Halesowen. He has undergone four separate treatments for bowel cancer over the years, two of them at the Alexandra Hospital in Redditch. The second there was by Sudip Sarker, a surgeon who had death rates twice as high as his colleagues and was accused of having errors on his CV – yet was allowed to carry on working by his Trust under supervision for three months after complaints were made and an investigation began.

Michael was urged to sue – but the consultants examining Sarker's operating history told him that, while that particular operation failed, it was no more likely to have been successful in another's hands. Another operation, at the QEH, led to unexpected complications that left him spending five months in intensive care, much of it in agonising pain. Now, something else has gone wrong, and he is back.

He shows me his stomach – the flat wrinkled lines from the separate surgeries. He doesn't complain: he knows his doctors have done the best they could. But he also knows that his patient pathway has only one likely destination.

"Most men, we ignore symptoms when we're younger," he reflects. "I had stomach pain – problems down below – for about eight months before I went to a doctor. Looking back, that was a big mistake. I should have gone to a doctor a lot earlier, and then I probably wouldn't have suffered as much." It's the flip side to the warnings to stay out of A&E: sometimes, it means people in genuine need won't get the right treatment in time.

One of Jeremy Hunt's mantras, as Health Secretary, has been the importance of eliminating mistakes – not least by using transparency to raise standards. Getting things right first time, he argues, is not only better but also cheaper, because it saves costs in the long term.

It's a mantra to which the QEH subscribes. In the Surgical Assessment Unit where I talk to Michael, matron Clair Phillips (another hugely impressive and experienced nurse) shows me the "Clinical Dashboard" – part of the hospital's in-house IT system, which allows every ward to see how every other ward is doing on a wide variety of measurements: "Missed Doses", "Infection Control", "Patient Feedback", "Adverse Events" etc. Within each category are further subcategories: "Patient Falls", "Pressure Ulcers", "Complaints Received", "Incidents Reported".

Some mistakes will still happen, of course. One scandalised patient tells me that she saw one of the waiters at the Costa Coffee concession in the atrium sweep the tables with the same brush he had used on the floor; she complained, and he was disciplined.

But the worst things in the NHS happen not when mistakes are made, but when staff don't have time to correct them – when the pressure gets so great that they start to treat patients not as people, but as objects to be shuffled through the system.

In America, experiments have shown that even the mildest imposition of time pressure – telling people they are running late, say – turns them from Good Samaritans who will help a man doubled over an alley into heartless monsters who will ignore his suffering. Why should doctors be different?

This is one of the things that makes the winter crisis so dangerous. As it becomes harder to get patients out of hospital and back into the community, so they stack up in overflow wards. One doctor I spoke to compared these to "Tardises" – seemingly endless, anonymous rooms packed with half-forgotten patients. And to man them, many hospitals resort to temporary staff, including locums who may not know their systems or be invested in its ethos.

This partly explains what happened in Mid-Staffs. With too many patients pouring through the doors, there was intense pressure to get them out of A&E within the four-hour target time. Yet once patients had been pushed out, they stacked up on the next level of the system, with too few doctors and nurses to care for them. The flow had broken down – and the result was misery and degradation on an industrial scale.

It was not a one-off, either. "We have seen individual wards where our teams have said 'We think this may be like Mid-Staffs'," Sir Mike Richards, the chief inspector of hospitals, said recently. "People weren't being cared for. They were left in soiled sheets and call bells were being answered. Staff were rude or abrupt with patients. There was a lack of attention, not giving them sufficient drinks, not making sure that people who had difficulty feeding themselves were getting fed."

The tragic irony, however, is that the very measures designed to protect us from this kind of thing, or from the similar failings at the Winterbourne View care home, may be contributing to a repeat performance.

In the wake of the Francis report into Mid-Staffs, staffing ratios were beefed up to ensure there would always be enough employees to look after the patients. "Because of what's happened, more and more people have been employing more and more nurses," explains Julie Moore. "I think the figure is around 40,000 nationally. That means you can't get additional nurses for love nor money."

As a result, during the winter months, hospitals have to pay huge amounts for locums – the total has gone up by a quarter in the past year alone – who may not be that much use anyway. And nursing homes can't expand to cope with the demand for their services, because they can't find the staff.

To make matters worse, the same care homes now live in such fear of breaching the rules, and of being punished by the tougher inspection regime, that they have become much more risk-averse in terms of admitting patients – especially those with difficult-to-manage conditions such as autism or dementia.

As Moore explains: "We've had nursing homes who have had, say, five vacant beds but they'll say 'We'll only take three this week, because we don't want to be overworked in case the Care Quality Commission come in.'"

Of course, it makes all kinds of sense to subject care homes to strict inspection regimes. As one doctor puts it, the kind of people willing to take a job wiping elderly patients' bottoms for £7 an hour may not be the most educated or motivated individuals.

But the kind of risk-averse culture which this kind of thinking has produced has also made it that much harder to move patients along through the system – and to find spaces for them at the end.

There has been another unintended consequence, too. The buzzword of the day within the health and care systems is "safeguarding" – the duty of doctors, nurses and managers to protect those, such as the young, or old, or disabled, who cannot protect themselves. It is a worth goal. But, inevitably, patients have learned to use this magic word for their own purposes.

"We've had cases where, because someone's been unhappy in a particular home, that's a safeguarding issue," says Andrew McKirgan. "That may well be genuine. But we obviously don't know what the severity of the issue is when a relative raises it – it could be that they just don't like the staff, or the home, or the cereal. But they raise it when they come in because they want a new nursing home, and they want you to sort it.

"It's one of those things that, for the right reasons, is going to have unintended consequences. Again, it's because the system is risk-averse. My worry is that whole hosts of things will raised under the safeguarding banner, and they all need to be investigated and assessed."

Which brings us on to the final main factor gumming up the system – namely, the great British public. In recent years, we have been encouraged to treat the NHS as consumers: to demand the same performance, choice and convenience as we would from our local supermarket.

But some within the health service believe that there is too much talk of patients' rights, and not enough of their responsibilities. It's not just families taking weeks to choose just the right nursing home for their relatives – and expecting them to be able to stay in scarce and expensive hospital beds while they do it.

Start talking to staff, and a litany of examples of selfishness start pouring out. Liz Miller tells me about a patient who deliberately broke a bariatric bed, then demanded to be taken to A&E. When he arrived, he "claimed he was being mistreated, that they were starving him, that his human rights were being abused. It turned out that they'd put him on a diet and he'd refused to eat."

Andrew McKirgan takes me through some more examples. "There was a guy from Bristol who was in a major trauma. He recovered, he was fit, but he had no home. So the ward contacted Bristol social services and arranged for temporary accommodation for him. And he turned it down, because it was in an area of Bristol he didn't like."

He starts to tell me about another case, where a particularly demanding patient and his carer were demanding to be moved to a new flat, even though there was nothing wrong with the old one bar a broken light bulb.

Sarah Carmalt, a senior nurse, interrupts to tell him that the same patient is now back in A&E: he reappeared with a broken crutch, claiming to have had a fall. He'll be kicked out in the morning, but it's another bed taken up for another night.

"Wards at times will have relatives say 'Mum can't come home because we're going on holiday for two weeks'," says Carmalt. "Or: 'We're having an extension built, for her to come and live with us, so she's got to stay here till that's done'.".

The young, says Miller, are the most demanding: "I've never seen an elderly patient demanding to be seen. But the younger generation want everything now. People say: 'This is my right, this is what I paid for – and they're right.'"

PART FIVE: THE LONG TERM

It is unfair to say that the NHS is not working. On the contrary: it has worked miracles. More than a million more people have been treated in this parliament than the last. More operations have been carried out. A&Es are seeing millions more people, but they are being seen much faster. In a comparison of 11 Western health systems by the American think-tank the Commonwealth Fund, the NHS got the best overall ranking, coming in first for quality and efficiency of care.

It is staffed, too, by some of the most impressive and dedicated people I have ever met. If I am ever ill, I hope that I am admitted to an A&E run by someone like Liz Miller – or to a ward run by a matron like Clair Phillips, who buys Christmas presents for the patients so they won't feel so lonely, or Margaret Harries, who runs the wards that look after elderly patients and won a Nursing Times award for coming up with a better way to tempt her charges – many of whom were categorised as unable to eat or drink – into having a cup of tea and a biscuit. These people and their colleagues are paid not very much money to do a staggeringly difficult job, and they do it with infinite dedication and grace.

But they, and others like them around the country, are struggling to cope with the rising tide described above. More people are waiting for planned operations – and more of those operations are being cancelled, as doctors prioritise the emergency cases streaming in via A&E. At primary level, six in 10 patients told the Patients' Association that they had to wait more than 48 hours to see their GP – and almost a third were unable to get an appointment within the week (and then would only get 15 minutes of their time). Productivity measurements show that the NHS simply isn't making the best use of the money we give it – and the costs of ageing, of new technology and new drugs, mean that there will be ever more demands on a strictly limited budget.

NHS reform has become politically toxic, especially in the wake of Andrew Lansley's Health and Social Care Act 2012. His big idea was to shift control of funding to GPs, thereby stripping away bureaucracy. But his plans became larded with so many compromises and alterations that the result was even more complication.

"They cut it from 118 quangos to 234, and they reduced the levels of bureaucracy above me from three to 24," says Julie Moore, sarcastically. "There's organisations I've not even heard of popping up these days."

The best way to understand it is to watch the video below, produced by the King's Fund think tank – though there are a few more bodies to add in that have been created since.
https://www.youtube.com/watch?v=8CSp6HsQVtw

The result is more levels of supervision, and more people and organisations weighing in on every decision. Andrew McKirgan describes how, on the morning after the hospital went to Level 4, he had to spend half the morning – when he should have been focusing on moving patients out of A&E and through the system – fending off endless demands for updates from on high.

Yet the alternative to further change is for the pressures to grow ever greater, to the point where the whole system is unable to cope.

To that end, there are all sorts of small improvements and changes that ought to be made. The different parts of the NHS – and of social services – can and should talk to each other more, rather than one part lining public lavatories with slogans along the lines of "Blood in your pee? Go to A&E" and then hospitals being surprised when their urology admissions start soaring.

If we're going to provide services in the community, we should make sure the money and infrastructure are there first, because otherwise people will just come back to A&E. That includes providing proper, 24/7 services outside of hospital, and GP appointments that last more than 15 minutes.

We also need to think about whether people should be dying in hospital beds or in their own homes, about whether tattoo removal should be funded on the NHS, about why some hospitals are paying less than £4 for blunt needles that cost others more than £30.

Oh, and if Julie Moore could change one thing about the NHS? It would be to stop training precisely the number of doctors or nurses that we calculate we might possibly need in 11 years' time, and start over-recruiting on an industrial scale – so that we are not forced to employ the lowest-quality personnel remaining, or held hostage to the particular specialities that doctors choose to go into, or to spend more on locums than we would have done on training staff in the first place. Especially since immigration restrictions mean we can no longer fill the gaps from the Indian subcontinent, which is what we've been doing for decades.

But above all, we need to think about tariffs. This is arguably the most powerful force within the NHS: more powerful even than old age, or compassion, or bureaucratic inertia. The tariff is the way in which hospitals and GP surgeries get paid and incentivised for their work. If the system isn't working, this is – fundamentally – the only way to change it.

At the moment, the system is based on a simple idea. Every time something is done to a patient – every time they move along their personal pathway – a payment is made. This is also how the Government keeps costs in line: a "national provider efficiency requirement" of 4 per cent is built into the tariff. What this means is that, after expected cost inflation of 2.7 per cent is factored in, hospitals are paid 1.3 per cent less, year after year, for carrying out the same operation. As a way of screwing efficiency out of the system, it works. But at some point, it will start to bite into the bone rather than the fat: already, the financial position of many NHS trusts is deteriorating, and while this may not be causing it, it certainly isn't helping.

The other problem with the tariff is that it has perverse consequences. Julie Moore indignantly rejects the idea (popular in parts of Whitehall) that hospitals "have got people out with huge nets like in Chitty Chitty Bang Bang, catching patients and bringing them in" – that executives like her will say: "We're a bit short this week, lads, so go and admit a few more through A&E."

But doctors in less scrupulous parts of the health service admit that the tariff system may mean that a patient has to walk through a few more doorways, and undergo a few more procedures, than is strictly necessary – or will be sent back to their GP for re-referral, on the grounds that the money per patient diminishes with each procedure, or will be categorised according to the most lucrative funding code, for example by being kept in for the night when they might technically be a day case.

The Lansley reforms have also had a distorting effect. In order to stop the surge of numbers into A&E, it was decreed years ago that hospitals would only be paid 30 per cent of the normal tariff for any emergency admission over and above the numbers in 2008/9 – the aim being to stop the Chitty Chitty Bang Bang effect, and cause hospitals to be more discriminating about their intake. (The remaining 70 per cent of the funds are devoted to "local investment in relevant demand management schemes, jointly owned by commissioners and providers", whatever that means.)

Now, however, budgets are controlled by GPs, via Clinical Commissioning Groups, or CCGs. And the 30 per cent discount means that they are effectively getting a volume discount for the patients they push up the food chain.

"If you wanted to incentive commissioners to provide care outside of hospital, you'd have charged them 300 per cent for every patient over and above a certain level, because then there would have been an incentive to do some alternative provision," says Moore. "Doing the 30 per cent means it's the cheapest option available, so why would you bother?"

It's not only tariffs that distort behaviour, but targets. Even on that Tuesday night, the senior managers were still trying to do what they could to keep people from breaching the four-hour limits, or the eight-hour limits that follow, because that is ultimately what they will be judged on.

"When you get to 3 hrs 59 minutes and you don't know what's wrong with somebody, you're more likely to admit them and not breach [the targets], even if the blood results will be back in half an hour," says Moore. "Every time you move a patient within a hospital, you add two days to their length of stay.

"If you have to admit because of the four-hour target, that patient is likely to stay in for a heck of a lot longer, because they pass on to another team, with a whole new pile of doctors and nurses. It's not good care. But it's the game we've got to play."

The holy grail – indeed, the only realistic long-term solution – is what is known as "end-to-end care". That is a system in which you don't get paid for everything you do to a patient, but for keeping a patient as healthy as possible. That means that you are positively incentivised to give a vulnerable patient an iPad – as they have in Airedale in Yorkshire – so that they can communicate instantly with their GP, easing the pressure on primary and secondary care both. It means that someone turning up in A&E is seen as a failure, because their problems weren't caught earlier – and that getting them out the other end becomes an urgent priority for the simple reason that it saves the system money.

At the moment, by contrast, Birmingham experimented with turning some of its spare estate into a DIY nursing home, to address the shortages elsewhere – but had to abandon the idea because the tariff system meant that it lost too much money by doing so.

The problem with this reform is that this will require billions of pounds currently hoarded in dozens of separate budgets to be brought together for the common good. And it will still have to battle against the forces described above – the increasing age of patients, which leads to increasingly complicated and difficult conditions; the increasing selfishness of our culture; the increasing risk-averseness that makes it harder to get anything done.

But it can be done. In fact, ministers are considering exactly this reform: to experiment with pilot schemes that get individual counties, or city regions, to work together and break the silos apart, on the understanding that they can keep many of the savings to reinvest.

There is also the issue of competition. At the moment, for all the hue and cry over the "privatisation" of the NHS, 94 per cent of its services are provided by the state. Only one hospital, Hinchingbrooke in Cambridge, is privately run – and that has been choked off from further contracts.

When Simon Stevens, the head of NHS England, produced his Five-Year Forward View recently, it said all the right things about reform and efficiency improvements – but failed to mention that competition and private providers could well be needed to deliver them.

It's only fair to say that, for most of the staff I talked to in Birmingham, this kind of thinking is anathema: they want to get on with treating patients, on behalf of a state-run medical system, without having to balance cost against benefits. Personally, I think there's a lot to be said for private provision bringing in new ideas and new ways of doing things – especially since, under the Lansley blueprint, such providers are only allowed to compete on quality, not cost.

But at the moment, we have an artificial semi-market that often gives us the worst of both worlds. "We need to have one system or the other," says Julie Moore. "We've neither got a market, nor a managed system – it's neither fish nor fowl. We say patients can choose, but the money doesn't follow the patient."

If you live in Redditch, in other words, you used to have to go to Redditch hospital: you took what you were given. Now, you have choice – so, pretty often, you end up in Birmingham. But Birmingham doesn't get the full amount of money for that, and doesn't have the operational or institutional freedom to expand to cope – and even if it did, it would still be reliant on social services from those areas to clear the new patients out.

"If Waitrose have too much footfall," says Moore, "they'll open another store. If things are really popular, their price will go up. We have none of that mechanism available to us. What we do have is excess regulation, inspection and bureaucracy.

"We're not allowed to set prices – they're set centrally, and in fact cut centrally. We're not allowed to set quality standards. We're not allowed to set our wage levels, or train the number of people we want, or employ the number of doctors we want. The only thing we have control over in running this as a business is how efficiently we do it, the quality of our service and the morale of our staff. We have no control over prices or volume."

Ever since it was set up, the NHS has been running to stand still. By and large, it has done a pretty good job: indeed, many of the problems we're seeing at the moment stem from how many more years we're all living, in large part as a result of medical advances.

There is no magic formula for solving the health service's problems once and for all: even if we brought in every reform that has ever been proposed, we would still need to pay a vast and ever increasing proportion of our GDP to treat our ageing population. The NHS has always been on the edge of crisis, and always will be.

But what I learned, during my week in Birmingham, is that there are things we can – and must – do better. Perhaps the most immediate short-term need, as outlined above, is to start paying as much attention to the numbers going out of hospital as coming in.

But beyond that, we need to focus on the incentives and tariffs that are pushing people towards our overcrowded and congested A&Es and away from the rest of the health service. Otherwise, we will be guilty of the cardinal sin in medicine: namely, treating the symptoms rather than the disease.

[mongers]

Worthy thread topic, let down by the Timmaysque comment. 

I did read about 40-405% of it, some interesting stuff, but you'll need to provide an ExecSum for some posters. 

[Sheilbh]

I think it'd be mad if I had something to add to that, beyond an exhortation to read on.

I've seen healthcare people and the journo back and forth on Twitter. Generally they're very impressed with it, lots of people saying it's the first journalist's piece that 'gets it'. I'm sure there's other stuff that he could have included but I think he basically wanted to make the article about the system, the importance of the flow (out as well as in) of patients and the incentives (especially since Lansley's insanity).

Only thing I'd add is that it does bolster my view that one of the biggest issues Western countries are going to face is care not healthcare and I don't think any of them have really got a system in place to do that. I think it's probably the next big challenge of the welfare state.

Following on from that is my view that we're not going back to the late 90s and the 00s. There's not going to be any more money for some time which again I don't think is reflected in our politics.

[sbr]

I have always had a thing for nurses.  I am disappointed that after 4 years of working in a hospital I never hooked up with one.

[Ideologue]

Only thing I'd add is that it does bolster my view that one of the biggest issues Western countries are going to face is care not healthcare and I don't think any of them have really got a system in place to do that.

I care, Sheilbh.

I didn't read the article.  I figured it would either make me mad because they're not running the NHS with the proper ruthless efficiency, thereby proving rightist critics correct; or that it would make me mad because it's just as good as it can get, thereby proving rightist critics correct.

[DontSayBanana]

PS, took me a minute to catch up- might want to have tagged for the Damn Yankees that A&E in this case meant hospital- to us, that area of the hospital is the emergency room or ER, and A&E is a cable network that mostly specializes in airing Agatha Christie adaptations.

I came into this thread expecting to hear that no new Poirot TV movies were going to be made.

[Sheilbh]

I came into this thread expecting to hear that no new Poirot TV movies were going to be made.

None are

Suchet filmed the final story and I think it's difficult to step into those shoes for some time. I wouldn't mind a new attempt at Marple though because the recent adaptations were awful

[jimmy olsen]

Thought this was going to be about the television channel.

[MadBurgerMaker]

PS, took me a minute to catch up- might want to have tagged for the Damn Yankees that A&E in this case meant hospital- to us, that area of the hospital is the emergency room or ER, and A&E is a cable network that mostly specializes in airing Agatha Christie adaptations.

I came into this thread expecting to hear that no new Poirot TV movies were going to be made.

Less Agatha Christie and more shitty reality TV lately.  So bad. 

[CountDeMoney]

Less Agatha Christie and more shitty reality TV lately.  So bad.

No shit.  Once upon a time Bill Kurtis walked the earth and ruled it with Investigative Reports, with a nice sprinkling of Law & Order reruns at 2am.  Now, you get Duck Dynasty and crazy white people fighting over storage unit auctions like they're Lord fucking Carnarvon.

That channel threw away the A for Arts in "Arts & Entertainment" a long time ago.

[Tonitrus]

Less Agatha Christie and more shitty reality TV lately.  So bad.

No shit.  Once upon a time Bill Kurtis walked the earth and ruled it with Investigative Reports, with a nice sprinkling of Law & Order reruns at 2am.  Now, you get Duck Dynasty and crazy white people fighting over storage unit auctions like they're Lord fucking Carnarvon.

That channel threw away the A for Arts in "Arts & Entertainment" a long time ago.

And some might say the E as well. 

It's like TLC...going from Connections, Great Castles of Europe, and Wings of the Luftwaffe to Honey Boo Boo. 

[Razgovory]

Fuck A&E.  Ever since they went all reality show, nothing worth watching.

[dps]

Less Agatha Christie and more shitty reality TV lately.  So bad.

No shit.  Once upon a time Bill Kurtis walked the earth and ruled it with Investigative Reports, with a nice sprinkling of Law & Order reruns at 2am.  Now, you get Duck Dynasty and crazy white people fighting over storage unit auctions like they're Lord fucking Carnarvon.

That channel threw away the A for Arts in "Arts & Entertainment" a long time ago.

And some might say the E as well. 

It's like TLC...going from Connections, Great Castles of Europe, and Wings of the Luftwaffe to Honey Boo Boo. 

I hate reality TV.  To start with, there's just so dang much of it anymore, and depending on what you consider reality TV, almost none of it is even remotely watchable.

I understand why TV executives like it--it's about the cheapest possible programming to produce--but I can't understand why viewers actually watch it.

[Razgovory]

You know what would kill reality TV?  Unionize production crews.

[Ed Anger]

I think we are stealing all the Arab and indian doctors.