Journey through the NHS

The system was slick and efficient. It had to be. Apart from the regular arrival of ambulances, a steady stream of people came via other means – on foot, in their own cars, in police vans. There were many more arrivals than departures with the inevitable result that the place was full when we arrived and it stayed full. Way beyond full really. They have shifts but no hours of opening. It never closes. And there is no regular amnesty period where people stop getting ill/beaten up/ hit by cars and so on, where it could empty and start afresh. The miracle is that they keep piling people in, keep the line moving, keep everyone scheduled and looked after. But they do. It was pretty much a miracle to see this unending line of people treated medically, but became almost surreal to see everyone treated politely and well; including the heroine addicts climbing the walls, the confused and frightened who lashed out and screamed and the drunks who groaned and moaned and wanted to roll off their trolleys on to the floor. And also the majority who were content simply to wait.

G’s trolley was parked by the magnetic whiteboard for a couple of hours so we spent the time working out the system. At first glance it looks low tech – magnetic cards, marker pens, handwritten lists on whiteboards, but the lists were cross-referenced using various codes (we didn’t crack them all) and no one gets forgotten. There was a computerised list, too, and terminals and paper notes. Eventually we managed to work out when we were next due for attention and what would be done. Another miracle: the listed actions happened to time, sometimes up to 10 minutes early, then the cards would be wiped and rewritten, the lists reordered.

Whoever designed the A&E Department with wide corridors probably had something in mind, but I doubt it was deliberately done to allow three trolleys to pass. I say that because if that had been the original aim, the design would have been just a tiny bit wider. Nonetheless, this full-to-overflowing world made good use of its wide corridors. Trolleys were parked down either side and in every corner. And there was *just* enough room for traffic down the middle. Waiting relatives had to cram into gaps to allow the system to flow. No chairs of course. No room. After several hours standing I hopped up on to the trolley with G. It got the weight off my feet and eased the traffic flow, but I wondered if it might be contrary to the rules. It probably should have been in terms of infection control but the place was so crammed that it could hardly make a difference. Saying that, there was plenty of hand-washing going on and alcohol rub everywhere.

We had been one of the ones who arrived by ‘other means’. The surgery wanted to send G by ambulance as an emergency, but G who had only gone there because his shoulder injury was playing up, could not be convinced he was ill. Of course, this wasn’t the first time he’d called into the surgery for something routine and been carted off by ambulance. It was the fourth. On all the other occasions he’d turned out to be OK after a night in hospital and he got stubborn. Even the fact of the mega-aspirin having magically cured the pain wouldn’t convince him. He felt a bit of self-medication (Guinness in the Queens) would sort him out.

In the end, he agreed to go to A&E but not in an ambulance. So I drove him and had strict instructions to drive right into the ambulance bay and to register him as an emergency. [I did. I was convinced I’d get clamped, but didn’t]

Then began the long and interesting journey through the NHS system. He was triaged and given stabilising treatment more or less straight away. Fairly quickly after that we were allocated to the Acute Assessment Unit for an overnight stay, but remained in A&E awaiting a bed. As it turned out, all the overnight obs were done in A&E because the bed didn’t become available until nearly midday the next day. The intensity of the unit was unbelievable. 12 hour shifts at this work rate must simply fly by and at the same time must be incredibly stressful and draining. But there’s a system to it that keeps it running smoothly, that keeps managing the impossible, and (despite all the recent bad press) does it all in a caring and good-natured way. No lack of compassion here, but I wonder how people interpret what they see.

There’s the guy who keeps shouting out at random; the other one curled up on his trolley. The nurses and medics bustle past, back and forth, no eye contact other than with each other. A beeline to the specific patient who is next on the list for treatment. Ostensibly they pay no attention to anyone else. On the face of it, it seems a little cold. What’s the harm in a reassuring smile or quick word on the way past? A couple of hours close observation (not a lot else to do whilst perched on the end of a trolley) and the potential harm became clear. With so many patients and more arriving all the time, 5 seconds, even 2 seconds, paying attention to those who wanted the quick word or reassuring smile would very quickly add up. There are only 30 lots of 2-seconds in a minute; many more than 30 patients crammed in. Lose a minute on every trip down a corridor and the system will soon snarl up; obs won’t be done to time, things will be missed. And the lack of attention turned out not to be that at all. One patient twisted on his trolley and let out a low groan (of the sort that I would have expected to be drowned in the racket) but there was something about the sound or the movement that signalled ‘could be serious’ and had a nurse there in a second.

The only thing they didn’t provide for G that might have helped him was sleep, but no one there had the power to make extra beds and extra staff appear. That’s in the politicians’ hands. I’m sure many politicians are honest and hard-working. I know some personally who certainly are. They didn’t all fiddle their expenses and they don’t all carp about working long hours, but sitting in the midst of this chaos, seeing the NHS distinguish serious from trivial, save lives, move people through the system smoothly and humanely as far as they could with the tools they’re given, I couldn’t help thinking that it’s the politicians who need to learn something from the NHS and not the other way round.

The Acute Assessment Unit was quieter, but still pretty chaotic, trolleys arriving, people being hustled back and forth. By the time G was allocated a bed, it was the following day, he had been told he was being sent to a different hospital and in fact already had a bed allocated there. All he was waiting for was an ambulance.  He was reluctant to spend any time on the newly allocated bed. He felt it was a waste of the clean bedding and that he might as well sit in the waiting room with me.

The nurse was tenaciously insistent and got him into bed. She was also amazingly good-natured with everyone whilst keeping them all to their routine. G wasn’t the only absconder. One of the others was a confused patient who wasn’t properly ambulant. I started out agreeing it was a shame to waste the bedding when we wouldn’t be there for long, but again it soon became clear why G should be with his bed.

The only way the system can work when it’s so overstretched is to have processes and procedures and stick to them. Betty Macdonald put it well in The Plague and I when she described the rigid routines at the Pines Clinic. It’s the only way to keep an overstretched system working. The big difference was that at the Pines in 1930s America the nurses were instructed to be cold, clinical and unsmiling. Here they were quite the opposite, but equally strict and for good reasons.

The cardiology ward at the new hospital was like a different planet. A good-sized room with its own phone, TV and bathroom. Not only one patient per bed, but one bed per allocated space for a bed (as opposed to one bed and several trolleys). In a way it was like being in a peaceful sunny meadow, with small groups of people dotted sparsely about the grass enjoying the peace and quiet. And towering above the meadow a huge dam, a great mass of people waiting to burst through. A&E was the mass behind the dam. AAU was the overflow. The cardiology ward was the meadow.

The analogy broke down a little on the peace and quiet front. The 5-legged obs machines beeped and screeched their way up and down the ward like busy little robots. Blood pressure and so on was taken every couple of hours night and day, so sleep was periods of dozing off and being woken. G was alarmed one night to be woken by a doctor who put a stop-tap in his arm. There’s probably a medical term for it, but G used the plumbing equivalent. Later that same night he became aware of activity down by his side and opened his eyes to see a nurse with a torch, who said not to worry, she was just changing his battery. He had to puzzle himself to full wakefulness to realise it was the battery on the mobile ECG machine that he was attached to throughout his stay.

He was allocated to the surgeons after 3 days but then delayed a few hours by the arrival of 2 emergencies. The medics arrived in teams and interrogated him on every aspect until they had the story straight and could make it fit with the observations charts. There was an air of quiet confidence and competence about every aspect that was very reassuring. We knew it was considered an A-team in terms of cardiac care and it showed.

If we’d been private patients in a private hospital, what would have been different? Maybe none of that scrum to start with, except that there’s no such a thing as private A&E because there’s no way to make it pay in the narrow way that defines profit. And anyway, within that scrum was the medical expertise we needed. And it’s hard to imagine a private hospital being much better appointed than the one where we ended up, though I guess there might have been flowers and carpets; maybe the TV would have come for free; the car-park might have been big enough. But there wouldn’t have been the medical expertise on tap.  It’s the medical care that costs a lot of money. We might have had earlier treatment but if anything had gone wrong, the specialists would not have been on hand because when money’s the only focus, you don’t keep expensive expertise hanging around, you buy it in parcels for specific purposes. It’s why private complications end up in the NHS.

That stretched-to-the-limit feeling was always there. G’s bed was being readied for the next patient almost as soon as he’d been wheeled down for treatment. And after a night on the close observation ward, he was up and in the day room at 7.30 AM so someone else could have his bed, though we didn’t get to leave until the afternoon because someone needed to find the time to bring new medication and a discharge form – which are things that can easily and understandably be knocked down the priority list. But we were offered tea, coffee, snacks and lunch while we waited and we had a stack of DVDs. We watched French & Saunders and Porridge.

On the way home, we stopped for a wander round the shops in Cottingham because G was desperate for some fresh air. Then home and a lot of sleep to catch up on. There are many ways to get from our house to the hospital. We’re one side of the city and it’s the other. The shortest route isn’t the quickest in the rush hour and there are several longest routes that are sometimes quicker, but they all converge to cross the railway at some point. I was late a few times, often caught at the level crossing, and twice by taking wrong turns. It’s a route I know well but a bit of inattention  can go a long way. One time I headed for the wrong hospital. That put half an hour on the journey. Another time I simply took a wrong turning, thought I was further along the way than I was so turned left and found myself in a narrow winding unfamiliar road with a large vehicle close behind and no obvious place to turn for an annoyingly long way.

The car windscreen now has frilly edges where all the car park tickets flutter side by side. I should have removed them instead of just adding more every day, but somehow I didn’t. Apart from the large one that appeared on the outside admonishing me for parking on the grass. Sorry about that. It pained me to leave tyre tracks on such a wonderful hospital, but there wasn’t a spare inch anywhere else to put the car.

Where are the photos? I took one. G thought it would be nice to have a record of him looking cheerful to show the family as reassurance. But despite the fact that he was by then relaxed and feeling fine, none of that came across. In the photo he looked ghastly, wires and machinery everywhere, battered and bruised. We decided not to scare anyone so no photos on this blog.