Top A&E doctors warn: 'We cannot guarantee safe care for patients anymore'

Patients at risk from combination of 'toxic overcrowding' and 'institutional exhaustion', say 20 heads of emergency departments

The Accident & Emergency crisis is now so severe that doctors can no longer guarantee safe care for patients, NHS officials have warned in a leaked letter seen by The Independent.

A combination of “toxic overcrowding” and “institutional exhaustion” is putting lives at risk, according to the letter to senior NHS managers from the leaders of 18 emergency departments. They warn that the rising number of patients presenting themselves for treatment has created a “state of crisis” in casualty departments.

In a chilling warning, they write: “What is entirely unacceptable is the delivery of unsafe care, but that is now the prospect we find ourselves facing on too frequent a basis.”

The letter will heap more pressure on the Health Secretary, Jeremy Hunt, who is due to respond to the troubles facing emergency units in a speech on Thursday. Last week, figures showed that the number of patients attending casualty units in England has increased by a million in the 12 months leading up to January 2013.

The 20 emergency medicine chiefs from the West Midlands tell how A&Es in the area – which serve a population of 5.3 million and have more than 1.5 million patient attendances a year – are being overwhelmed by “unprecedented and relentless pressures”.

In the letter sent to NHS trust chief executives and clinical commissioning managers last Friday, they call upon the Government to take immediate and radical action to fix an “emergency system failing to cope”. Mike Farrar, chief executive of the NHS Confederation, which represents all organisations that provide NHS services, will be quizzed by MPs about the crisis on Tuesday.

Speaking before his appearance at the Health Select Committee, he conceded that urgent care services were “getting closer to the cliff edge,” with A&E admission increasing by 51 per cent over the past 10 years.

Adding his voice to calls for Government action, Mr Farrar said: “If we continue with this trend we will see another extra half a million patients cramming into our A&E department in the next three years. This will be simply impossible for our hospital services to cope with, despite the heroic efforts of staff to date.”

The letter from the 20 A&E leaders talks of the “institutional exhaustion” of the nursing, medical and even clerical staff who being pushed ever harder by the growing volume of work with little outside support. It also describes how doctors and nurses are being forced to work in what are verging on dangerous environments.

“All of our EDs [Emergency Departments] have been under immense pressure for the last few months,” the letter states. “There is toxic ED overcrowding, the likes of which we have never seen before.

“Nurses and doctors are forced to deliver care in corridors and inappropriate areas within the ED, routinely sacrificing patient privacy and dignity and frequently operating at the absolute margins of clinical safety.”

Its authors explain that casualties are unequipped to “safely care” for this increase in patient numbers, of which a large percentage are elderly people with more complicated medical and social needs. They further warn that overcrowding is likely to lead to more deaths in hospitals and reveal that standards of care are deteriorating as serious clinical incidents and delays are rising.

But in perhaps the most alarming statement they admit that the problems facing West Midlands A&E departments have escalated to the point where doctors can no longer guarantee “safe and high quality” care. The letter states: “The aforementioned issues have led to us routinely substituting quality care with merely safe care; while this is not acceptable to us, what is entirely unacceptable is the delivery of unsafe care; but this is now the prospect we find ourselves facing on too frequent a basis.”

Among the other issues raised in the document is the ongoing failure to recruit much-needed new doctors to emergency medicine, with many junior medics being put off by the “Herculean burden of work”.

Meanwhile, the introduction of the NHS 111 helpline and financial penalties imposed on ambulance crews has only exacerbated the emergency care crisis, according to leading clinicians.

The 111 phoneline has previously been blamed for increasing pressure on A&E with delays in responses to calls leading to patients going to casualty instead of seeing an out-of-hours doctor. And the advice line’s operators have been criticised for sending paramedics to deal with minor complaints such as toothache and diarrhoea.

Dr Cliff Mann, from the College of Emergency Medicine, which last week produced a report calling for A&E services to be overhauled, said the concerns in the West Midlands” echo those of emergency medicine doctors throughout the UK.”

A spokesman for NHS England in the West Midlands said: “Emergency Departments across the West Midlands have been experiencing high levels of demand. This increase reflects a rising demand for emergency care, although nationally over the last three weeks the Emergency Department target to see 95 per cent of all patients within 4 hours has been met. This has also been reflected in the West Midlands, where performance has greatly improved over recent weeks.

However, it is anticipated that we will continue to see peaks in demand at busy times and for this reason NHS England has asked its area teams to work with clinical commissioning groups and trusts to produce plans to manage peaks in demand more effectively.”

Health Minister Lord Howe said: "We know that the reasons for current pressures on A&E are complex and we are already taking action with NHS England to address them now and in the future.

"NHS England is freeing up cash to help ease the immediate pressures but long term we need to look at how the NHS works as a whole, how it works with other areas such as social care and how it deals with an ageing population and more people with long term conditions. That is what we are doing.

"Because of reforms, doctors now have the freedom to provide the health services their patients really need before they ever get to hospital. We have seen several examples of local services - led by clinical experts - working together more effectively and reducing A&E attendances in the process. Reforms have created the environment for this to happen far more."

Case study: Dying patient, 91, was left in a cubicle for 11 hours

Jack Bailey, 91, spent 11 hours in a cubicle waiting for a ward after being taken to the A&E department of the University Hospital of North Staffordshire in May 2012 with breathing and abdominal problems .

He died the next day. His daughter-in-law Susan told a Staffordshire paper, The Sentinel: “I am furious that he should spend so long in that department when we have spent millions on a new hospital... Elderly people need looking after and it is about preserving their dignity. His last few hours really weren’t helped by this ordeal.”

A trust spokesman said: “Mr Bailey was triaged quickly and then seen by a senior doctor within three hours, who made the decision to admit him. The emergency centre staff gave Mr Bailey continuous care and regularly monitored his condition throughout the night.”

THE LEAKED LETTER

FAO: CEOs of Acute Trusts and heads of Clinical Commissioning Groups in West Midlands region

Dear Colleague,

We write as a group of Service Leads for Emergency Medicine in the West Midlands, representing Emergency Medicine consultants in the region, with responsibility for eighteen of the region's twenty one Emergency Departments (EDs). The EDs of the region manage in excess of 1.5 million patient attendances annually, in a region with a population of 5.36 million. This represents 8.5% of all ED attendances in England.

Following a winter and spring of sustained, extraordinary pressures throughout the EDs in the region, we now believe we are in a state of crisis which needs to be more widely acknowledged and moreover urgently addressed. This issue has in recent days and weeks been highlighted by NHS England, the Care Quality Commission, the Royal College of Nursing and the College of Emergency Medicine; we echo the sentiments of these organisations and highlight the fact that this crisis has been particularly and intensely felt throughout the West Midlands and surrounding region. It has come to a point where we must voice our most pressing concerns regarding the safety and quality of care currently being delivered in EDs across the region.

All of our EDs have been under immense pressure for the last few months. This pressure has been unprecedented and relentless, and felt by every ED in the region. All have shown inexorable rises in attendance rates, year on year, coupled with increasing intensity in workload, as we care for a rapidly aging population with complex needs. There is toxic ED overcrowding, the likes of which we have never seen before. Nurses and doctors are forced to deliver care in corridors and inappropriate areas within the ED, routinely sacrificing patient privacy and dignity and frequently operating at the absolute margins of clinical safety.

We regularly see our EDs overwhelmed with patients, with all cubicles occupied, and no egress into the hospital forthcoming, while patients continue to pour through the doors. Our departments are simply not equipped to safely care for such numbers of patients, an increasing proportion of whom are elderly and frail with complex medical, nursing and social needs. All of the available evidence demonstrates that in-hospital mortality is increased when the ED is overcrowded and patients have to wait excessively for beds. Such overcrowding is now the norm in our EDs. In addition, we are seeing an inevitable and unsurprising increase in serious clinical incidents and complaints, as well as delays and deficiencies in care. And for every incident reported, we know there are multiple examples of substandard care that go under the radar. We and our staff are carrying a huge burden of clinical risk which no other agency seems willing or able to share.

While matters have recently come to a head, this situation has been in the making for a number of years, as evidenced by the fact that the recruitment of doctors to Emergency Medicine is in a state of national crisis, and our region has not escaped the problem. The Herculean burden of work, responsibility and clinical risk is so obvious to junior doctors that they are unwilling to join us in the practice of what we once considered the most rewarding areas of clinical medicine, and instead opt for more attractive and sustainable careers. There is institutional exhaustion amongst ED staff, at all levels, across nursing, medical and clerical. We appear to be the only healthcare workers in our organisations who are expected to work under these conditions, and it is not sustainable. Recruitment is almost impossible, and retention is becoming hugely challenging. The relentless volume of work, coupled with a perceived lack of clinical support from outside the EDs is demoralising and destructive.

Recent developments such as the introduction of 111 and financial penalties for holding ambulance crews in ED are touted as solutions to the crisis: however we as ED physicians recognise that these measures will actually make the problem worse instead of better, and evidence is already emerging to support our opinions. Furthermore the unilateral and dictatorial manner in which these and other policies have recently been introduced have only served to compound the problems in our departments.

The position is such that we can no longer guarantee the provision of safe and high quality medical and nursing care in our EDs. It is not a case of standards slipping, but the inevitable consequence of being forced to work in sub-standard conditions. The aforementioned issues have led to us routinely substituting quality care with merely safe care; while this is not acceptable to us, what is entirely unacceptable is the delivery of unsafe care; but this is now the prospect we find ourselves facing on too frequent a basis.

As a group of committed clinicians, we have worked hard to improve safety, quality, efficiency and timeliness of care in our departments, but have now exhausted all of our own resources. The pressures in ED and the ambulance service reflect an overall emergency system failing to cope -a coordinated system -wide response is now urgently needed. We know there is no simple answer to this conundrum; however as things have continued to escalate in this unrelenting fashion with detrimental effects on patients and staff alike, it would be unethical of us not to highlight this to our Executive teams and Clinical Commissioning Groups. Furthermore, we firmly believe and strongly recommend that ED leads should be intimately involved with and consulted on the commissioning of Emergency services in the region, as well as other related emergency care changes-such as 111. He that wears the shoe knows where it pinches; it is imperative that the experts in delivering Emergency Care- i.e. ourselves and our colleagues, are an integral part of its development and reconfiguration.

We reiterate our profound distress with the state of EDs in the region; and, while not wishing to apportion blame or devolve ourselves of responsibility, we call urgently on behalf of our patients and our staff for a radical Health Economy-wide response to the urgent care needs of the population of the Midlands. We furthermore call for our EDs to be suitably staffed and supported whilst under such pressure and while longer term solutions are put in place.

Yours sincerely,

M Bernadette Garrihy, WM Regional Representative to College of Emergency Medicine,

Terri Bentley, Joint Clinical Lead for Emergency Medicine, Mid-Staffordshire Hospital,

Bob Coupe, Joint Clinical Lead for Emergency Medicine, Mid-Staffordshire Hospital,

James Crampton, Clinical Lead for Emergency Medicine, Burton NHS Foundation Trust,

James Davidson, Clinical Lead for Emergency Medicine, UHCW, Coventry,

Ola Erinfolami, Clinical Lead for Emergency Medicine, Solihull Hospital,

James France, Clinical Lead for Emergency Medicine, Worcester Royal Hospital,

Magnus Harrison, Clinical Lead for Emergency Medicine, University Hospital of North Staffordshire,

Christopher Hetherington, Clinical Director for Countywide Emergency Medicine Directorate, Worcestershire Acute Hospitals NHS Trust, Alexandra Hospital, Redditch,

Ruchi Joshi, Clinical Lead for Emergency Medicine, Walsall Healthcare NHS Trust,

Aidan MacNamara, Clinical Director of Emergency Medicine, Heart of England Foundation Trust,

Adrian Marsh, ED Lead at Shrewsbury and Telford NHS Trust

Rajan Paw, Service Head for Emergency Medicine, Dudley Group of Hospitals,

Mark Poulson, EM Lead for Sandwell and West Birmingham Hospitals,

Arne Rose, Lead Clinician for Good Hope Hospital Emergency Department, Sutton Coldfield,

Martin Smyth, Clinical Director for Emergency Medicine, South Warwickshire Foundation Trust,

Ben Stanhope, Clinical lead for ED, Birmingham Children's Hospital,

Kumaran Subramanian, ED Lead at Shrewsbury and Telford NHS Trust,

Juliette Walton, Clinical Lead for Emergency Medicine, Wye Valley Trust Hereford.