Happy Hour in A&E makes everyone miserable
ANOTHER SHIFT finished, the night is young, and I for one am glad happy hour is over. Late at night, surrounded by colleagues and patients alike, A&E can feel remarkably lonely when working at pace. The mind wanders when natural breaks arise.
I think back to that deliciously disturbing bar scene from The Shining by Stephen King where Jack Torrance, a caretaker charged with maintaining the Overlook Hotel, sells his soul for a drink from bartender Lloyd, or more accurately, more than a few. The dialogue is poetic.
Jack: Hi, Lloyd. A little slow tonight, isn’t it? [laughs]
Lloyd: Yes, it is, Mr. Torrance. What’ll it be?
Jack: I’m awfully glad you asked me that, Lloyd. Because I just happen to have two twenties and two tens right here in my wallet. I was afraid they were gonna be there until next April. So here’s what: you slip me a bottle of bourbon, a little glass, and some ice. You can do that, can’t you, Lloyd? You’re not too busy, are you?
Lloyd: No, sir, I’m not busy at all.
Jack: Good man! You set ’em up and I’ll knock ’em back, Lloyd. One by one. “White man’s burden,” Lloyd, my man, white man’s burden. [Jack opens his wallet and finds that it’s empty] Say, Lloyd, it seems I’m temporarily light. How’s my credit in this joint, anyway?
Lloyd: Your credit’s fine, Mr. Torrance.
Jack: That’s swell. I like you, Lloyd. I always liked you. You were always the best of ’em. Best god-damn bartender from Timbuktu to Portland, Maine – or Portland, Oregon, for that matter.
Lloyd: Thank you for saying so.
It’s that line that hits home every time in A&E, something triumphant in the face of inevitable defeat. You set ’em up and I’ll knock ’em back.
That is at times how it feels when patients arrive via their GP, the ambulance service, or self-presenting with their idea of what constitutes being acutely unwell… and that is very variable indeed. Of course, we see everyone who arrives at our door, no matter who or how they were lined up for us.
The flow seems relentless and often is, yet there’s a pattern in the puzzle and a clockwork in the chaos because many admissions are not simply unnecessary but predictably so. One of the greatest failings of health politics is the assumption by most on the right, and almost all on the left, that the system is fine. The system works as intended, only there just isn’t enough money and resources put in to explain the lack of satisfactory outcomes.
The left champion investment and the right champion savings but the potency of the bullshit is about the same. Levels of spending, as an outcome of itself, has become de rigour and to invert the concept of efficiency, the more we spend the better we must be doing as a health service. Record spending as a policy goal, growth in demand as an inevitable liability to manage with investment and reform… whatever those terms ever mean.
Then a dyspeptic night owl tugs at his stethoscope and blasphemes against doctrine,
“No, the system does not work as intended. It does not work well at all. The more we spend the more we waste, the easier it is to access care regardless of need, the more inefficient the allocation of resources becomes. We are spending far too much and so is every country because globalism means everyone makes the same mistakes by consensus. Yes, it is possible that everyone is doing it wrong when they all agree in what they are doing.”
A&E tends to matter in this regard for many reasons. It is where people first come when they feel very unwell. Uncertainty is high and so is risk. Illness is subjective and while people know they are ill they don’t know how, why or how bad it is. Risk is danger, and the default of de-risking is to escalate every uncertainty to the highest common multiple… “A&E can sort it out so I don’t have to.”
Supply-induced demand rules supreme because it is easier and faster to access A&E than any other speciality and people given the choice don’t like to wait. Carers likewise would rather their concerns were spent overnight on a corridor than in a care home or awaiting a clinic or GP visit. This becomes a serious issue when patients in care and the very elderly present to A&E because their likelihood of admission is very high and this is very expensive.
Here’s a few particular cocktails I knock back during happy hour, typically 5 to 7pm on a weekend and then 11am to 5pm on a Monday.
- The 5 O’clock Specials… coming right up. GPs are busy. Very busy. Clinics overrun daily. By 5pm they are done and if you are unwell, complex or presenting with red flag symptoms GPs often send in cases that simply needed decent primary care and require it before the sun goes down. The problem? Everyone has gone home. Every major specialist consultant is away picking up the kids and having their tea. The 5 O’clock Special ends up waiting hours for junior staff to see, and without very senior cover, they risk manage by admitting and scanning just about anything that shuffles in.
- Death in the Afternoon… Complex patients with abnormal tests and conditions worsening over days or weeks arrive at their GP in a poor state because of delays accessing care. They arrive at a stage where urgent scans are essential, and without operating space they will board in corridors overnight deteriorating… yes they are called boarders. Rules to improve patient safety for inpatients work against acute admissions because late at night only life threatening procedures are performed… and patients wait for the day team to operate as they deteriorate or else they receive emergency care as they crash in resus, having spent 6 hours in the waiting room to ripen up for the night team. Some of these turn out especially badly.
- Four Days and a Month… there are patients who are quite stable but have suffered from little or no symptomatic relief for weeks waiting for their GP to review and diagnose them. Psychological exhaustion, fear, desperation and frustration from weeks of pain or breathlessness make ordinary people simply crack. Once work is finished, once the kids are back home, in they come. They could have seen their GP, but they just couldn’t get a slot for the day they cracked.
- Algorithm Martinis… NHS 24 and 111 are meant to divert people from A&E… in reality they do the opposite. Protocols and algorithms work to minimise operator risk and certain buzzwords send you to A&E even if you’re tap dancing like Fred Astaire. All too often these systems simply lie. My favourite garnish is the text message to the patient saying they have booked an appointment for the patient in A&E. It takes a refractory sense of humour not to laugh… there are NO appointments in A&E. It’s A&E. Such deceptions hurt everyone as do magic promises by referrers that “you need a scan / operation / transfusion.”
Well excuse me, but that is the decision of the physician ordering the treatment and it places undue pressure on A&E to do tests and procedures not indicated to avoid complaints. It is common practice and it is foul because no audit trail links back to the offending referrer. This is where supply-induced demand becomes malignant and distracting from those in greatest need by needless inflation of expectations. WE REALLY NEED AUDITS AND FEEDBACK.
- Silver Surfers… one of the most wasteful, distressing and undignified admission groups are those from care homes who are ill, and have been for a very long time, who deteriorate. It is a scandal of itself. Care homes are trapped. Ceilings of care below the obvious ‘Do Not Resuscitate’ are not there and often not clear when they are. Litigation from undertreatment is a serious risk so overtreatment becomes the norm.
Does a head injury from a fall three days ago need seen? Yes. Right now, by blue light ambulance, at 4am? Maybe, but probably not. Numerous guidelines for timely acute investigations exist that allow for next day appoint slots to be created but none of this is available to night shift workers in homes… so… in they come.
Dare anyone ask the obvious? Why are they coming? What are we going to do to and for them at 4am on a Saturday morning? Is it appropriate to give injections of water to those who are struggling to drink because they are in fact dying? Is spending £1000 to give a dying patient 2 litres of brine through a vein before sending them back to where they came even remotely useful in an event horizon beyond the next morning? Again, maybe but probably not.
The answer to happy hour is a good bartender and this means making those triaging patients to manage demand appropriately. Out of hours GPs? Too busy. Triage nurses? Variable but often highly junior. All the while we take experienced nurses out of A&E to turn them into nurse practitioners to do the jobs of junior doctors, for more pay, while there is a glut of junior doctors… the system is NOT working as intended.
Instead we could use GPs currently out of work to focus on care home call outs; to avoid needless visits to hospital and use advanced nurse practitioners as dedicated triage specialists so old men are not tested for pregnancy and 22-year-old girls with heartburn do not have serial troponin tests performed because clearly, they are not having heart attacks.
Yes we can and should flip GP appointments so HIGH FIVE patients are seen early in the day and quickly. If their age is high, their acuity is high, their risk is high, their risk of admission is high and their level of pain is high, seeing them quickly stops them deteriorating on the day and reduces admissions costing thousands by making the right decisions early. GPs must offer same day slots for these particular patients through a dedicated advance access system.
The NHS has long over relied on junior staff in frontline roles with resource allocation falling by the wayside. The NHS does not audit unsound referrals and takes no action when people game the system to offload responsibility when they are paid precisely to take responsibility. The four hour target, universal and pure, is woefully outdated in a world where the NHS is not allowed to say “No”, or even “Not Yet”, “see the GP”, “come to tomorrow’s clinic”, and instead spends £1,500 to treat a sore throat.
When the bar is free, the bar is full and it’s never a quiet night in A&E. But if the goal is to offload professional risk in a system that eschews risk and loss adjustment, the free drinks will continue. Acute care is ripe for reform and sorely needs it. We can do more with less, and yes we can spend less when we are not doing wasteful things. Maybe the system is working as intended, just not for patients.
Until we take allocative efficiency seriously and ask even what it means you will find me at the bar, knocking back what is set up for me… and you’re paying the tab.
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