The Sunday evening call from my consultant colleague was perfectly timed. Our cricket team’s penultimate game of the season had come to a premature end with a heavy defeat and I had not yet sipped the consolatory beer which awaited in the clubhouse. It had been a challenging weekend for those working on AMU. Bank Holiday weekends are never easy, particularly in August when many of the new junior doctors are still finding their feet. This weekend the problem was compounded by overnight gaps in the middle grade rota which had not been filled by our usual locum agencies. Senior House Officers plugging registrar vacancies had provided a solution of sorts, but lack of flow into medical beds over the previous night had led to some lengthy delays in the emergency department. The duty executive had requested a ‘consultant-delivered solution’ to prevent any repeat. Our consultant weekend rota ensures a daytime consultant presence on AMU with overnight availability from home. But the idea of ‘pulling an all nighter’ after two long and challenging days was not a safe prospect for my colleague. So I volunteered. How hard could it be? I had done blocks of 7 consecutive night shifts as an A&E SHO and 60 hour weekends as a House Officer. In our day….etc,…but of course things have changed a lot since then. The numbers of patients being admitted as emergencies has risen substantially, as has their complexity and acuity. So here are a few immediate reflections based on my observations of a single night managing the Acute Medical take:

• Consultant physician presence after midnight has limited impact on overnight patient flow

 Late night discharges are uncommon and most patients deemed unwell enough to be referred to the medical team at that time are likely to benefit from observation until morning. Though I was able to discharge one patient after midnight, following careful discussion and agreement, such cases are likely to be unusual.

• Getting the treatment plan right from the outset may shorten length of stay

A clearly documented consultant review may help to ensure early morning discharge, freeing up beds for the next cohort of arrivals. The morning consultant post take ward round can take up to 4 hours but was considerably shorter for my colleague working the Bank Holiday Monday morning, enabling him to focus on discharges and new admissions.

• Most ‘overnight problems’ do not start overnight

The patients I saw in the emergency department between midnight and 5am had mostly been in the hospital since the early evening, and most of the ‘crises’ had arisen during the daytime. The fact I was seeing them at that time reflected delays in the system by which people arrive in hospital and staffing levels during the afternoon evening.

• Carers and families often stay with the patient until they have ‘settled into the ward’

 It is unusual for a member of the patient’s family to be present during a morning ‘post take’ ward round; but many of the patients who I saw on Sunday night were still accompanied by their families or carers. This provided the opportunity to glean some collateral history or to discuss an escalation plan which otherwise would have been delayed until ‘visiting time’ next day.

• Establishing escalation plans and ceilings of care was a key benefit of consultant presence

 Identifying those patients who will benefit from critical care review is crucial; however it is  often much harder for junior doctors to define ceilings of care when patients are first admitted to hospital.  Presence of a consultant to initiate these difficult discussions with a patient and their carer may help to avoid inappropriate escalations of treatment – the importance of this was evident throughout that night.

The idea of consultant physicians working night shifts would have been hard to contemplate a decade ago. As emergency pressures rise and gaps in our middle grade rotas become ever more prevalent, the concept of a resident AMU consultant between midnight and 8am may not be so far-fetched. But this will come at a cost. Under the current consultant contract a ‘programmed activity’(PA) of consultant time after 7pm is 3 hours, as compared to 4 hours during daytimes. Most consultants will have around 8 clinical PAs in their contract, so a 12 hour night shift from 8pm-8am will comprise half of their weekly work schedule. To provide this service on a seven day basis, in addition to a weekday and weekend daytime presence will require a lot more consultants than we have at present.

Would this be a cost effective use of resources? The number of individuals whose outcome will be changed by the presence of a consultant physician after midnight is likely to be small. Discharge decisions at this time, particularly for older patients, are fraught with danger and usually better deferred until the morning. For those patients presenting after midnight who are acutely unwell and deteriorating, the skills of an intensivist are more likely to be required than those of a physician. There will be some quality benefits, but these may be hard to measure and justification of a business case to provide this kind of expansion will require hard data.

Based on my observations on that Sunday night, the immediate approach should be to boost staffing during the afternoon and early evening, when most of the patients arrive in hospital. Ensuring the presence of enough senior decision makers so that all patients have undergone initial assessment, investigation and seen a consultant before 10pm is more likely to bring benefits: earlier discharges, appropriate escalation decisions, the opportunity to talk to a patient’s family before they leave the hospital premises, and hopefully better outcomes. Such schemes need to be piloted so that any benefits can be quantified.

Overnight consultant physician presence may be inching closer, but we currently have neither the resources nor the personnel to deliver this on a large scale. Recruitment to acute and general medicine training posts has not been easy over recent years and the necessary expansion is likely to take a decade or more to realise. We need to use what we have now as effectively as we can; allowing consultants to sleep and arrive fresh for the start of the day may be a better option than asking them to ‘pull the all nighter’.

‘This is your captain speaking: I am afraid there is going to be a sixty minute delay to the start of our journey’.

The fuselage shudders under the collective groan of the 240 disappointed passengers hearing these words over our plane’s PA system. Until a moment ago the Boeing 757 appeared ready for departure to Gatwick, via the island of Skiathos. However the airport at Skiathos only has capacity for two planes, and there are already two planes in situ. We cannot depart for this 15 minute ‘hop’ until space has been created…..’for safety reasons’.  For some this now means a delay to the start of their holiday; for others like me, our arrival home from Greece will be later than expected. The Captain reiterates his apology, followed by a reassurance that ‘your safety is our top priority’.

My mind turns to thoughts of what is probably going on in hospitals across the UK right now: it is Friday afternoon, so the deluge of pre-weekend emergency referrals will have started. Clinicians and bed managers will be working hard to create the necessary capacity to receive those patients for whom admission will be required. But the wards are already full, and inevitably some will arrive before that capacity has been created; a backlog will soon start to build up in the waiting rooms and corridors of acute medical units and emergency departments. Triage processes will ensure that the sickest patients will be allocated to areas in which they can be seen and treated most quickly, but some will face delays. As the patient:staff ratio rises, the amount of time which can be afforded to each patient will fall; there is a danger that someone, somewhere, will miss something important….

The airline industry is heralded as the paragon of safety to which healthcare systems should aspire, but as the temperature rises on this hot Greek afternoon, the stark contrast in our approaches when capacity is ‘full’ cannot be clearer. There is a reason for the difference: airline delays are inconvenient for passengers, but can always be ‘trumped’ by safety concerns. A short delay is an acceptable price to pay to ensure that you eventually reach your destination unscathed. In urgent healthcare, delays can also compromise safety; waiting is generally bad for your health. If paramedics announced to their passengers that they’d been asked to wait on the patient’s Tarmac until hospital capacity had been cleared, the resulting groans might represent more than just disappointment.

Clearly there are times when a delay to admission may be an acceptable option – safety in healthcare often requires different levels of risk to be balanced; managing this balance is a key skill for senior clinicians working at the interface between primary and secondary care. However until there is a recognition of the need to maintain empty capacity in acute receiving areas of all hospitals there will often be a feeling that we are selecting the ‘least bad’ option at times when the number of admissions exceeds the number of discharges.

My flight proceeds uneventfully and we touch down the predicted hour later than scheduled. As we taxi to Gatwick’s South terminal, a quick scan through my 200 unread emails reveals a staffing challenge for the weekend ahead: two vacant medical SpR shifts remain unfilled and the usual  locum agencies have been unable to help. There is a plea for colleagues to help the on-call medical consultant, who will need to ‘act down’ to provide cover. I am left wondering what announcement our Captain would have made if his First Officer had been absent and no replacement could be found. I suspect I would still be sitting on a very different piece of Tarmac.