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News NHS Crisis: Voices from the Front Line

Doctors in England say workload is unsustainable, as pressure hits morale

BMJ 2023; 380 doi: (Published 16 January 2023) Cite this as: BMJ 2023;380:p114
  1. Gareth Iacobucci
  1. The BMJ

Doctors in England have told The BMJ that the pressure they are facing this winter is the toughest in memory, given unprecedented levels of demand. Work is relentless and unsustainable, and doctors fear for patients’ safety.

Ian Higginson, vice president of the Royal College of Emergency Medicine, painted a bleak picture of emergency departments this winter. “We’re suffering from the most significant overcrowding that most of us can remember in our careers,” he told The BMJ. “Predominantly [this is] because we can’t find beds for our patients when they need admitting, so our departments become completely full.”

As a result ambulances cannot offload patients and are then unable to respond to calls, and the whole system is clogged up. “Most of that pressure falls on the emergency department. The net effect of that is we see this terrible overcrowding and all the consequences,” said Higginson.

He cited recent evidence, based on data from the NHS’s Getting It Right First Time (GIRFT) programme, showing that for every 82 patients who wait in an emergency department for more than six hours there’s one associated death. “Many, many patients are coming to harm as a result of overcrowding,” he warned. “And that harm is, sadly, in many cases leading to a death associated with crowding.”

Nick Scriven, former president of the Society for Acute Medicine, told The BMJ that the government’s promise of extra money to purchase care home beds to discharge medically fit patients from hospital beds was unlikely to help.1 “In our part of the world care home beds aren’t empty . . . so we’re not quite certain how much that’s going to benefit us. It might get one or two but it’s not a long term solution.”

A consultant geriatrician in South Yorkshire who wished to remain anonymous warned that if social care wasn’t sorted quickly “the NHS is at risk of dying.”

“The emergency department is full of people waiting for medical beds, sometimes for days,” the consultant said. “All the wards in our department last week had extra patients—for example, three patients in a two bedded bay, four patients in a three bedded bay, with screens instead of curtains, pretty close to complete strangers—and this isn’t just for a night or two.”

Primary care demand “not sustainable”

GPs have also been dealing with a surge in demand, exacerbated recently by a spike in cases of group A streptococcal infection and rising rates of flu and covid, in addition to the ongoing backlog in secondary care.

Caroline Rickard, a GP in Faversham and medical director of Kent Local Medical Committee, told The BMJ, “It’s the relentlessness of it that is causing GPs to struggle and feel stressed, because every single thing that we do there are implications if we get it wrong. I’ve had some colleagues reporting that they have up to 80 patient contacts in a day, and that’s just not sustainable.”

David Mummery, a GP in southwest London, said his on-call days had been particularly bruising this winter. “You are firefighting from the very beginning,” he said. “On the busiest on-call day I’ve seen maybe 35-40 patients just on the morning list. It’s just relentless. Essentially you’re at your desk staring at a screen, ploughing through results, tasks, consultations, telephone calls, face-to-face appointments.

“Not only that, there’ll be lots of knocks on the door from nurses saying, ‘Can you see this patient?’ There’ll be instant messages from reception saying, ‘There are no antibiotics left at the pharmacy, can you do another [prescription]?’”

Mummery said the surge in respiratory viruses had piled pressure on practices this winter. “There’s also the backlog of people on hospital waiting lists, who often get worse and need assessment, and the delays in cancer diagnosis,” he added. “It’s multifactorial, but I would say it’s the worst winter in memory in terms of demand.”

Yorkshire GP Zoe Norris, chief executive at Humberside LMC, described the current situation as “dire.” She said, “It doesn’t matter whether people are practising in an affluent area, a deprived area, whether it’s rural or urban, whether they are well staffed or not well staffed. The relentless pressure at the moment just can’t be overstated.”

Morale hits rock bottom

Emma Radcliffe, a GP in Tower Hamlets in east London, said staff as well as patients were being affected by illness. “It is quite a toxic mix of increased demand and staff illness,” she said. “We feel busier than we ever have been. And I think probably we’re a little bit less able to cope with it because our morale is at an all time low.”

The Royal College of Emergency Medicine’s Higginson said that across all parts of the service “the inability to provide good care” was “grinding people down.”

Nick Grundy, a GP partner in London and lead at the support group GP Survival, painted a similar view. “I think morale is dreadful. It doesn’t feel good [that] you can’t deliver the care you want to,” he said. “My main worry is that I think people are already burning out and leaving. You don’t get those people coming back. Whether they’re paramedics, nurses, care home workers, GPs. Once they’re gone, they’re gone.”

Mummery said that the huge pressures across the board had also put a strain on relationships between primary and secondary care.

“So many referrals from primary care are rejected now,” he told The BMJ. “It’s a bit ironic that integrated care was supposedly about bringing people together and getting on well. I would say the relationship between primary and secondary care has deteriorated rather than got better. And that’s probably a symptom of the pressures that everyone is under.”


  • Additional reporting by Elisabeth Mahase