Just before 5pm, during a momentary afternoon lull, paediatrics nurse Martin Dean is leaning against the counter in the cluttered nurses' tearoom. As his tea bag stews a Tannoy alert warns A&E staff that a three-year-old who has been hit by a car will shortly arrive by ambulance.
He leaves his tea, walks back through the corridors, past a drunk, blood-smeared woman who is wandering around the corridors weeping and swearing, back to the resuscitation room, where staff are preparing a bed for the child. Someone has written "Car vs Child" on a whiteboard by the bed in red marker pen.
At 4.59pm a woman is wheeled in on a stretcher, sitting half-propped up, with her daughter sandwiched between her legs. The girl isn't moving but her eyes are open and watching what is going on around her.
An A&E doctor in green scrubs speaks to the mother in Pashto, quickly translating for his colleagues as he talks to her. "Mum says she was crossing the road and she was hit by a car, tossed in the air and landed on her head," he says. The mother is crying as she is speaking, eyes wide with horror, a red anxiety rash creeping up her neck. She explains that her daughter lost consciousness for a few minutes, and cried inconsolably when she came around.
"Crying is good," the doctor reassures her, slipping between languages. "The way her neck was moving, that was pretty reassuring."
Another doctor looks into the girl's eyes, listing visible signs of injuries for colleagues, noting the lacerations to her head.
What follows showcases the NHS at its best. By 5.15pm the child, Ameena, has been seen by five doctors and is about to be anaesthetised, so that x-rays and scans can be taken. She is moved with great care from her mother's knee to another bed, attention paid to ensuring that her head and back do not move. "All right sweetheart," the paediatrician says as he puts a gas mask over her mouth and nose. "Alright. Nice and still. Good girl." The nurse holds the child's hands so she can't bat the mask away.
But outside the resuscitation room, a queue of patients in wheelchairs and on stretchers is along the corridor, because so many staff have been diverted to look after Ameena. One elderly man is sitting in a wheelchair with his head slumped into his chest. Behind him is a woman on a stretcher with white cream smeared all over her face, and behind her is another man in a wheelchair eating a sandwich. The drunken woman has fallen on the floor, and is still crying when the nurse picks her up. The nurse is trying to find out her full name, but she just weeps and hugs the nurse, who reassures her and then retreats to wash her hands with antiseptic soap. Left alone, the woman stops crying and starts shouting: "Ah fuck off. You bastards."
Senior nurse Clare O'Carroll is on the phone trying to get a bed for a patient to be transferred to. "No female beds," she says, and writes something on her hand.
The department, of course, is well-equipped to deal with real emergencies, but struggles to manage the unceasing flow of patients, many of whom arrive with minor complaints. While the girl is being treated, six ambulances arrive in the space of five or 10 minutes, unloading patients into an already full A&E department. "We are trying to get on top of it," O'Carroll says.
Despite efforts to set up community drop-in health centres where patients can go instead, the numbers coming into the emergency department of Heartlands hospital in east Birmingham are rising steadily.
When Aidan McNamara, clinical director of emergency medicine at Heartlands, started as a consultant 12 years ago, 74,000 patients made their way to the hospital's A&E; by last year, that number had risen by 50% to 113,000.
Partly this is the result of the ageing population, and the rise in the number of very frail and vulnerable elderly patients who need medical help; partly it is due to rising alcohol abuse, he thinks, with staff seeing more and more patients who have been injured in alcohol-fuelled fights, have fallen downstairs when drunk, are simply brought in unconscious, or have chronic conditions such as cirrhosis of the liver. Of the patients who return to A&E three or four times, "80% of them will have alcohol as either the main or major contributory issue" McNamara says. The department has seen one patient more than 230 times – as a result of a combination of mental health and alcohol issues.
The number of people coming in with very serious complaints – because they've had a heart attack or been in a car accident – has stayed fairly constant, but there are growing numbers of people who turn up with the kind of problems they might previously have taken to their GP. McNamara thinks this is the result of medical services failing to keep up with a service culture that is increasingly available 24/7, of failing to respond to a society where both parents work and are unable to take their child to the doctor during regular office hours, and also the result of the disappearance of extended family networks so that parents are less able to consult grandparents for advice about their child's health, and rush straight to the hospital instead. "The system is not clear to people so they access it in the way they think that the system intended them to do," he says.
The hospital's chief executive, Mark Newbold, says: "We get tens of thousands of people every year who come to A&E who should have gone to their GP. The worry about queues in A&E is not that someone with a sore finger is waiting a long time, it's that someone who is elderly, who needs to come into hospital, might be waiting a long time to come into a comfortable bed."
The net result is that staff are under pressure to process growing numbers of patients, trying to filter them and divert them in different directions, according to the severity of their conditions. "You try to prioritise the sickest patients, but that can be quite challenging when the group of people you are selecting them from is bigger; that can make it harder," McNamara says.
Staff are constantly racing to make sure patients are seen within the four-hour target imposed by the government, but swelling numbers makes this a constant challenge. Once a patient has been in the department for more than four hours, an angry warning signal flashes up on the admissions computer, and staff need to make a note justifying the delay.
"The speed with which patients can move into hospital is a barometer of how well the hospital is functioning. They can only move if there are beds for them to move to," McNamara says.
Earlier this year a critical report was published by a local newspaper showing that ambulance staff wasted 8,997 hours as they waited to admit patients to Heartlands because there was no space for them inside the department.
McNamara says there has been an increase in the number of people calling ambulances to take them to hospital, often inappropriately; he routinely sees people coming in by ambulance with toe injuries. "We can get 25–30 ambulances an hour, and we find it very, very difficult to cope with."
O'Carroll spends the late afternoon racing to process admissions, and says later: "A lot of people find it easier to dial 999 than go to a GP."
An elderly and confused man is brought in after falling at a bus stop. In the next cubicle there is a woman lying down, calmly eating a packet of Quavers. Further along the corridor, a woman with a large bandage around her head is accompanied by three tearful grown-up daughters, who explain that she fell and hit her head on the sink in the care home where she lives.
Next door, a frail, white-haired woman is having some difficulty catching her breath, and begins groaning: "Help. Help me. Help." No one is immediately free to help her, so her husband goes to the nursing station to grab someone. "She's really bad," he says with fear in his voice.
Something strange has happened to the floor of the department, installed 18 months ago during a £1.3m department facelift, and it has bubbled up and become unsafe, so builders are reflooring the stretch of corridor where ambulance staff wheel stretchers from the entrance lobby towards the staff; for the next few days the paediatrics emergency department has been closed, and all the other departments have been squeezed together. Staff respond calmly to the disruption. "If you've got anybody who has died, use paeds," one of the nurses instructs staff as they start their shift. "Paeds is to be used for any bereaved families."
"It's very different from what you see on television. These are real people and their problems are real," Ahmed Ismail, one of the department's consultants, says. But the afternoon unfolds much in the vein of a medical drama, only with the added sensation of air-conditioning, the pervasive smell of alcoholic handwash and the unedited swearing.
One theme not usually dwelt on by scriptwriters is the pressure to cut costs. The Heartlands emergency department has to make 5% savings every year, over three years, slicing about £800,000 a year from the budget. McNamara thinks this can only be done with NHS-wide restructuring, so that the flood of patients coming into the department (often unnecessarily) can get treated elsewhere.
"If we need to take cost out, we would have to take staff out, which is difficult to do given the increase in numbers coming in. The only way is to divert to other services.
"We are trying to meet it," he says, referring to the savings target, and choosing his words judiciously. "We are going to try, but we will really struggle to do it."
But more junior staff members wonder how £2.4m can be saved over three years, pointing out that to make cuts of that size would require large reductions in staffing numbers. "We are well short of achieving this. Where do they want that money to come from? How can you shave that amount of money from a service that is very pressured?" one employee, who wanted to remain anonymous, wrote in an email.
The hospital's head nurse is already looking at costs that can be snipped out of the system, considering new ways of bulk-buying supplies and planning to replace the relatively-new cubicle division paper curtains that are thrown away after every outbreak of an infectious disease with the old-style cotton curtains that can simply be washed and reused.
A new clinical decisions unit has been created in the emergency department to hold patients who need to be monitored for a few hours, perhaps because they've fallen or have chest pains, while doctors decide whether they really need to be admitted or can simply go home.
This will save money by stopping beds from being taken up with people who aren't really very ill. A specialist elderly care doctor has also been recruited to work full-time in the emergency wing, to make sure the rising number of frail and elderly patients are properly and swiftly looked after – or sent home – a measure that should also shave costs caused by inappropriate hospitalisation.
By 7.16pm the girl hit by a car has come back from being scanned, and doctors are bringing her round from her anaesthetic. The tension by the bed is easing. One doctor begins to complain about his difficult journey to work. "The traffic was terrible getting here from Solihull." Another asks a colleague which school he decided to send his child to. It is clear that the crisis is over. The girl's mother begins to relax and smiles at something the doctor says to her in Pashto. "I'll talk to you step by step. Don't panic. You'll be the first to know," he says.
The child is wheeled out to the scanning department, leaving a small pile of clothes and a pair of pink trainers by the side of the bed.
O'Carroll is getting ready to go home, tired after a busy shift. "Twelve hours is a long time. By this point you get a bit dazed," she says. "It was fairly quiet, as days go. Nobody died, which is good."
All patient names have been changed.
