It is just after lunch on a Thursday and the Accident and Emergency department is a hive of activity with nurses, doctors, healthcare assistants and paramedics busy tending to patients.
Every trolley bay is full, an overflow area in a corridor is being used, and a few ambulances are beginning to queue up outside the Norfolk and Norwich University Hospital. And this is supposed to be a quieter day at A&E in Norfolk's main hospital.
'Quiet days were a long time ago,' said Victor Inyang, emergency clinical director.
The hospital has come under increasing pressure in recent months to meet a big surge in demand, which has led to incidents of several ambulances being queued up outside the front doors with patients waiting to be seen by staff.
The problem came to a head on Easter Monday when a makeshift tent was erected by the ambulance service to potentially treat patients after up to 15 ambulances were waiting for up to three hours.
New figures show that the N&N is experiencing a year-on-year increase in A&E admissions after seeing 90,700 patients last year, compared to 58,107 emergency and minor injury cases in 2002.
Dr Inyang added that the hospital was also spending a longer time treating more complex cases as Norfolk's population gets older.
'Ten years ago there was a 70/30 split with the majority of patients being walk-in and 30pc were ambulance service patients. Now we have an almost 50/50 split. The numbers have gone up and the split between minor illnesses and serious illnesses has changed and we are getting sicker patients. GPs have their own pressures and stresses and we have our own pressures and stresses. We are trying to find a solution and I do not think we have done that well in the past,' he said.
The A&E department has 15 trolley bays for emergency admissions and around 14 nurses on duty at any one time, working alongside healthcare assistants, consultants and junior doctors.
Staff work 12 or 10 hour shifts, which start at different times to meet the predicted peaks and troughs in demand.
Kirsty Rowden, A&E matron, said the hospital used a computer system that looked at the number of admissions over the last five years and predicts how many patients will be coming through their doors on a daily basis.
'If you look at the data, most days are very similar. It goes up at 10am and peaks at 2pm and goes up again from 4pm to 5pm and from 11pm it goes down.
'Mondays and Fridays are always much busier days and Sundays are the busiest days of the week. The number of sports injuries at a weekend pushes things up,' she said.
The hospital hit its target last year, which requires 95pc of patients attending an A&E department to be seen, treated, admitted or discharged in under four hours.
However, the trust had fallen slightly short of that target in recent months following a very busy February and March, she said, where there was a 30pc increase in demand during the last bank holiday.
Mrs Rowden added that staff were looking forward to some positive changes at the hospital in the coming months.
'The whole system is under pressure and so many parts of the system are under pressure. There is a real push for everyone to work together. We struggle when 11 ambulances arrive at the same time and we may be able to see that six are on their way to us. However, private ambulances are not tracked on the system and we do not know when they are coming. We are not blaming people. It is hard to access a GP, but there are so many contributory factors for the pressure we are under and under Project Domino we are trying to work together. We are working together with the ambulance service, primary care, GPs and community health to provide the best possible service for patients.'
Last month, officials from the Clinical Commissioning Groups for Norwich, South Norfolk and North Norfolk pledged an extra £2.5m to the A&E department to be invested in the recruitment of 20 front-line doctors and nurses. The hospital has also trialled turning part of A&E into an Initial Assessment Unit – after visiting Nottingham University Hospital – that will allocate a senior nurse and healthcare assistant per patient to improve the handover and treatment of patients arriving by ambulance. The new model is set to be adopted when the NHS trust has boosted its staff numbers.
Bosses are also looking to remodel and refurbish the department to improve ambulance turnaround times and reduce waiting times. About 14pc of East of England Ambulance Service patients currently wait more than an hour outside A&E.
Dr Inyang added that the hospital was working closely with ambulance service, GPs, primary care providers and community health services to improve urgent care across central Norfolk as part of Project Domino, which was launched last year. He added that the trust was looking at different ways of working, including recruiting more staff specialising in the care of the elderly. 'We have some really fantastic staff who are very assertive and work very hard and all embrace change when they see the change benefits the patients.'
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