I decided to call my mother’s geriatrician Dr Singh, who asked whether we wanted to bring her into the hospital. I explained that I thought she was going to die and that we didn’t want her to be dragged off by strangers in an ambulance to the corridors of a crowded A&E department. We wanted her to slip away peacefully in her own home, surrounded by family and with the dignity she deserved. I didn’t even want to move her back to the bed. Dr Singh’s wise advice was not to make any intervention myself. For obvious legal reasons we should call a GP, just as my dear mother had done for her father sixty years ago. So I set about trying to find medical help on a Saturday.
Thanks to the Labour government, NHS GPs were given a pay rise in 2003 for abrogating all responsibility for patients outside daytime working hours and at weekends. The much-cherished family doctor was terminated for reasons of financial and political expediency. Out-of-practice hours is now a Russian roulette system in which the sick either take themselves to hospital or call a help line known as NHS 111, a deeply frustrating system introduced by the Conservative government that shifted decision-making from doctors to lay call handlers. The public were told: ‘If you need immediate emergency help, call 999. For all other urgent healthcare needs, there is 111. If you need to see a GP urgently, the service will make sure this happens. If you need to see a nurse or need an urgent home visit out of working hours, NHS 111 will organise it.’ How reassuring was that!
At midday, this professor of surgery dials 111 and a dialogue of incomprehensible stupidity begins. The lay call handler reads out her lines – ‘Do you need an ambulance?’ I reply with clarity that my beloved mother is dying and I would like her to be relieved of the breathlessness and distress that she is currently suffering. She needs the kind attention of a GP in her own home. I then receive a barrage of wholly inappropriate questions about whether she is still breathing or bleeding and lots of other crap, none of which bears any relevance whatsoever to the reality of the situation. I become more assertive. I am a doctor. I know what the patient needs. I do not need someone who may have worked in Sainsbury’s last week to reconsider that decision. The call handler is now confused, unable to depart from protocol. She will get her supervisor to call me back. This reminded me starkly of my adventures in China in 1978, but even the so-called ‘barefoot doctors’ were better!
I sat holding my mother’s hand, intermittently checking her faltering pulse. Short of oxygen, her strong heart had slipped into rapid atrial fibrillation. The telephone was still clutched in my other fist. When it rang, my mother stirred, coughed, then dribbled blood-stained fluid from her nose. The same ridiculous process began once again, with the same inane questions. I made it clear that I did not want an ambulance to bring my mother to hospital. The conversation was going nowhere. Our situation was deteriorating and I sensed that there was no help to be had.
‘I will get our medical officer [the one sitting in the call centre directing traffic] to call you on this number,’ the frustrated woman eventually told me.
After further delay the doctor called, and I left him in no doubt about the nature of the situation and what I believed should happen. Even he took some persuading, but he agreed to send the single GP covering the whole region. I just wanted my poor mother to have some morphine. In the meantime, Sarah the nurse made her as comfortable as possible, moistening her lips and cooling her brow with a cold flannel.
Then her breathing changed perceptibly from its regular, laboured, heaving pattern to an intermittent, irregular gasping that doctors call Cheyne–Stokes respiration. Now I knew she didn’t need the doctor anymore. Divine help had arrived. Her pulse was thready and slowing. Her eyes rolled, then remained shut. Her breaths became more intermittent, eventually fading away altogether. I looked at my distraught father and stated the obvious. She’s gone.
I don’t need to explain how it feels when your mother dies, but death for her came as a great relief. Relief that – in 2016 – she couldn’t access from the medical profession. I guess I wanted that doctor to arrive more than my mother did. I needed to tell myself that I had done everything possible to help her when the time came. Yet the system I’d toiled in without a single day of sick leave in more than forty years had finally let me down when my family needed it. I became increasingly bitter about that.
A very sympathetic lady GP arrived at 4.30 pm, ten minutes after the passing, four and a half hours after I’d sought help. She was profoundly embarrassed and described the system as in chaos, which meant she couldn’t reach us any sooner. It was fitting testament to a broken NHS. It made no difference that our family was full of doctors. No one was there to help. My mother died peacefully at home, surrounded by her family. Had she lived in a nursing home, an ambulance would have shipped her off to the accident department to die on a trolley in a busy hospital corridor.
June 2016. I was in the hospital late in the afternoon when my lawyer daughter Gemma called me in a state of anxiety. Unusual for her, but my eighteen-month-old granddaughter was vomiting repeatedly, couldn’t keep anything down and was becoming lethargic and floppy. When my daughter rang the GP’s surgery, she was told that there were no more appointments that day so she should find a pharmacy for advice, which is what is recommended by NHS England. Having done just this, the young lady pharmacist was hesitant to offer any opinion on a dehydrated child and suggested the 111 route. Halfway through these discussions my daughter decided that she had no confidence whatsoever in what she was hearing, so she called me in Oxford to ask my advice.
As a paediatric surgeon, certain words triggered alarm bells for me. ‘Lethargic and floppy’ in a baby often spells low blood sugar and immediate danger, so I told Gemma to go directly to the children’s emergency department at Addenbrooke’s Hospital in Cambridge, and I called the unit myself, hoping that they would be seen on arrival.
I let Gemma know that she was not alone in abandoning the prescribed process, as a great number of intelligent patients abandon 111 calls. The chair of the British Medical Associations General Practitioners Committee referred to 111 as a ‘disaster zone’ because of the number of calls that were inappropriately triaged. It was a relief that the kindly sister in charge at Addenbrooke’s was happy to take my call. I then set off on the dreaded M40, M25, A1 journey to my old hospital in the middle of rush hour. Few things can be more stressful than a distant medical emergency in your own family. When I arrived, the little bundle was being rehydrated with glucose through a drip in her arm. Everyone felt safe by now – great hospital, great doctors and nurses. It was getting her there that was the problem.
Within twelve months I received another urgent call from Essex. Returning from the school run, Gemma witnessed a little old lady stumble into the main road and fall heavily on her face. Gemma stopped her car in a position to shield the woman from oncoming traffic. Covered in abrasions and bruises, the victim was in great pain and appeared to have a fractured collar bone, so Gemma stayed at the roadside and asked another passer-by to fetch the lady’s elderly husband, who brought a chair and sat beside his prostrate spouse. It was a bizarre tableau, but no one felt confident enough to shift the poor, immobile woman. The obvious course of action was to call for an ambulance, which is precisely what Gemma did.
Once again my lawyer daughter was faced by the rote of triage questions: ‘Is she breathing, is she bleeding, can you see the baby’s head? Sorry, wrong questionnaire.’ I jest, obviously, but after a frustrating and mostly pointless set of questions she was told that an ambulance would be on its way, but it could take up to four hours. As it turned out it wasn’t as bad as that; it was three hours and forty minutes. As my daughter sat comforting the pair, someone else directed the traffic around this human obstruction.
A passing fire engine stopped to enquire about the incident. What they said was along the lines of ‘Don’t blame the ambulance service. Their vehicles are queuing outside the hospital waiting to unload. The accident department is full because they can’t send any pat
ients to the wards. The wards are full because they can’t discharge their patients into the community. A quarter of the beds are occupied by patients who don’t need to be there, but there is nowhere else to look after them.’
My daughter thanked them for their reassuring insight and they moved on. The elderly lady was hypothermic when she eventually reached Addenbrooke’s, just ten miles away.
What do Albert Einstein and our treasured NHS have in common? Answer: they were brilliant for their time, but when they reached seventy they both died from something eminently treatable. In Einstein’s case, it was an aortic aneurysm for which he persistently refused surgery, a common obstinacy and resistance to change that is difficult to understand. For the NHS, it’s the ‘free for all at the point of delivery’ principle that is impossible to sustain because the population is aging and only a proportion of us pay taxes to pay for it. And free healthcare has long been a tourist industry.
The NHS of 2018 is unrecognisable from how it used to be in 1948, when it was established. Modern medicine relies on thousands of drugs and increasingly complex technology, both of which have become vastly more expensive with time. My own specialty has changed immeasurably since I came to Oxford in 1986. Much of the surgery we did for coronary artery disease has been superseded by coronary stenting under local anaesthetic, often on a day-case basis. When performed during a heart attack, this technique restores blood flow to the dying muscle and if done in time can salvage a significant amount of it. Some of those saved do go on to suffer heart failure, but they might soon receive an injection of stem cells down that catheter too. Even though the results are marginally better with coronary bypass surgery, who would honestly prefer a foot-long incision up the sternum and another in the leg or arm to harvest the graft conduits?
Even prosthetic heart valves can now be inserted by a cardiologist. They are rolled on to the end of a catheter, then unfurled forcibly within the diseased valve, an approach that is already routine in older age groups in some European countries. Less invasive techniques are being developed for the mitral valve, but in those for whom conventional mitral valve surgery remains preferable, this can now be undertaken through a small incision in the right chest wall supported by robotics or enabling technology.
Most abdominal aortic aneurysms, such as the one that killed Einstein, no longer need open surgery through a large abdominal incision. An endovascular stent graft, usually deployed on a catheter from the groin under detailed X-ray screening, excludes the swollen part of the aorta from within. The same innovative techniques are suitable for many aneurysms in the chest, and they hugely reduced the volume of my aortic surgery practice. Instead of ten days in hospital following major open surgery with cooling and circulatory arrest, the patient can often go home by the end of the day. In children with congenital heart disease, narrowed vessels can be dilated then stented open, while abnormal vessels and holes in the heart can be closed using catheter-based technology. My talented colleague Neil Wilson was the UK’s leading light in this respect, but he had to emigrate to carry on.
And finally back to heart failure, the only fatal disease with a worse prognosis than cancer. Those suffering from it experience breathlessness on the slightest exertion, constant physical exhaustion, an inability to lie flat, a distended abdomen and legs, then complete dependence upon others. I am really proud of my efforts to develop an alternative to heart transplantation, but although I first implanted a permanent rotary blood pump in 2000, in 2018 these pumps have yet to be made available for the thousands of terminally ill patients under sixty-five years old in the UK who are not eligible for one of the handful of donor hearts. Even with this brutally ageist approach, less than 1 per cent of those who might benefit from a transplant ever receive a donor organ. How would you feel if your son or daughter were dying from heart failure? If the system cannot provide lifesaving technology, change the system.
I last vented my frustration on these issues at a conference at the Texas Heart Institute in September 2017. Although the meeting was called ‘Advances in Cardiovascular Medicine’, the convenors also wanted me to reflect on the seventy-year anniversary of socialised medicine. I declined to do that, as I had no desire to run down the NHS. But the Americans are not stupid – they are watching us carefully. When I witnessed practical demonstrations of their state-of-the-art technology I found myself reminded of another trip. I was in India, trying to reach the far side of a lake in Udaipur on a bakingly hot Rajasthan afternoon, but my taxi was held up by the untouchable sacred cows languishing in the road. On the horizon my destination shimmered into view, the opulent Lake Palace Hotel. The NHS is just such a sacred cow, and being in Houston again felt like looking across the waters of the lake in wonder at the opulence. How did we allow our beloved NHS to reach this situation?
In the 1990s my colleagues in Oxford and I each performed between 500 to 600 heart operations a year. We were a finely honed production line of cardiac surgery, with a great team and excellent results, and surgeons came from all across the world to observe what we had achieved. But it became politically incorrect to work that hard in the NHS and every opportunity was taken to criticise us. We were told we should be spending more time on surgical training, attending outreach clinics in far-flung general hospitals or participating in management meetings. Anything, in fact, apart from doing what we had been trained to do – something that others couldn’t do – which was operate on sick hearts. Political correctness and the system eventually won out. Now the six cardiac surgeons at my hospital each perform around 150 operations per year, fewer than 1,000 cases a year between all of them.
2 January 2018. As the seventieth anniversary of the NHS kicked off, the newspaper headlines repeated the same old stories: ‘14 ambulances queuing to discharge patients outside one hospital yesterday’; ‘Bed-blocked hospitals issue plea to relatives to take patients home’; ‘36-hour trolley wait for dementia patient’; ‘Pensioner dies from heart attack after 4-hour wait for an ambulance’; ‘24 NHS trusts on black alert since New Year’; ‘55,000 planned operations cancelled this month’.
And so it went on. A prominent politician described going off to Europe for brain cancer treatment that was unavailable on the NHS. A baby with a heart tumour must go to the Massachusetts General Hospital for surgery because no one can do it in the UK. So is our NHS the envy of the world? I really don’t think so. It has just become more financially adept, saving money before saving lives.
On 11 January, sixty-eight senior consultants representing half of the A&E departments in the country wrote to the prime minister, saying that ‘patients are dying in hospital corridors amid intolerable NHS conditions.’ This was no exaggeration – a toxic combination of rising demand, jam-packed hospitals and wholly inadequate social care had created a tidal wave that swamped our understaffed and under-resourced emergency departments. But better to wait for hours to be seen than not be seen at all. My friend Chris Bulstrode was Professor of Orthopaedics at Oxford University before he retired early to retrain as an emergency medicine doctor. He provided an interesting perspective on the role of A&E following the demise of family GPs:
It should really be called the department for patients no one else wants. If the police can’t cope with a mentally ill person or the family can’t cope with an elderly relative or a GP can’t solicit an urgent outpatient appointment, they just send them to the emergency department. I fear that if we don’t do something radical soon the system will collapse and bring the whole NHS down with it.
Many of us share his sentiments and fear that the politicians have misjudged the mood. The situation in early 2018 was chaotic and impossible to comprehend, unless you witnessed it for yourself. The prime minister responded by declaring that ‘the NHS is better funded than ever before’ and ‘better prepared for this winter than ever before’. All we hear from politicians is the same fantasy and deceit. Apparently, the suspension of elective operations that rendered many thousands of staff and
their facilities idle was all part of the seasonal ‘masterplan’. For the past ten years, these same senior figures presided over thousands of hospital bed closures, the disintegration of mental health and social services, and the damaging alienation of the medical and nursing professions. What’s more, the perpetual overseas recruitment drive that aims to poach trained staff from the developing world is a disgrace in itself.
Those who ask whether I would follow the same career path again usually appreciate the immeasurable time and effort put into the role and the impact this has had on any semblance of family life. When I trained, then during the early years of my consultant career, we worked in a more supportive environment alongside teams brimming with enthusiasm. Although I was repeatedly chastised for going off piste to save lives, it was usually with the wag of a finger and a grin, followed by the profound gratitude of a grateful family. These days it would be instant ‘gardening leave’ followed by a lawsuit – assuming that the patient hadn’t brought one first. So who takes these chances now?
Before answering, I sometimes relate the story of what happened to the surgical pioneer Charles Bailey after he’d achieved that first successful mitral valvotomy in the United States. For a while he was a hero, but before long he was subject to three lawsuits in Philadelphia. These outraged him, and, disillusioned by the increasingly litigious environment, he simply quit surgery, retrained in law and joined the lucrative medico-legal business himself.
Clearly, some cases of clinical negligence are justified. But I refer to it as a business because that is exactly what it is. Anyone who feels aggrieved about any aspect of their care can now formulate a complaint and mount a ‘no win, no fee’ fishing expedition at the NHS’s expense. So-called medical experts line up to siphon off any extra cash they can make. The lawyers get paid a fortune and sometimes the patient emerges intact. Often they don’t. They then spend the rest of their lives feeling aggrieved and depressed about something that they should simply have discussed with their surgeon. But from our perspective, the NHS, with its focus on death and misery, has encouraged doctor-bashing instead of putting a stop to it.
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