In one of my recent jobs, in 2016, I would arrive every morning on my ward to greet the most senior nurse, the ward sister, as she grappled with how she would manage with all the nurses missing from that day’s rota. She would weigh up whether she would be forced to close beds to patients or whether, with superhuman effort, her depleted band of nurses could manage to keep the whole ward open. In other words, in this zero-sum game, would it be patients or nurses who would suffer more today? Once, to my shock, this tough, uncomplaining, seemingly imperturbable colossus – the absolute heart and soul of our ward – broke down and started to cry. There is only so much fudging and firefighting even the most resilient of professionals can take.
‘You know what’s really done it?’ she said to me. ‘It’s the bloody Zumba. I mean, for Christ’s sake! Zumba!’
Periodically in the NHS, staff surveys reveal such abject depths of low morale among staff that Trusts are prodded to come up with ‘initiatives’ to lift our spirits. In 2015, Simon Stevens, the CEO of NHS England, announced various ways in which NHS organisations would be supported to help their staff ‘stay well’, including stress-busting classes in yoga and Zumba. Needless to say, my own Trust’s newly instigated lunchtime Zumba classes were predicated on the notion that we could stroll along for a relaxing dance during our notional ‘lunch hour’. Book groups and lunchtime walks were also on offer for all those doctors and nurses with an hour to spare in their day, equating to no one I knew in the hospital.
‘I mean, seriously, what sodding lunch hour?’ muttered the ward sister. I smiled in rueful agreement. Only managers and CEOs monumentally out of touch with what life is like on the ground could imagine that such activities, though desirable, were feasible. That they were offered nonetheless felt like an insult. We needed more staff, not a token gesture towards our ‘wellbeing’. Sod yoga, sod book groups and sod sodding Zumba.
Occasionally, I too am prone to tears. When working recently in a job designed for three doctors, one of the three of us went on an unforeseen six-month absence. Needless to say, the last thing my cash-strapped Trust – itself beholden to wildly unrealistic government ‘efficiency savings’ – wished to do was pay for a replacement locum doctor, so the two of us who remained were largely left to shoulder three doctors’ jobs, regardless of workload. It was tiring, miserable and sometimes risky.
Under these overstretched circumstances, our attention to detail was not, nor could be, up to the standard we expected of ourselves. Every day, my colleague and I were uncomfortably conscious of the fact that our patients were being shortchanged. And in a system driven by top-down cuts – the government expects the NHS to make £22 billion of ‘efficiency savings’ by 2020 – this is not unusual, it is the norm. Ministers of state declare their heartfelt commitment to patient safety, while being fully aware that our capacity to provide safe and compassionate care is painfully curtailed by lack of resources. Unable to influence the system that constrains us, we are nonetheless responsible for making that system work for our patients. The buck stops with us and, if anything goes wrong, you can guarantee it will be the individual doctor or nurse, not a politician, who is hung out to dry.
Jennifer Middleton’s voice suddenly hardened.
‘The way they treated him was disgusting. You wouldn’t treat an animal like that, let alone a human being.’
Briefly, her face twisted with hostility and the effort of forbidding her tears to spill. Nobody made a sound in the living room, which suddenly felt too small to contain her grief. Occasionally, even under glaring lights and with a camera rolling, a television interview ceases to feel like a production as the crew are held spellbound by the story. I had known that Jennifer’s testimony was likely to be harrowing. Prior to filming, I had made a deliberate calculation not to talk through her story with her in advance, recognising how powerful its rawness might be on camera. Her late husband observed us from the photos displayed on every table, windowsill and the mantelpiece. With all our oversized equipment squeezed inside, the tiny living room felt like a claustrophobic shrine. I asked Jennifer if she would like to stop, but an impatient flick of her wrist shut me up as she continued, in the grip of her story.
It was the late 1990s, perhaps a year or two into the first New Labour government, and I had been commissioned by Channel 4 to make a film about the state of the NHS. This was the era of the postcode lottery. The health service had been underfunded for years and an array of NHS treatments were being dispensed or denied according to where a patient lived. Stories of rationing by postcode abounded. I interviewed one woman with metastatic breast cancer who was fighting her local health authority to fund the drug that, had she lived on the opposite side of her street, she would have been eligible to receive for free. In North Wales, I met a man who had been waiting over eighteen months for lifesaving coronary artery surgery. He had already suffered two heart attacks and his arteries were so clogged with cholesterol that even walking a few steps caused him crippling chest pain. Three times he had arrived at his local hospital for surgery, only to be turned away when lack of beds caused his operation to be cancelled. Another heart attack, his cardiologist had told him, would kill him, yet the hospital’s Department of Surgery was in understaffed meltdown, cancelling operations daily. Only when this tough former steelworker began to cry did I appreciate how much fear was hidden behind his gruff exterior.
‘I’ve paid taxes all my life,’ he told me, ‘and now I’m probably going to die because there’s no money in the NHS for my operation. That’s not right. That can’t be right.’
The most shocking story of all concerned Jennifer Middleton’s husband, David. Earlier in the year, he had been diagnosed with bowel cancer. After surgery to remove his tumour, he faced months of chemotherapy, which would be strictly timetabled in four-weekly intervals until a scan would determine whether he remained cancer free.
‘He was quite positive at the start of the chemo,’ Jennifer told me. ‘We both were. Our attitude was that the cancer was gone and the chemo was going to keep it that way.’
But, in David’s hospital, rationing was biting in a different way. The oncology day unit he was due to attend for his chemotherapy was in the grip of a funding and staffing crisis. Almost every day, there were insufficient nurses and doctors to put up the drips and administer the drugs, meaning patients would arrive for treatment only to be sent back home again. It was every bit as brutal as it sounds.
‘The first time it happened,’ said Jennifer on camera, ‘we thought it must be a one-off. David was disappointed because he knew the chemo was what was going to kill the cancer, but, when the nurse explained they just didn’t have enough staff that day, we actually felt a bit sorry for them. But then it happened the next time, and the one after that. We realised it was just routine. Literally every time we arrived for David’s chemo, I would sit there panicking every time a nurse came round, thinking, Please don’t stop in front of us; don’t let it be him today; please don’t let it be him. Everyone was the same, just thinking, Please let me get my chemo; don’t let me be one of the ones who get sent home. It happened all the time. It was disgusting.’
A consultant oncologist who worked at the hospital, deeply distressed at what his patients were being forced to endure, agreed to speak to me off the record. The hospital had cut staff numbers, he explained, and, no matter what they did, the remaining doctors and nurses could not safely treat everybody.
‘You have to understand,’ he told me, ‘this isn’t just horrendous for the patients on the day, it is potentially affecting their chances of survival. If chemotherapy is delayed and not given according to schedule, there’s no guarantee it will be as effective. It’s entirely possible that patients are dying because of these delays.’
‘Why isn’t the number of patients being reduced to match the number of staff?’ I asked.
‘They just expect us to manage,’ he answered. ‘They don’t want to know about patients being sent away. They’re not the slightest bit intere
sted in us trying to tell them.’
Several months into his chemotherapy, after his cancer recurred and spread, causing increasingly distressing and undignified symptoms, David died.
‘I will never know if it could have been different,’ his wife told me. ‘Maybe he could have lived. They treated him like dirt and I will never forgive them.’
At the time, I was so intent on exposing the story – the hospital, I believed, must be publicly held to account – it never occurred to me to imagine these events from the nurses’ perspective. Nor, in retrospect, did I delve sufficiently deeply into whether external budget constraints were driving the understaffing in a manner over which the hospital had little control. Now, as a clinician myself, I find it hard not to flinch at the thought of having to work in such a traumatic environment. Imagine deliberately choosing to specialise in oncology. You have committed yourself to caring for people with the disease that is steeped in more taboo and fear than any other. But, each morning, you arrive at work to see the drawn faces of your patients packed into the waiting room, knowing – as they do – that some of them will be turned away. Maybe, like the patients, you make your own silent plea. Please don’t let ward sister pick me to have to tell them. Not today, not again. But, since you are pretty good at the communication side of things, you are sent out yet again to do the dirty. Now you feel the weight of every pair of eyes as they follow you around the room. The patients know exactly what it means if you alight in front of them. As you approach the first one to break the bad news, an elderly gentleman stripped to the bone by his cancer, his wife’s eyes start to fill with tears before you have uttered a word. They have been here so many times before.
‘I’m so sorry,’ you begin, as her sobs grow louder. ‘We don’t have enough staff today and I’m afraid we need to ask you to come back tomorrow when hopefully we’ll have more nurses.’
As they gather their coats to depart with the cancer untreated, as so many times before, you scour the room for the next name on your list, while privately burning with shame.
When something unacceptable happens to a patient in the NHS it is never, in my view, excusable. But it does not necessarily follow that the individuals whose acts or omissions caused cruelty or harm are to blame for their behaviour. Sometimes, in spite of their best efforts, doctors and nurses are as trapped within a failing system as the patients whose care is being compromised. And there is a unique form of anguish that stems from causing – or being unable to prevent – harm to your patient when all you ever wanted to do was heal. Jennifer Middleton’s anger towards the doctors and nurses who treated her husband ‘like dirt’ is entirely understandable. Yet, in a sense, those frontline staff were being treated with equal contempt by their own employer: forced to go out and face the failed patients, the reluctant human face of corporate disdain. Even the culpability of the hospital management is questionable. If a hospital’s budget, imposed from on high by an NHS funding settlement set according to political priorities, cannot safely meet the needs of its patients, then everyone from the CEO downwards may be embroiled, whether they like it or not, in the delivery of substandard care.
In today’s culture of increasing complicity and compromise – where the standard of care is too often curtailed by inadequate numbers of staff – it is small wonder our doctors and nurses are quitting the NHS. To them – demoralised, disempowered and permanently exhausted – the options are hardly attractive. Be disillusioned, be resentful, be cruel, be indifferent, be depressed, be unsafe, be a shadow of the doctor or nurse you once dreamed of, let down yourself, let down your patients, let go of treasured principles, be overwhelmed with stress, withdraw until you cease to give a damn, concede defeat, get out while you can. Like rats on the Titanic, staff are fleeing the NHS out of selfpreservation. You mourn the loss of every good colleague – hating to think of all that expertise wasted – yet a part of you silently envies them.
Mid Staffs, in short, may have been extreme, but the dynamics that led to it are everywhere in the NHS today. At any moment, in our hospitals, frontline staff are acutely aware that our wards may be only a whisker away from disaster. As a journalist-turned-doctor, I find that the most soul-destroying aspect of this knowledge is that the politicians who lead the NHS are every bit as cognisant of the knife edge upon which the NHS teeters, yet choose, for political expediency, to deny this. The former BBC Newsnight arch-inquisitor Jeremy Paxman is famously misquoted as adopting as his opening premise in interviews, ‘Why is this lying bastard lying to me?’ Increasingly, for NHS staff, there is only one word of difference between Paxman’s question and the one we ask of the political custodians of the NHS: ‘Why is this lying bastard lying about me?’ Clearly, such suspicion and hostility cannot be constructive. But, arguably, our cynicism is inevitable, born out of repeated exposure to the silver-tongued assurances fed to the public that the NHS is thriving, really thriving, when we all know it is anything but.
Typically, the dissonance between what we experience as NHS staff and the political denial of our own lived experiences surfaces most strikingly when the latest NHS performance statistics appear to reflect badly on the government’s stewardship of the health service. In early 2016, for example, in response to the worst ever monthly figures from NHS England since records began, the president of the Society for Acute Medicine, Dr Mark Holland, felt compelled to speak out. All over the country, tens of thousands of patients were waiting more than four hours to be seen in A&E, more than six weeks for supposedly urgent scans, and more than four hours on a trolley before being given a hospital bed. Given Jeremy Hunt’s apparent commitment to eliminating eleven thousand avoidable deaths by tackling the infamous ‘weekend effect’, Holland made the point that the daily overstretch within our hospitals was now so severe as to be itself potentially life-threatening:
A government which has the laudable aim of reducing hospital deaths by 11,000 [he told the Guardian] must recognise overcrowded hospitals that are full of sick patients in overstretched medical units will contribute to avoidable deaths. The ability to deliver acute medical care is reaching crisis point and any other crisis affecting our society would be acknowledged and addressed. The volume of patients and disease severity is so much that we are now functioning at the edge of what is possible.’15
But, in a manner reminiscent of the Mid Staffs board of governors, the Department of Health’s response to Holland’s fears about possible patient deaths was to tartly dismiss them, while accusing him of exaggerating the problems within the NHS:
‘This is patent nonsense,’ a departmental press spokesman stated, ‘and does a disservice to our hospitals and staff coping well under huge pressure.’10
Clearly, the intended audience of these glib denials is not the NHS staff who know better, but the voting public who must, at all costs, be mollified into thinking the health service is safe in government hands. Alas, their unintended consequence is to drive a subsidiary audience – the doctors and nurses fighting tooth and nail to stop the NHS going under – wild with frustration and impotence.
The official government response to Mid Staffs, published in 2014 and running to two volumes in length, emphatically vowed that finance would ‘never again be allowed to come before quality of care’.16 The irony was not lost on NHS staff that, later the same year, NHS England’s ‘Five Year Forward View’ was also published, estimating that, if NHS funding and demand continued at current levels, the health service would be £30 billion in debt by 2020.17 The government, in refusing to provide more than £8 billion of this shortfall, condemned the NHS to five years of the most draconian cost-cutting in its history. From my frontline perspective, it is glaringly obvious that, far from safety being placed above finance, the two are now locked in an unholy alliance in which risk increases as budgets are cut. The government has rigged the system. Staff and Trusts must excel in patient care while being denied the resources to enable them to do so.
Post-Mid Staffs, the official government mantra is candour.
According to Jeremy Hunt, embracing the lead of Sir Robert Francis, the brave voices of whistleblowing staff must never again be ignored. Yet, when staff speak out about the wisdom of imposing unachievable ‘efficiency savings’ while expecting standards and safety to be maintained, they are batted away with casual disdain. Mr Hunt, the doctor in me wants to scream, if £10 million worth of cuts can wreak havoc like Mid Staffs, how can you not be quaking in your ministerial shoes at the misery that 2 million times that amount is going to unleash upon the nation’s patients? How can your government possibly claim to care about patient safety?
In the end, trying to function as a conscientious doctor or nurse within a system governed by politicians who respond with selective deafness to your patient-safety concerns is arguably the most demoralising thing of all. Continuing to care – indeed, continuing full stop – is a tall order.
‘I’m done,’ my friend Hannah announced one day. ‘I can’t do this any more.’ We’d spent three years of medical school and two years as doctors together. During that time she had evolved from brilliant student into brilliant doctor, the kind you would pray your loved ones might be treated by in hospital. Latterly, marooned in a faraway district general hospital plagued by excessive numbers of doctor rota gaps, she was being forced by her Trust to work routinely the jobs of two doctors. No shrinking violet, she didn’t hold back.
‘I’ve told them a thousand times people are going to die,’ she told me. ‘I can’t keep people safe if I’m carrying two doctors’ bleeps and have double the number of patients to look after. But they don’t give a shit. Sometimes it’s like a war zone. They just don’t want to know.’
Your Life In My Hands--a Junior Doctor's Story Page 11