Broken NHS

The papers are screaming vociferously about the current crisis in the NHS. People are dying in the back of ambulances whilst stuck in a queue to get inside the hospital, and still more patients are dying on trolleys or chairs in corridors once they get in through the front doors. As a Guardian-reading lefty, I have subsequently been subject to a smorgasbord of sensationalist statistics over the last couple of months. For example, in September 5,025 patients waited for more than 12 hours to be admitted to hospital in England[1]. The figure for October was 7,059 people – the highest number on record apparently[4]! The target that 95% of patients attending A&E should be seen within four hours has also apparently gone out of the window, as they are currently only hitting an unseemly 62%[3]. Furthermore, an estimated 6,097 people in the UK died in 2020-2021 due to the roadblock of A&E delaying their care[4]. The Association of Ambulance Chief Executives also recently weighed in to give their perspective, and suggested that up to 160,000 patients in England are coming to harm because they are sat in ambulances outside of hospitals. Of those, approximately 12,000 patients could apparently have experienced severe harm as a result of this delay[2][4]. 

From a more surgical viewpoint, 13,061 elective were cancelled during October and November because of shortages of beds and staff[3]. Whilst on-call, I am being called to review patients who have been glumly sat in A&E for one, two, and in some cases, more days. This leads to some rather confused history taking overnight, when both surgeon and patient have utterly lost their grip on time, date and place! Also, by the time I see emergency patients, they have invariably waited so long that their symptoms have abated and they can go home, or they have become sick as dogs. Equally, both emergency and elective patients wait so long for their operations that procedures that should be straightforward are invariably longer, with more complications, worse outcomes and are associated with longer post-operative hospitals stays afterwards.

But why is this happening, and what can be done about it? The hospital’s higher ups are rightly pouring resources and attention onto A&E, who have been given the power to ride roughshod over the other departments in the hospital. A&E SHOs (Senior House Officers) are being paid £75/hour, compared to the £50/hour I get offered as a Registrar (a more senior grade) if I work an extra locum shift. Additionally, A&E now have the right to admit patients to a specialty of their choosing without much say or scope for discussion from that specialty. Furthermore, they now demand that patients are seen by a specialty within 30 minutes of referral, regardless of what else (such as being in the middle of an operation) that team may be engaged in. ‘Flow’ through A&E has become sacrosanct, and given the sobering statistics that I have just quoted above, I don’t really have much scope to whine about this!

But despite these measures, patients are still festering in ambulances and corridors, and operations are still being cancelled. The obvious question therefore, is what can be done about it? A question which undoubtedly has kept many NHS managers, a group of proficient and dedicated professionals I’m sure you’ll agree, working well beyond their usual 16:00 knocking off time.

Well, on being handed the reins of power the first thing that I would address is the daily scene of a room full very highly paid, skilled and experienced surgeons and anaesthetists, all of whom arrived in the hospital early before 07:00 and will leave late after 19:00, sat around looking disgruntled and drinking coffee for hours at a stretch. A day typically starts at 08:00 with a senior scrub nurse plodding through a clipboard of briefing points that they are obliged to cover before we can do any actual work. These days, this always includes a gloomy pronouncement detailing the staff deficit in recovery. Some gentle inquiries have led me to understand that these staff are now all working over the road in The Spire, where despite it being the cut throat world of Big Business Private Medicine, they are clearly better paid and better treated. Not having sufficient staff in recovery means that after an operation is finished, rather than sending for the next patient on the list, there is a long delay whilst the patient who has just had an operation occupies the theatre until staff become available in recovery. Meanwhile the surgeons go and drink more coffee and feel disgruntled.

Availability of staff in recovery is not be any means the only rate limiting step. Because the only porter on shift, likely being paid close to minimum wage, has to have a lunch break, the sick patients continue to sit on an overflowing ward getting sicker and sicker whilst the operating theatre remains empty waiting for him to polish off his sandwich. All positions of theatre staff are short, which for example means that in my hospital there is currently only capacity to run a single emergency theatre. This theatre has to be shared between General, Plastic, Thoracic, Vascular and Paediatric Surgery specialties. Operations out of hours are strictly limited to life and limb saving procedures. 

Similarly, I have consumed countless cups of coffee because a ward has inadvertently fed a patient or failed to get them into a gown or there has been some other lapse of basic organisation. Just this week for example there was a patient on the list who had previously been cancelled and brought back due to poor kidney function. Unfortunately, no-one had thought to re-check her renal function in the intervening time, so we all sat around for several hours waiting for a fresh set of blood results to come back from the lab. This scenario also happens most days with COVID swabs that were never taken. On Monday I received a bleep from the ward to say that a perfectly stable, well woman who should have gone home on Saturday morning following her operation on Friday was still unnecessarily occupying a bed because someone had forgotten to rota the junior doctor over the weekend to sign off her otherwise completed discharge summary! Meanwhile, frustrated surgeons sit in a small room drinking coffee and complaining that they could have got through eight cases by that time of day, if only they had a theatre to work in and a patient to operate on.

But the impact of poorly managed and staffed theatres goes well beyond feeding the caffeine addiction of surgeons and keeping them in hospital beyond their teatime. Every appendix I have removed in the last few months has been swimming in a pool of pus of its own making, and I have forgotten what a normal gallbladder looks like. Even the sickest patients sit on a ward taking up a bed for several days before they eventually make it into an operating room, where their operation takes several hours longer due to all of the pus that needs to be washed out. Post-operatively, patients who would have been expected to go home the same or next day, instead have to stay for several more days of recovery. Patients who would have needed several days in hospital following their operation instead require several days in the High Dependency Unit. Needless to say, some patients who would have survived, do not make it due to the lack of theatre capacity. Ultimately, as the papers have clocked on to recently, some patients don’t even make it as far as the front door! 

The much-maligned Jeremy Hunt, for all of his ill-intentions, weasley ways and unadulterated repugnance, unquestionably hit on some viable solutions. His calls for a NHS that functions 7 days a week, 24 hours a day and his stated aim to recruit 5,000 more GPs would indeed address the current crisis without the requirement to buy a single additional hospital bed. Unfortunately, he attempted to achieve these laudable ambitions by deeply offending NHS staff by calling them lazy and unprofessional, forcing a new contract on unwilling junior doctors that led to a cut in their pay and worse working conditions, and removing nursing as a potential career to untold bright young hopefuls by removing their study bursary. Staff left in their droves, and those who remain continue to feel burnt out, unappreciated and deeply disillusioned. The phrase that the NHS runs on goodwill is undoubtedly true, but the goodwill is quickly dissipating and the NHS culture that has taken decades to develop is only tenuous being kept alive by the remaining staff who are teetering on the edge of burn out, long-term sick leave and the realisation that an alternative career may be an attractive alternative.

A dent unquestionably needs to be made in the backlog of elective cases in order to stop patients presenting as an emergency, and surgical patients who do present as an emergency need to be operated on quickly and discharged to prevent the bed blocking that is crippling A&E and the ambulance service. In order to operate on patients however, in the short term a functioning operating theatre, and the staff to run it is required. This means recruiting and employing staff, and treating them with enough decency that they stay to work and build their skills in the long term. In the longer term there will need to be a new generation of competent, well trained surgeons as well!

Non-medic friends are disbelieving when I tell anecdotes illustrating how much blatant bullying and sexism still exists day to day in the NHS. They are surprised at how relatively low my take-home pay is compared to their expectation, and how I am routinely expected to work and study well beyond the hours for which I am paid. Female surgical trainees are told that they should think about switching careers to become a GP or at the very least a breast surgeon, because they will undoubtedly end up pregnant and ruining their careers anyway. Male surgical trainees who suggest that they may like to play a part in the raising of their children, or pursue interests outside of surgery are openly mocked. Lip service is officially given to less than full time working, maternity/paternity leave, work-life balance, sick leave, personal development and whistle blowing, but the reality on the ground is that any trainee who shows an inclination towards these concepts is swiftly and brutally ostracized. These are just a few examples of the things that I have personally experienced are wearing thin with surgeons in training, and I have little doubt that colleagues of all ilks have more profound and numerous challenges and grievances.

What ideas do you have to save the NHS and the suffering of the patients it serves? How bad is your caffeine habit as a result of delays in theatre? Do you have any examples of how your goodwill is being exhausted? What measures, such as availability of crèches, gym passes, hot food, flexible working, more respect, better organisation, a more considerate rota or some study leave would make your job or training more tolerable in the long term?

1. https://www.theguardian.com/society/2021/nov/07/long-waits-at-ae-becoming-normal-warn-doctors-groups
2. https://www.theguardian.com/society/2021/nov/14/patients-are-dying-from-being-stuck-in-ambulances-outside-ae-report
3. https://www.theguardian.com/society/2021/dec/07/doctors-report-13000-cancelled-operations-in-uk-over-two-months
4. https://www.theguardian.com/society/2021/nov/18/a-and-e-overcrowding-uk-deaths-year-doctors-treatment