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Has strong become the respectable face of skinny for young women?

A generation of Instagram stars and personal trainers are challenging old-fashioned notions of femininity, replacing images of thinness or fecundity with brute strength. Whether this is healthy is another matter

Young woman with a six-pack


Cult of muscle … young women increasingly aim for a ‘ripped’ physique. Photograph: Getty Images

”Imagine you’re a Page 3 girl and they’re going for the butt shot,” says Chloe Madeley, helpfully.

It is a grey January morning in a gym near Leicester and Madeley, a former TV presenter turned personal trainer and Instagram phenomenon – and the daughter of daytime telly pairing Richard Madeley and Judy Finnegan – is trying gamely to teach me the correct posture for squats with weights. Bum stuck out, shoulders pinned back, move from the hips. None of this is dignified. It is also killing my hamstrings, although there is only a wimpy 5kg weight on the bar I am lifting, compared with the 60kg she usually manages.

But Madeley is kind, funny and ridiculously encouraging. Half an hour of pumping iron with her leaves me in an unexpectedly good mood. My head feels clearer, lighter. And there is something very appealing about the insouciance with which she strolls through the weights area, past all the men in sleeveless Ts doing press-ups.

Once upon a time, gyms divided rigidly by gender: treadmills and pilates classes for the ladies; grunting men lifting weights by the mirror. Women shied away from dumbbells for fear of getting bulky or embarrassing themselves. Men’s fitness magazines featured rippled torsos and articles about protein shakes, while the female versions were all bikini bodies and how to be your happiest self.

Well, not any more. “Shed kilos, build muscle, strip fat,” screams the cover of January’s Women’s Health magazine, alongside features on getting a “strong mind” and “killer abs”. Inside, editor Claire Sanderson describes proudly how she hip-thrusted 130kg (a move that involves lying down with a barbell across your middle and pushing your hips skywards) as part of a January transformation feature.

Rival magazine Women’s Fitness, meanwhile, offers “21 days to strong”, a diet and workout plan that will ensure you can shift furniture upstairs on your own. Even Davina McCall now boasts the jutting abs and sharply carved physique of a bodybuilder, prompting the Sun to ask whether the 50-year-old has “gone too far” for her latest fitness video.

Gaby Hinsliff works a pair of dumbbells under Chloe Madeley’s instruction


Gaby Hinsliff works a pair of dumbbells under Chloe Madeley’s instruction. Photograph: Fabio de Paola for the Guardian

Yet she is only reflecting a cult of muscle that is all the rage on Instagram, led by a new generation of so-called fitness influencers such as Madeley, the 26-year-old Australian blogger Kayla Itsines, the 29-year-old American Massy Arias (famous not only for her abs, but for the speed with which they snapped back after the birth of her baby last year) and Alice Liveing, the British personal trainer who coached Sanderson for her hip-thrusting challenge.

Their feeds are a mixture of filmed workout routines, zippy motivational messages and photographs of their dogs and their breakfasts. Itsines in particular is hot on sharing “before” and “after” pictures of ordinary women who have followed her method. But the best adverts for their burgeoning business empires are invariably their own bodies. These women are built like athletes, not scrawny models: slim, but with biceps, calves and formidable six-packs (plus, in the case of 24-year-old US fitness guru Jen Selter, a famously Kardashian-esque behind). What is most striking, though, is how influential they have become in young women’s lives.

Middle-aged readers are more likely to be familiar with Madeley’s parents than with the 30-year-old personal trainer herself, yet her diet and fitness book The 4-Week Body Blitz has shot into the January bestseller charts. You may never have heard of Liveing, but at 24 she has three bestselling books, a clothing line at Primark and numerous corporate partnerships to her name.

These women’s brands were built independently of mainstream media, on Instagram and YouTube, where moody shots of perfect abs combine with ass-kicking, vaguely feminist sentiments. If that sounds superficial, their “strong in mind and body” mantra perhaps resonates deeper with anxiety-prone millennials, who increasingly use exercise to manage their mental health.

Five years ago, Madeley was working in TV, worrying that she lacked a passion in life, when her then-boyfriend introduced her to weightlifting. At the time, she says, she suffered badly from anxiety and was experiencing “panic attack after panic attack”. But lifting made her feel capable and strong.

“I would say weightlifting – this methodical act that results in physical and mental feelings of strength, capability, accomplishment – has absolutely had a massive ripple effect on my life. I feel like if I got into a sticky situation I could handle it, I can do it, it’s fine,” she says.

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The ‘ripped’ look – where every muscle stands out – involves stripping away almost all your body fat

“If I do start to get anxious, I have an outlet, a form of CBT, something I can do to focus all my energy.” She compares lifting to cooking, another soothingly repetitive process that many find relaxing because the rhythm – all that chopping and stirring – takes over.

There is something unexpectedly touching about this, just as there is something thrilling about shattering the myth that strength and power are not feminine. But have we really learned to value bodies for what they can do, not merely how they look? Is strong becoming the respectable face of skinny?

Vicky McCann’s fitness career began at the age of 13, when she got a job tidying the changing rooms of a local gym. She moved into teaching aerobics, then lifting weights. In 1990, she entered her first bodybuilding competition. Since then, she has twice been world champion in the so-called natural branch of the sport, which strictly forbids the use of steroids, male hormones and other artificial enhancements, including cosmetic surgery. She also runs her own gym in Perth, Scotland.

McCann, who at 48 still competes, says more women are entering the sport, but primarily via “bikini-body” competitions, a kind of bodybuilding-lite where contestants must be extremely toned, but much less musclebound than in traditional contests.

“It’s a halfway house, almost a cross between a fitness pageant and a beauty pageant,” says McCann, who prefers the more heavyweight version. “A lot of these women, I don’t see them as muscular – I’d almost describe it as a wedding day. They get a chance to wear a fancy bikini and have their hair and nails done and look pretty.” Hopefully, she says, some will be inspired nonetheless to move into bodybuilding proper.

Massy Arias models her clothing line for US retailer Target.


Massy Arias models her clothing line for US retailer Target. Photograph: Target

However, even this much muscle on a woman can be controversial. The actor and Strictly Come Dancing contestant Gemma Atkinson, who owes her strong physique to boxing and weights, endured sniping from some Strictly fans last year about being supposedly “too masculine” for dancing. Yet she was one of Women’s Health’s most popular cover stars, reflecting changing aspirations among younger women.

“We have a very different ideal of what we aspire to be. That’s shifted, even looking at things like covers of magazines and female role models that have risen up the ranks,” says Liveing. “Serena Williams – she wouldn’t have been a typical aspirational physique before, but she’s physically strong, she’s amazing, she’s achieved so much.”

Liveing got into weights while studying musical theatre, after her dance teachers told her she wasn’t strong enough. She says the perception that lifting was not for women only made it more appealing. “I love it when my clients are shocked by their own strength, because we haven’t been allowed to believe we were able to do that until now,” she says. “It’s breaking the taboos of being as strong, if not stronger, than men.”

She argues that the biggest case for women lifting weights, or working against their bodyweight in “resistance” exercises such as press-ups, lies in the health benefits. It can help maintain bone density, which is important for avoiding osteoporosis; it can help prevent muscle wastage as women age, potentially allowing them to stay active and independent for longer. (The actor Sheila Hancock recently announced that she had taken up weights, aged 84, after realising that she was struggling to lift hand luggage into plane lockers.)

Pumping iron can also aid weight loss. The greater a woman’s muscle mass, the higher her metabolic rate and the more calories she should burn, even at rest. According to Sanderson, this is what is driving many women away from burning fat through running or cardio and towards building muscle. “I was a complete cardio queen 10 years ago, doing triathlons and spinning classes like my life depended on it and running marathons,” she says. “Now I don’t do much of that at all and I’m probably in the best shape of my life.”

But there is a crucial difference between being in shape and the very lean – “shredded” – look gaining currency. Aiming to be strong, capable and powerful is one thing. Wanting to look it takes us into murkier waters. Women can certainly build muscle by exercising, albeit more slowly than men, given their lower testosterone levels. But the “ripped” look – seemingly borrowed from bodybuilding, where every muscle stands out – involves stripping away the body fat that would otherwise blur that definition. That is where diet comes in.

Sanderson says it is important to be honest about how much effort goes into looking like the Instagram poster girls and how attainable it is for mere mortals. “It’s their job to look that way – and all power to them. They live and breathe it. But, in my experience, in order to look that lean, that cut, you have to follow a really strict nutritional plan, which not many people would want to do.”

Judging by the meal snapshots these women constantly upload, that means a high-protein, fairly low-carb diet involving a lot of eggs, sweet potatoes, kale and chickpeas. Cutting out alcohol or sugar is relatively common, as is training five or six days a week. They may look like girls next door, but these women have the iron discipline of professional athletes.

Jen Selter is one of the Instagram influencers to have built her brand outside of the mainstream media
Jen Selter is one of the Instagram influencers to have built her brand outside of the mainstream media. Photograph: jenselter/Instagram

“I eat all day long, I have a very varied and balanced and healthy diet, but it’s very structured and disciplined,” says Madeley, who manages by giving herself a break from the regime every few weeks. “You get three weeks of not drinking at parties, not sharing the birthday cake at the office and you think: ‘At some point, I’m going to have to give myself at least a day off or I’m going to get really fed up.’”

McCann eats 2,000 calories a day in the run-up to a competition, when she is focused on shedding fat and revealing muscle, but her diet will be heavily restricted and precision-calculated. “I eat very bland when I’m dieting. I count out my food, weigh and measure it. But I don’t crash diet, I do it over a long period of time.” She worries, however, about newcomers to bikini-body contests relying on very low-carb plans to get in shape fast.

Eating this strictly is not necessarily disordered in itself, but rigid diets can easily be taken to extremes by vulnerable people. A recent spate of stories about anorexic people crediting bodybuilding for their recovery set distant alarm bells ringing. It is easy to see how such a regime might satisfy a need for control.

There is anecdotal evidence of people with eating disorders channeling their fixation into exercise, says Liam Preston, head of the Be Real body-image campaign, launched by a group of charities following a parliamentary report on the crisis in young people’s body confidence. “They can get obsessive about going to the gym, rather than obsessing about eating. But that’s a mental health problem, so I don’t know that exercise solves it.”

The broader problem he identifies, however, is people chasing fashions in body shape – strong or skinny – regardless of whether they are healthy. “We see so many crazes online and you’ll find people who go from one to another, trying everything. It’s about trying to build resilience, a feeling that their body is fine the way it is.”

The YMCA-led campaign is now working with schools to boost younger children’s body confidence, in the hope that this will make them less likely to seek solutions for imaginary faults in their teens. “We always try to go with the message that being happy and healthy is more important than anything else; it’s not about the way you look. If you want to go to the gym, that’s great, but are you doing it for the right reasons?”

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Aiming to be strong, capable and powerful is one thing. Wanting to look it takes us into murkier waters

In fairness, Instagram’s fitness queens seem intensely aware of their social responsibilities. They constantly repeat that there is not one “right” way to look, that followers should be kind to themselves, that it is all about balance.

“It’s really important, I think, to impress upon your audience the importance of not using social media as a way of comparing us – use it as a tool of information, but don’t sit there letting it make you feel bad about yourself,” says Liveing. She was originally known as Clean Eating Alice, but reverted to her name recently after becoming worried about clean eating’s association with faddy, exclusionary diets. Food matters in training, she says, but “not excessively so”.

Madeley is cheerfully upfront about putting on five pounds over Christmas. She reminds followers regularly that the aspirational images they see all over social media are invariably of fitness models at their competitive peak. (A common tactic is training hard for a photoshoot, then trickling out the resulting pictures over several weeks of posts; that way the public persona stays eternally ripped, even if the model does not.)

Sanderson, meanwhile, insists it is unfair and outdated to accuse magazines such as hers of potentially fuelling eating disorders. “We look at wellness in a much more holistic way these days – there’s much more awareness of mental health and nutrition. We don’t have a certain aesthetic – I’m almost 40, I’m curvy, I’ve got two kids and I run the biggest fitness magazine in the country.” In this month’s editorial, she stresses that, after a few Christmas parties, her abs are not looking like they did in the issue’s photoshoot – and that is just fine.

But however seriously individuals take their responsibilities, the cumulative effect of scrolling through endless pictures of washboard stomachs can be powerful. While writing this article, I created an Instagram account following only fitness influencers, clean-eating bloggers and the odd celebrity suggested by the site’s algorithms once it had detected me behaving like a millennial gym bunny.

My time on fitness Instagram was, admittedly, nicer than my usual social media experience (arguing about Brexit on Twitter). But when all you see all day on your phone is amazing bodies, it is surprisingly easy to get sucked in. On day one, I rolled my eyes at all the posts about sautéed kale. After a week, I had been running, cooked a lot of chickpeas and wondered about the hand weights that have spent the past 15 years in the loft.

Arguably, that is no bad thing, given that the biggest threat to the average Briton’s health is failing to get off the sofa. Many of us need a gentle prod. But the risk of promoting any one shape as ideal is that those whose bodies do not conform naturally can easily be left feeling inadequate. “Thank God we’re getting rid of the stigma that women shouldn’t have muscles, that if a woman does she looks like a man. I’m so happy we’re breaking down those barriers,” says Madeley. “But why do we need to bash other people in order to get there?”

White House doctor says Trump will remain ‘fit for duty’ for years

Physician says president has benefited from ‘a lifetime of abstinence from tobacco and alcohol’ though he could stand to exercise more

He does not exercise, has a long history of eating McDonald’s and drinking Diet Coke, and is just short of obese. Yet Donald Trump’s health is “excellent”, his mind is “sharp” and he only needs four or five hours’ sleep a night, the presidential physician said on Tuesday.

How can that be? “Some people have just great genes,” a navy doctor, Ronny Jackson, told reporters at the White House. “I told the president that if he had a healthier diet over the last 20 years, he might live to be 200 years old … But I would say the answer to your question is he has incredibly good genes and it’s just the way God made him.”

It is the kind of language that the US president will appreciate. But it drained the room like air escaping a crumpled balloon. Some in the media had come to bury Caesar, not to praise him, only to find the good doctor swatting away every sceptical question with a sunny optimism that would have been mocked as hyperbole if it had come from Trump’s own mouth.

“He is fit for duty,” Jackson insisted, disappointing the president’s critics, then rubbing salt in their wounds. “I think he will remain fit for duty for the remainder of this term and even for the remainder of another term if he’s elected.”

There was also news that will come as little surprise to anyone who follows Trump’s Twitter feed. “He doesn’t sleep much,” Jackson said, estimating that Trump got four to five hours a night. “He’s probably been that way his whole life. That’s probably been one of the reasons he’s been successful.”

It was an insight that evoked memories of the former British prime minister Margaret Thatcher, who got by on four hours a night.

The annual presidential physical exam, carried out last Friday, took about four hours and involved 12 medical consultants. Jackson, promising that he would hold nothing back, began with a summary of the findings: Trump is 6ft 3in tall and weighs 239lb. His body mass index (BMI) of 29.9 puts him in the category of being overweight for his height. A BMI of 30 or higher is considered obese.

His blood pressure was 122 over 74, which is normal, and his total cholesterol was 223, which is higher than recommended. He has a resting heart rate of 68 beats per minute, with regular rhythm and no abnormal sounds.

Jackson said he would increase Trump’s current low dose of the statin drug Crestor in an effort to get his so-called “bad” cholesterol, or LDL level, below 120; it is presently 143. Trump is also taking the medications aspirin, Propecia – to prevent male pattern hair loss – and a multivitamin.

“The president’s overall health is excellent,” Jackson said. “He had great findings across the board but his cardiac health stood out. Hands down he is in the excellent range … He continues to enjoy the significant long-term cardiac and overall health benefits that come from a lifetime of abstinence from tobacco and alcohol.”

And yet Trump, 71, the oldest person ever elected to the presidency, is infamous for long decades of dining on burgers and doing little to keep fit apart from regular rounds of golf. Jackson admitted: “I would say right now, on a day to day basis, he doesn’t have a dedicated, defined exercise programme, so that’s what I’m working on.”

But even nothing has its upside: “The good part is we can build on that prettily easily.” There were chortles in the room.

The presidential physician said of Donald Trump’s health: ‘He doesn’t sleep much. That’s probably been one of the reasons he’s been successful.’


The presidential physician said of Donald Trump’s health: ‘He doesn’t sleep much. That’s probably been one of the reasons he’s been successful.’ Photograph: Xinhua/Rex/Shutterstock

Jackson found yet more grounds to be positive: travelling overseas last year, on 14 or 16-hour days, the staff were exhausted but “the president had more stamina and more energy that just about anybody there”.

But the doctor will work with the first lady, Melania Trump, to develop an aerobic exercise routine for the president. “The president has acknowledged that he’d be healthier if he lost a few pounds,” he said.

As for Trump’s diet, that too has improved, according to Jackson. “He’s gone to the White House now: he’s eating what the chefs are cooking for him. They’re cooking a healthier diet for him now and we’re going to continue to work on them, make that even healthier.”

The check-up also included a cognitive assessment at Trump’s own request, in part as an attempt to combat a recent spate of stories raising concerns about his mental health following the publication of Michael Wolff’s book Fire and Fury. At the time, Trump tweeted that he was a “stable genius”.

The president did “exceedingly well”, scoring 30 out of 30 on the Montreal Cognitive Assessment which screens for illnesses such as Alzheimer’s and dementia. Jackson added: “He’s very sharp. He’s very articulate when he speaks to me and I’ve never known him to repeat himself around me. He says what he’s got to say. He speaks his mind. I’ve found no reason whatsoever to think the president has any issues whatsoever with his thought process.”

And although Trump is facing a nuclear showdown with North Korea, criticism from the media and record low approval ratings, it seems he never gets stressed. “I’ve never seen the president stressed out about too much … He has a very unique ability to just get up in the morning and reset.”

There were questions about TV, Twitter and drugs, but still Jackson failed to throw the reporters a bone during the hour long session. Jackson said Trump had told the White House press secretary, Sarah Sanders, to allow the doctor to remain at the podium and not leave any questions unanswered.

Mexico: 500 years later, scientists discover what killed the Aztecs

Within five years, 15 million people – 80% of the population – were wiped out in an epidemic named ‘cocoliztli’, meaning pestilence

Scientists identified a typhoid-like ‘enteric fever’ for which they found DNA evidence on the teeth of long-dead victims.


Scientists identified a typhoid-like ‘enteric fever’ for which they found DNA evidence on the teeth of long-dead victims. Photograph: FabioIm/Getty Images

In 1545 disaster struck Mexico’s Aztec nation when people started coming down with high fevers, headaches and bleeding from the eyes, mouth and nose. Death generally followed in three or four days.

Within five years as many as 15 million people – an estimated 80% of the population – were wiped out in an epidemic the locals named “cocoliztli”. The word means pestilence in the Aztec Nahuatl language. Its cause, however, has been in questioned for nearly 500 years.

On Monday scientists swept aside smallpox, measles, mumps, and influenza as likely suspects, identifying a typhoid-like “enteric fever” for which they found DNA evidence on the teeth of long-dead victims.

“The 1545-50 cocoliztli was one of many epidemics to affect Mexico after the arrival of Europeans, but was specifically the second of three epidemics that were most devastating and led to the largest number of human losses,” said Ashild Vagene of the University of Tuebingen in Germany.

“The cause of this epidemic has been debated for over a century by historians and now we are able to provide direct evidence through the use of ancient DNA to contribute to a longstanding historical question.”

Vagene co-authored a study published in the science journal Nature Ecology and Evolution.

The outbreak is considered one of the deadliest epidemics in human history, approaching the Black Death bubonic plague that killed 25 million people in western Europe in the 14th century – about half the regional population.

European colonisers spread disease as they ventured into the new world, bringing germs local populations had never encountered and lacked immunity against.

The 1545 cocoliztli pestilence in what is today Mexico and part of Guatemala came just two decades after a smallpox epidemic killed an estimated 5-8 million people in the immediate wake of the Spanish arrival.

A second outbreak from 1576 to 1578 killed half the remaining population.

“In the cities and large towns, big ditches were dug, and from morning to sunset the priests did nothing else but carry the dead bodies and throw them into the ditches,” is how Franciscan historian Fray Juan de Torquemada is cited as chronicling the period.

Even at the time, physicians said the symptoms did not match those of better-known diseases such as measles and malaria.

Scientists now say they have probably unmasked the culprit. Analysing DNA extracted from 29 skeletons buried in a cocoliztli cemetery, they found traces of the salmonella enterica bacterium, of the Paratyphi C variety.

It is known to cause enteric fever, of which typhoid is an example. The Mexican subtype rarely causes human infection today.

Many salmonella strains spread via infected food or water, and may have travelled to Mexico with domesticated animals brought by the Spanish, the research team said.

Salmonella enterica is known to have been present in Europe in the middle ages.

“We tested for all bacterial pathogens and DNA viruses for which genomic data is available,” and salmonella enterica was the only germ detected, said co-author Alexander Herbig, also from Tuebingen University.

It is possible, however, that some pathogens were either undetectable or completely unknown.“We cannot say with certainty that S enterica was the cause of the cocoliztli epidemic,” said team member Kirsten Bos. “We do believe that it should be considered a strong candidate.”

Doctors and nurses: ‘When May and Hunt tell the public the NHS is not in crisis, that is a lie’

An 81-year-old woman with chest pains dies while waiting three hours and 45 minutes for an ambulance. Patients are photographed lying on the floor of an A&E unit that has run out of beds, trolleys and chairs. Memos from inside another hospital reveal that its doctors “have been on their knees with workload pressure”. Over six weeks more than 90,000 emergency patients get stuck in the back of an ambulance outside a hospital, waiting to be transferred into the A&E.

These events, which have all happened in England since late November, graphically illustrate the winter crisis tightening its grip on the National Health Service in recent weeks. Worrying, but at the same time predictable. Similar things happen every winter. Flu, bad weather and people struggling to breathe is a recurringly risky combination.

But what is different this year is the intensity of the strain on the NHS. Official NHS figures show that record numbers of patients have been directly affected – by delays in their care, by being diverted to a different A&E than that originally planned, or having their operation cancelled, for example. The proportion of A&E arrivals treated within the supposed four-hour maximum has hit a record low. Doctors have voiced their most acute concern ever about the risk of such conditions leading to poor care. A letter to Theresa May signed by 68 A&E doctors complained that patients have died prematurely after prolonged spells spent in hospital corridors.

As pressures have intensified the prime minister has stuck with impressive doggedness, though increasing implausibility, to her script, on television and when answering questions in parliament. The NHS is the best prepared it has ever been for winter. Health services always come under extra strain at this time of year. We are putting record sums into the NHS.

She did feel obliged to apologise to patients affected by the NHS’s unprecedented cancellation of tens of thousands of operations in December and January for the pain, worry and inconvenience that would mean for them. But then she told the BBC’s Andrew Marr Show last Sunday that that unexpected move was all “part of the plan” to help the NHS withstand a demanding winter.

But a crisis? Definitely not, she insisted.

If anything, she suggested, the NHS itself was part of the problem, for not doing enough to keep people well so that they don’t need hospital care in the first place.

Jeremy Hunt, her health secretary, loyally conveyed the same message – at least until 3 January. Then, in one of the growing number of tweets he may quickly regret posting, he subconsciously gave the game away by asking, with reference to Tony Blair: “Does he not remember his own regular NHS winter crises?”

The interviews that follow capture some of all this chaos and also NHS staff’s feelings – frustration, powerlessness, despair, sadness, rage – about the inability of the teams they are part of, and of the visibly underfunded, chronically under-staffed service they proudly work for, to respond adequately to all those needing their help. Denis Campbell, health policy editor

Dr Adrian Harrop

Junior doctor, A&E, Scarborough hospital

Dr Adrian Harrop photographed in SCarborough


Adrian Harrop: ‘We are not managing.’ Photograph: Gary Calton for the Observer

I’m a relatively junior doctor, but I’ve sampled emergency care in many different parts of the UK, and I’ve seen five winters in A&E departments. The staff in Scarborough are among the most hardworking, kind-hearted people I’ve ever had the pleasure of working with, from the executive board and the consultants to all my fellow junior doctors, nurses, healthcare assistants. This crisis has nothing to do with the shortcomings of frontline staff.

However, when the hospital is placed under the degree of pressure it’s been experiencing in the past few days, it becomes unsafe. And the services we’re able to provide are simply inadequate for the needs of the population.

Typically, a bay within a hospital ward would have three beds down each side. This week, we’ve activated the maximum-capacity protocol, which means we’ve put a bed in the middle of each bay. But even after that, when we’ve got as many staff working as possible, yet again the department is completely full. Every single cubicle is filled with a patient on a trolley, every single part of the corridor has patients down it. We have to have what’s called a “corridor nurse”. Then the assessment area of A&E is full of patients on trolleys, and the resuscitation area – which has three bays for the sickest of the sick patients, people with major traumatic injuries – that room is filled with patients too. I’ve then got a queue of paramedics with patients on stretchers going all the way down the corridor to the main entrance of the hospital. The department is entirely full: I’ve not got a single space to take another acutely unwell patient.

The number of ambulances covering this area of Yorkshire is frighteningly low, particularly at night, and they have to spend half their time in a queue in our A&E. I’ve heard their radios going off, and the person on the other end of the line is pleading with all the crews saying: “Please, is there anybody who can respond to this call?”

Last week, we had a patient who dialled 999 twice over a period of four hours stating in clear terms: “I can’t breathe.” An ambulance didn’t arrive, so their family had to come and drive them up to the hospital, and they collapsed on to the front desk of our A&E reception area, unable to breathe. They had to be rushed immediately to an operating theatre to be intubated to keep their airway open. The patient’s windpipe had narrowed to the size of a pinprick, and if that patient had arrived at hospital 10 minutes later, he would have been dead. That is a reflection of how critically low the capacity within the system is.

This crisis is not a bolt out of the blue – all year we’ve been expecting it. Acute respiratory disorders such as pneumonia, COPD [chronic obstructive pulmonary disease] and asthma flare up in winter. Influenza is also an enormous problem – genuine, diagnosed influenza is a very, very serious illness. On top of that, each year we’re seeing an ever-increasing number of what I’d call the frail elderly: people of advanced age, who have multiple co-morbidities and are dependent on carers. Their problems are complicated by increasing rates of dementia.


The government either needs to get these resources in place, or admit that it wants this health service to fail

Last year was slightly worse than 2016, which was slightly worse than the year before, and so on. The difference in 2017, I think, is that things reached a tipping point. The demands on our service outstrip our ability to provide care.

The government seems to love publishing figures saying we’re spending more on the NHS than ever before, but that’s a meaningless statement. Every year, the total number of patients requiring admission to hospital has gone up, the total number of beds has gone down, and, year on year on year, the total amount of money that we’ve had available to spend – in real terms – has gone down.

This conversation can become personal and party-political, and it’s important to remember that the current problems within the health service are not solely the responsibility of the Conservative party. We’ve been mismanaging the health service for an awfully long time. But the facts speak for themselves: the amount of money available per person is significantly lower than it was last year, or the year before, or the year before that. And I would place the blame for that squarely at the feet of the Tory government. They have opted to spend, effectively, less and less as a proportion of our GDP, and less per capita, than in previous years. Among healthcare professionals, this is almost a universally held view.

I don’t want to make this a personal attack on Jeremy Hunt. In fact, during the cabinet reshuffle, I was really hoping that Jeremy Hunt wouldn’t get taken off health, because then everyone might think “Hallelujah! Problem solved!” I’m glad he hasn’t gone, actually, because it allows us to continue this conversation. When May and Hunt tell the public the NHS is not in a crisis, that is a lie. It’s an ongoing crisis, and it can’t be allowed to continue any longer.

The thing that got to me today was a patient who came in with an acute, sudden-onset heart problem. They’d thought about calling an ambulance, but because of everything they’d seen in the media, they didn’t want to come to the hospital and bother anybody. Eventually, they drove themselves in and sat in the waiting room for over two hours. This person was in tears saying, “Doctor, I’m so sorry, I didn’t want to cause a nuisance.” I said to them – and I was nearly crying myself – “You are what I’m here for. Please don’t ever be made to feel like you’re inconveniencing me.” The fact that people with severe, emergency medical problems are feeling that they have to apologise to me – that’s sickening. We should be welcoming these people into our hospital with open arms, saying: “This is what you paid your taxes for: so that when you’re 80, and you need us, you can come to hospital.” We want to give people the treatment they need and deserve, and we can’t. We can’t because we haven’t got the resources to do that now. And if that is not a crisis, then I dread to think what a crisis looks like.

Up until now, we’ve just about managed, we’ve been able to claw our resources together. But we’re not managing now. The government either needs to get these resources in place, or admit that it wants this health service to fail. If we’ve got enough money to pay off the DUP, to pay for Brexit, to pay for Trident, we’ve got enough money to make sure that an 80-year-old woman with pneumonia has got a warm hospital bed to spend the night in. Interview by Kit Buchan

Molly Case

Cardiac nurse, King’s College hospital, London

Molly Case 29 Nurse at Kings College in London 09/01/18 Photographer ; Sonja Horsman


Molly Case, at Kings College in London: ‘My job is a pleasure and a joy. It’s only difficult because of starved resources.’ Photograph: Sonja Horsman for the Observer

I work on a high dependency unit: our patients might require organ support, invasive monitoring, or immediate care after surgery. These are big, major operations, life-changing and life-saving. We have a lot of people rushed in by air ambulance, people who have suffered a heart attack, and also people from the area who have been stabbed. On a normal day I wake up at 5.30am and it’s a 12-hour shift; night shifts start at 7.30pm. It’s an absolutely fantastic job. I’m hugely passionate about cardiac nursing – it’s amazing what the heart can do, but when it goes wrong it’s frightening, and everything can deteriorate quite quickly.

Being on a specialist unit in some way we’re shielded from the winter crisis, but something that has had a knock-on effect is beds. We’re running at 98% capacity and you can’t necessarily hold a bed free in case a person comes in with a heart attack. But if somebody does come in, they will need a level two bed, with all the equipment. What that means for our unit is that sometimes patients are too quickly identified as stable enough to be stepped down to the ward or discharged too early, and that puts them at risk.

Something that nurses live by is Florence Nightingale’s words: “The very first requirement in a hospital is that it should do the sick no harm.” And when you’re stepping down people inappropriately, through no malice or ill intent, it feels like you’re putting somebody at risk. If there were more beds it just wouldn’t be a problem. This isn’t me being self-deprecating, but our jobs are not hard – they are a pleasure and a joy. They are only difficult because of the starved resources.


It’s a vicious cycle: if we can’t get patients home because there’s no social care then nothing will get better

The most difficult moment for me this winter was when my dad, who’s 80, broke his hip, and I saw first-hand what A&E was looking like in the midst of everything. So many elements of the winter crisis affected him. He lay on the floor for hours at home after calling an ambulance, which breaks my heart. When he got to A&E he stayed there all night: there simply was no bed to go to and his pain was absolutely immense. When he did get his hip fixed there wasn’t a level two bed for him to go to after the operation, where he could have been monitored more closely.

Every winter NHS staff ready themselves for all the classic things – trips and falls, fractures, flu. But this year it’s reached its peak. The NHS is under enormous strain, and feeling the effect of chronic underfunding. Morale is low. Nurses don’t necessarily want to be paid more, they want to be appreciated. I’ve seen so many of my colleagues joining private agencies on top of their NHS job to boost their salaries, because they have to.

I’m confused as to why the government let it get so bad before they’d even talk about doing something. We need less talking, more doing. We are at breaking point. The behind-the-scenes dismantling of the NHS is no longer a secret: people are well aware of it. It’s frightening – it’s affecting people’s lives, their careers, their health, and the government are 100% entirely responsible. I think that once the NHS has gone, which is the way it’s going, we will be in a very sorry state.

I think it all begins with social care, which is often overlooked. If there was more support in the community – more district nurses, mental health services, GPs, specialist nurses looking after the elderly at home – people wouldn’t be coming into hospital in the first place. Social care is absolutely pivotal to saving the NHS, but there’s no money in it. It’s a vicious cycle: if we can’t get patients home because there’s no social care then nothing will get better.

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Molly Case performs a poem at the Royal College of Nursing, 2013.

But what I’d like to say is that NHS staff just get their heads down and get on with it. I will forever be thankful to them for looking after my dad and all of us. They make sure that patients are laughing and comfortable and pain-free, and if operations are delayed they keep people updated. They’re so good at making people feel better even when they’re at their most vulnerable – I think it’s the best job in the world and a real privilege. The small things we do as nurses make such a difference, and people remember what you do for them in hospital for the rest of their lives.

When I first started my career three years ago I was so frightened at the way [nurses and NHS staff] were perceived in the media. We were so demonised off the back of the atrocious things that happened in Mid Staffs. But the tide has turned: public trust in us is at an all-time high. The public is starting to see that this is a systemic failing to do with underfunding, under-staffing and devaluing of staff.

It’s the government we’re battling now. Even though it’s a monolithic institution to have as an opponent, I prefer it to be this way than for the public to perceive us negatively. It is hugely important to me and my colleagues that the public see us for what we are – caring and compassionate. Interview by Kathryn Bromwich

Dr Helgi Johannsson

Anaesthetist, St Mary’s hospital, Paddington, London

Anaesthetist Helgi Johannsson photographed at St Mary’s Hospital, Paddington


Helgi Johannsson at St Mary’s Hospital, Paddington: ‘Despite the comradeship there’s a lot of anger.’ Photograph: Karen Robinson for the Observer

Essentially, my team and I look after patients having operations and keep them alive during those operations. We also keep patients on the intensive care unit (ITU) alive. We are involved in the resuscitation and treatment of critically ill patients throughout the hospital, from the operating theatre to ITU. So we’re there manning the life support machines and looking after those patients at the worst time in their lives.

St Mary’s is a major trauma centre. It covers all of northwest London right out towards Watford, the M25 and beyond. In the past two years, we have seen a 40% increase in Blue Calls – the most seriously unwell, ambulance-delivered cases. Why? The closure of two small emergency units in north London has definitely contributed to the increase, but I wonder if it’s also just down to an older, sicker population. Plus, tourism in London is booming since the pound fell and we’re the catchment hospital for Oxford Street and the West End, so you can imagine how many tourists we get.

We’re limited as to how much we can expand to accommodate this rise in patients because one third of our buildings are more than 100 years old and by no means fit to be modern hospitals. The Cambridge Wing at St Mary’s is 147 years old and, like many of the other Imperial Trust buildings, it is crumbling and very difficult and expensive to maintain. I pray for a new build every day but the cranes don’t seem to be moving in yet. Last summer the ceilings in two of our medical wards were about to fall down and needed urgent repairs, so we had to move our patients out into other wards, which put a lot of pressure on the rest of the hospital. The wards are back up and running now and I am grateful for that because if they weren’t this current black alert would have tipped us over the edge.


These past few years have been a sustained period of famine – there’s no other word for it – and it shows

The combination of having to do the emergency work and trying to get through some of the more routine work – cancer surgery, vascular aneurism surgery and so on – as well is a major headache at the moment. Patients on the routine operating lists are our biggest problem. They have been waiting for their surgery, they have worked their lives around the date of their operation, made childcare arrangements, psyched themselves up and then on the day they have their operation cancelled because we don’t have a bed. That really affects us. Those patients are human beings just like you and me. It’s been a major decision for them to undergo this operation and then at the last minute it’s put off. The uncertainty is a real killer. It’s really upsetting, actually.

Recently, there was a woman in her 50s who was due to undergo a weight-loss operation, which is quite high-risk surgery. She had made a lot of arrangements, it had taken two years to get to this stage and she had come from a long way away, at least 100 miles. She got up at four in the morning, drove all the way into London and we thought we were going to be able to do it but at the very last minute her bed got taken by an emergency and we had to send her home. It was just so galling.

She was very understanding. Our patients always are and it makes me even more angry that they are so reasonable and they understand the pressure we are under. Obviously, she was very upset: she was in tears and I was close to tears myself because I really felt for her. It was heartbreaking. Those situations are a daily occurrence.

On New Year’s Day I was doing a junior doctor’s shift because we had gaps on our junior rota. It was a really busy night. The conditions in A&E were just awful. There were patients everywhere. Patients on trolleys in corridors. There weren’t any seats for the walking wounded. There were people standing around, sitting on the floor. The whole system was absolutely paralysed. It wasn’t lack of staff in the emergency department that was the problem: our Trust has been very good at providing adequate staffing. It’s the bed blockade: we cannot get our patients to where we need them to be – on the wards – because of the lack of beds. And that’s immobilising the emergency department. You can’t find anywhere to see your patients and you can’t just do your normal job.

We are pretty good at processing our patients but the TV news does not lie and it’s a very familiar sight these days to see the whole of the ambulance park completely full with ambulances and us having to clear the way for the most urgent cases. On top of this there is a real problem getting our critically ill patients into ITU because we are unable to get the patients who are already in there out on to the wards. Lately, we were getting to the stage where we couldn’t actually do emergency operations because we had too many patients waiting for intensive care beds.

None of this is helped by George Osborne’s disastrous cut to social care funding, which means we cannot get the patients who are ready to leave us but still need some help back to their homes.

The atmosphere at the hospital remains good. There is a definite camaraderie among the staff that’s a direct result of feeling embattled. We were involved in some of the major incidents last year, including the Westminster Bridge terrorist attack and the Grenfell Tower fire and, although these events placed a lot of strain, both practical and emotional, on the hospital, they also brought us closer together. They made us realise how important it is that we support each other during periods of difficulty.

Despite the comradeship, there’s a lot of anger about the way the NHS has been treated in the past five to eight years. We’ve always gone through peaks and troughs in funding but these last few years have been a sustained period of famine – there’s no other word for it – and it’s really beginning to show now. But I’m optimistic for the future. I am very much a glass-half-full person. I don’t think the British public will allow things to get worse than this. This is a wake-up call. The fifth richest nation in the world can do well by its old people and can do well by its sick people. It cannot get any worse now.

I knew when I went into medicine that it was not going to be a clock-in at 9am, clock-out at 5pm kind of job. I wouldn’t want that. Nor is being a doctor in any way glamorous. On my night shift on New Year’s Day one of our patents vomited all over me and the nurse working with me: it went literally everywhere, head to toe, even in our hair. Luckily we were able to shower and change into fresh scrubs and to have a laugh about it. But I wouldn’t change my life. I love the variety, the excitement, the unpredictability and the fact that you are training the next generation of doctors. That’s why I stay in the NHS – you just don’t get that kind of job satisfaction in the private sector. It’s a real giving thing for me. I’m so proud to be in the NHS. Interview by Lisa O’Kelly

Doctors and nurses: ‘When May and Hunt tell the public the NHS is not in crisis, that is a lie’

An 81-year-old woman with chest pains dies while waiting three hours and 45 minutes for an ambulance. Patients are photographed lying on the floor of an A&E unit that has run out of beds, trolleys and chairs. Memos from inside another hospital reveal that its doctors “have been on their knees with workload pressure”. Over six weeks more than 90,000 emergency patients get stuck in the back of an ambulance outside a hospital, waiting to be transferred into the A&E.

These events, which have all happened in England since late November, graphically illustrate the winter crisis tightening its grip on the National Health Service in recent weeks. Worrying, but at the same time predictable. Similar things happen every winter. Flu, bad weather and people struggling to breathe is a recurringly risky combination.

But what is different this year is the intensity of the strain on the NHS. Official NHS figures show that record numbers of patients have been directly affected – by delays in their care, by being diverted to a different A&E than that originally planned, or having their operation cancelled, for example. The proportion of A&E arrivals treated within the supposed four-hour maximum has hit a record low. Doctors have voiced their most acute concern ever about the risk of such conditions leading to poor care. A letter to Theresa May signed by 68 A&E doctors complained that patients have died prematurely after prolonged spells spent in hospital corridors.

As pressures have intensified the prime minister has stuck with impressive doggedness, though increasing implausibility, to her script, on television and when answering questions in parliament. The NHS is the best prepared it has ever been for winter. Health services always come under extra strain at this time of year. We are putting record sums into the NHS.

She did feel obliged to apologise to patients affected by the NHS’s unprecedented cancellation of tens of thousands of operations in December and January for the pain, worry and inconvenience that would mean for them. But then she told the BBC’s Andrew Marr Show last Sunday that that unexpected move was all “part of the plan” to help the NHS withstand a demanding winter.

But a crisis? Definitely not, she insisted.

If anything, she suggested, the NHS itself was part of the problem, for not doing enough to keep people well so that they don’t need hospital care in the first place.

Jeremy Hunt, her health secretary, loyally conveyed the same message – at least until 3 January. Then, in one of the growing number of tweets he may quickly regret posting, he subconsciously gave the game away by asking, with reference to Tony Blair: “Does he not remember his own regular NHS winter crises?”

The interviews that follow capture some of all this chaos and also NHS staff’s feelings – frustration, powerlessness, despair, sadness, rage – about the inability of the teams they are part of, and of the visibly underfunded, chronically under-staffed service they proudly work for, to respond adequately to all those needing their help. Denis Campbell, health policy editor

Dr Adrian Harrop

Junior doctor, A&E, Scarborough hospital

Dr Adrian Harrop photographed in SCarborough


Adrian Harrop: ‘We are not managing.’ Photograph: Gary Calton for the Observer

I’m a relatively junior doctor, but I’ve sampled emergency care in many different parts of the UK, and I’ve seen five winters in A&E departments. The staff in Scarborough are among the most hardworking, kind-hearted people I’ve ever had the pleasure of working with, from the executive board and the consultants to all my fellow junior doctors, nurses, healthcare assistants. This crisis has nothing to do with the shortcomings of frontline staff.

However, when the hospital is placed under the degree of pressure it’s been experiencing in the past few days, it becomes unsafe. And the services we’re able to provide are simply inadequate for the needs of the population.

Typically, a bay within a hospital ward would have three beds down each side. This week, we’ve activated the maximum-capacity protocol, which means we’ve put a bed in the middle of each bay. But even after that, when we’ve got as many staff working as possible, yet again the department is completely full. Every single cubicle is filled with a patient on a trolley, every single part of the corridor has patients down it. We have to have what’s called a “corridor nurse”. Then the assessment area of A&E is full of patients on trolleys, and the resuscitation area – which has three bays for the sickest of the sick patients, people with major traumatic injuries – that room is filled with patients too. I’ve then got a queue of paramedics with patients on stretchers going all the way down the corridor to the main entrance of the hospital. The department is entirely full: I’ve not got a single space to take another acutely unwell patient.

The number of ambulances covering this area of Yorkshire is frighteningly low, particularly at night, and they have to spend half their time in a queue in our A&E. I’ve heard their radios going off, and the person on the other end of the line is pleading with all the crews saying: “Please, is there anybody who can respond to this call?”

Last week, we had a patient who dialled 999 twice over a period of four hours stating in clear terms: “I can’t breathe.” An ambulance didn’t arrive, so their family had to come and drive them up to the hospital, and they collapsed on to the front desk of our A&E reception area, unable to breathe. They had to be rushed immediately to an operating theatre to be intubated to keep their airway open. The patient’s windpipe had narrowed to the size of a pinprick, and if that patient had arrived at hospital 10 minutes later, he would have been dead. That is a reflection of how critically low the capacity within the system is.

This crisis is not a bolt out of the blue – all year we’ve been expecting it. Acute respiratory disorders such as pneumonia, COPD [chronic obstructive pulmonary disease] and asthma flare up in winter. Influenza is also an enormous problem – genuine, diagnosed influenza is a very, very serious illness. On top of that, each year we’re seeing an ever-increasing number of what I’d call the frail elderly: people of advanced age, who have multiple co-morbidities and are dependent on carers. Their problems are complicated by increasing rates of dementia.


The government either needs to get these resources in place, or admit that it wants this health service to fail

Last year was slightly worse than 2016, which was slightly worse than the year before, and so on. The difference in 2017, I think, is that things reached a tipping point. The demands on our service outstrip our ability to provide care.

The government seems to love publishing figures saying we’re spending more on the NHS than ever before, but that’s a meaningless statement. Every year, the total number of patients requiring admission to hospital has gone up, the total number of beds has gone down, and, year on year on year, the total amount of money that we’ve had available to spend – in real terms – has gone down.

This conversation can become personal and party-political, and it’s important to remember that the current problems within the health service are not solely the responsibility of the Conservative party. We’ve been mismanaging the health service for an awfully long time. But the facts speak for themselves: the amount of money available per person is significantly lower than it was last year, or the year before, or the year before that. And I would place the blame for that squarely at the feet of the Tory government. They have opted to spend, effectively, less and less as a proportion of our GDP, and less per capita, than in previous years. Among healthcare professionals, this is almost a universally held view.

I don’t want to make this a personal attack on Jeremy Hunt. In fact, during the cabinet reshuffle, I was really hoping that Jeremy Hunt wouldn’t get taken off health, because then everyone might think “Hallelujah! Problem solved!” I’m glad he hasn’t gone, actually, because it allows us to continue this conversation. When May and Hunt tell the public the NHS is not in a crisis, that is a lie. It’s an ongoing crisis, and it can’t be allowed to continue any longer.

The thing that got to me today was a patient who came in with an acute, sudden-onset heart problem. They’d thought about calling an ambulance, but because of everything they’d seen in the media, they didn’t want to come to the hospital and bother anybody. Eventually, they drove themselves in and sat in the waiting room for over two hours. This person was in tears saying, “Doctor, I’m so sorry, I didn’t want to cause a nuisance.” I said to them – and I was nearly crying myself – “You are what I’m here for. Please don’t ever be made to feel like you’re inconveniencing me.” The fact that people with severe, emergency medical problems are feeling that they have to apologise to me – that’s sickening. We should be welcoming these people into our hospital with open arms, saying: “This is what you paid your taxes for: so that when you’re 80, and you need us, you can come to hospital.” We want to give people the treatment they need and deserve, and we can’t. We can’t because we haven’t got the resources to do that now. And if that is not a crisis, then I dread to think what a crisis looks like.

Up until now, we’ve just about managed, we’ve been able to claw our resources together. But we’re not managing now. The government either needs to get these resources in place, or admit that it wants this health service to fail. If we’ve got enough money to pay off the DUP, to pay for Brexit, to pay for Trident, we’ve got enough money to make sure that an 80-year-old woman with pneumonia has got a warm hospital bed to spend the night in. Interview by Kit Buchan

Molly Case

Cardiac nurse, King’s College hospital, London

Molly Case 29 Nurse at Kings College in London 09/01/18 Photographer ; Sonja Horsman


Molly Case, at Kings College in London: ‘My job is a pleasure and a joy. It’s only difficult because of starved resources.’ Photograph: Sonja Horsman for the Observer

I work on a high dependency unit: our patients might require organ support, invasive monitoring, or immediate care after surgery. These are big, major operations, life-changing and life-saving. We have a lot of people rushed in by air ambulance, people who have suffered a heart attack, and also people from the area who have been stabbed. On a normal day I wake up at 5.30am and it’s a 12-hour shift; night shifts start at 7.30pm. It’s an absolutely fantastic job. I’m hugely passionate about cardiac nursing – it’s amazing what the heart can do, but when it goes wrong it’s frightening, and everything can deteriorate quite quickly.

Being on a specialist unit in some way we’re shielded from the winter crisis, but something that has had a knock-on effect is beds. We’re running at 98% capacity and you can’t necessarily hold a bed free in case a person comes in with a heart attack. But if somebody does come in, they will need a level two bed, with all the equipment. What that means for our unit is that sometimes patients are too quickly identified as stable enough to be stepped down to the ward or discharged too early, and that puts them at risk.

Something that nurses live by is Florence Nightingale’s words: “The very first requirement in a hospital is that it should do the sick no harm.” And when you’re stepping down people inappropriately, through no malice or ill intent, it feels like you’re putting somebody at risk. If there were more beds it just wouldn’t be a problem. This isn’t me being self-deprecating, but our jobs are not hard – they are a pleasure and a joy. They are only difficult because of the starved resources.


It’s a vicious cycle: if we can’t get patients home because there’s no social care then nothing will get better

The most difficult moment for me this winter was when my dad, who’s 80, broke his hip, and I saw first-hand what A&E was looking like in the midst of everything. So many elements of the winter crisis affected him. He lay on the floor for hours at home after calling an ambulance, which breaks my heart. When he got to A&E he stayed there all night: there simply was no bed to go to and his pain was absolutely immense. When he did get his hip fixed there wasn’t a level two bed for him to go to after the operation, where he could have been monitored more closely.

Every winter NHS staff ready themselves for all the classic things – trips and falls, fractures, flu. But this year it’s reached its peak. The NHS is under enormous strain, and feeling the effect of chronic underfunding. Morale is low. Nurses don’t necessarily want to be paid more, they want to be appreciated. I’ve seen so many of my colleagues joining private agencies on top of their NHS job to boost their salaries, because they have to.

I’m confused as to why the government let it get so bad before they’d even talk about doing something. We need less talking, more doing. We are at breaking point. The behind-the-scenes dismantling of the NHS is no longer a secret: people are well aware of it. It’s frightening – it’s affecting people’s lives, their careers, their health, and the government are 100% entirely responsible. I think that once the NHS has gone, which is the way it’s going, we will be in a very sorry state.

I think it all begins with social care, which is often overlooked. If there was more support in the community – more district nurses, mental health services, GPs, specialist nurses looking after the elderly at home – people wouldn’t be coming into hospital in the first place. Social care is absolutely pivotal to saving the NHS, but there’s no money in it. It’s a vicious cycle: if we can’t get patients home because there’s no social care then nothing will get better.

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Molly Case performs a poem at the Royal College of Nursing, 2013.

But what I’d like to say is that NHS staff just get their heads down and get on with it. I will forever be thankful to them for looking after my dad and all of us. They make sure that patients are laughing and comfortable and pain-free, and if operations are delayed they keep people updated. They’re so good at making people feel better even when they’re at their most vulnerable – I think it’s the best job in the world and a real privilege. The small things we do as nurses make such a difference, and people remember what you do for them in hospital for the rest of their lives.

When I first started my career three years ago I was so frightened at the way [nurses and NHS staff] were perceived in the media. We were so demonised off the back of the atrocious things that happened in Mid Staffs. But the tide has turned: public trust in us is at an all-time high. The public is starting to see that this is a systemic failing to do with underfunding, under-staffing and devaluing of staff.

It’s the government we’re battling now. Even though it’s a monolithic institution to have as an opponent, I prefer it to be this way than for the public to perceive us negatively. It is hugely important to me and my colleagues that the public see us for what we are – caring and compassionate. Interview by Kathryn Bromwich

Dr Helgi Johannsson

Anaesthetist, St Mary’s hospital, Paddington, London

Anaesthetist Helgi Johannsson photographed at St Mary’s Hospital, Paddington


Helgi Johannsson at St Mary’s Hospital, Paddington: ‘Despite the comradeship there’s a lot of anger.’ Photograph: Karen Robinson for the Observer

Essentially, my team and I look after patients having operations and keep them alive during those operations. We also keep patients on the intensive care unit (ITU) alive. We are involved in the resuscitation and treatment of critically ill patients throughout the hospital, from the operating theatre to ITU. So we’re there manning the life support machines and looking after those patients at the worst time in their lives.

St Mary’s is a major trauma centre. It covers all of northwest London right out towards Watford, the M25 and beyond. In the past two years, we have seen a 40% increase in Blue Calls – the most seriously unwell, ambulance-delivered cases. Why? The closure of two small emergency units in north London has definitely contributed to the increase, but I wonder if it’s also just down to an older, sicker population. Plus, tourism in London is booming since the pound fell and we’re the catchment hospital for Oxford Street and the West End, so you can imagine how many tourists we get.

We’re limited as to how much we can expand to accommodate this rise in patients because one third of our buildings are more than 100 years old and by no means fit to be modern hospitals. The Cambridge Wing at St Mary’s is 147 years old and, like many of the other Imperial Trust buildings, it is crumbling and very difficult and expensive to maintain. I pray for a new build every day but the cranes don’t seem to be moving in yet. Last summer the ceilings in two of our medical wards were about to fall down and needed urgent repairs, so we had to move our patients out into other wards, which put a lot of pressure on the rest of the hospital. The wards are back up and running now and I am grateful for that because if they weren’t this current black alert would have tipped us over the edge.


These past few years have been a sustained period of famine – there’s no other word for it – and it shows

The combination of having to do the emergency work and trying to get through some of the more routine work – cancer surgery, vascular aneurism surgery and so on – as well is a major headache at the moment. Patients on the routine operating lists are our biggest problem. They have been waiting for their surgery, they have worked their lives around the date of their operation, made childcare arrangements, psyched themselves up and then on the day they have their operation cancelled because we don’t have a bed. That really affects us. Those patients are human beings just like you and me. It’s been a major decision for them to undergo this operation and then at the last minute it’s put off. The uncertainty is a real killer. It’s really upsetting, actually.

Recently, there was a woman in her 50s who was due to undergo a weight-loss operation, which is quite high-risk surgery. She had made a lot of arrangements, it had taken two years to get to this stage and she had come from a long way away, at least 100 miles. She got up at four in the morning, drove all the way into London and we thought we were going to be able to do it but at the very last minute her bed got taken by an emergency and we had to send her home. It was just so galling.

She was very understanding. Our patients always are and it makes me even more angry that they are so reasonable and they understand the pressure we are under. Obviously, she was very upset: she was in tears and I was close to tears myself because I really felt for her. It was heartbreaking. Those situations are a daily occurrence.

On New Year’s Day I was doing a junior doctor’s shift because we had gaps on our junior rota. It was a really busy night. The conditions in A&E were just awful. There were patients everywhere. Patients on trolleys in corridors. There weren’t any seats for the walking wounded. There were people standing around, sitting on the floor. The whole system was absolutely paralysed. It wasn’t lack of staff in the emergency department that was the problem: our Trust has been very good at providing adequate staffing. It’s the bed blockade: we cannot get our patients to where we need them to be – on the wards – because of the lack of beds. And that’s immobilising the emergency department. You can’t find anywhere to see your patients and you can’t just do your normal job.

We are pretty good at processing our patients but the TV news does not lie and it’s a very familiar sight these days to see the whole of the ambulance park completely full with ambulances and us having to clear the way for the most urgent cases. On top of this there is a real problem getting our critically ill patients into ITU because we are unable to get the patients who are already in there out on to the wards. Lately, we were getting to the stage where we couldn’t actually do emergency operations because we had too many patients waiting for intensive care beds.

None of this is helped by George Osborne’s disastrous cut to social care funding, which means we cannot get the patients who are ready to leave us but still need some help back to their homes.

The atmosphere at the hospital remains good. There is a definite camaraderie among the staff that’s a direct result of feeling embattled. We were involved in some of the major incidents last year, including the Westminster Bridge terrorist attack and the Grenfell Tower fire and, although these events placed a lot of strain, both practical and emotional, on the hospital, they also brought us closer together. They made us realise how important it is that we support each other during periods of difficulty.

Despite the comradeship, there’s a lot of anger about the way the NHS has been treated in the past five to eight years. We’ve always gone through peaks and troughs in funding but these last few years have been a sustained period of famine – there’s no other word for it – and it’s really beginning to show now. But I’m optimistic for the future. I am very much a glass-half-full person. I don’t think the British public will allow things to get worse than this. This is a wake-up call. The fifth richest nation in the world can do well by its old people and can do well by its sick people. It cannot get any worse now.

I knew when I went into medicine that it was not going to be a clock-in at 9am, clock-out at 5pm kind of job. I wouldn’t want that. Nor is being a doctor in any way glamorous. On my night shift on New Year’s Day one of our patents vomited all over me and the nurse working with me: it went literally everywhere, head to toe, even in our hair. Luckily we were able to shower and change into fresh scrubs and to have a laugh about it. But I wouldn’t change my life. I love the variety, the excitement, the unpredictability and the fact that you are training the next generation of doctors. That’s why I stay in the NHS – you just don’t get that kind of job satisfaction in the private sector. It’s a real giving thing for me. I’m so proud to be in the NHS. Interview by Lisa O’Kelly

When private meets public sector: the history of a tangled relationship

Interaction between the private and public sectors can be a politically charged process in the UK, not least when the contracts that underpin such a partnership go wrong. Here are some recent examples of cooperation between public bodies and private companies that have caused controversy.

Scottish schools

A private finance contract to build a series of Edinburgh schools became a costly embarrassment after the new buildings were found to be faulty and one partly fell down. A report into the deal found that the contractors had used substandard concrete to build the schools, all of which were considered unsafe and in need of substantial repair. But a review by the council found that the financing behind the Edinburgh Schools Partnership (ESP) was not to blame. ESP is a private finance initiative (PFI), a popular form of funding for projects whereby a company pays the upfront construction cost and is then paid back over time by the government, which effectively pays the constructor to lease the property. However, the review did say there were aspects of the way in which the PFI methodology was implemented that “increased the risk of poor quality design and construction”.

Virgin Health

Private firms scooped almost 70% of the 386 contracts to run clinical health services put out to tender in England during 2016-17. They included the seven highest-value contracts, worth £2.43bn between them, and 13 of the 20 most lucrative tenders. Last year, Virgin Care, owned by Richard Branson sued six clinical trusts after it lost an £82m bid. It secured an out-of-court settlement. It also went on to win £1bn worth of contracts.

London Underground PPI

Bob Kiley, tube boss in the early 2000s


Bob Kiley, tube boss in the early 2000s, described the PPP financing model for transport improvements in London as ‘fatally flawed’. Photograph: Channel 4

A series of public-private partnerships (PPPs) were signed by the last Labour government in 2002 and 2003 to upgrade and carry out maintenance on London’s tube network. Described at the time by then tube boss Bob Kiley as “fatally flawed”, by 2010 the process had unravelled. In exchange for carrying out complex work on an ailing network, the businesses behind the contracts would receive a monthly payment that would increase or decrease depending on whether they hit targets for measures such as train cleanliness and reliability of services. The process became mired in endless rows over costs; the biggest contractor, Metronet, eventually went bust and the other, Tube Lines, was bought out.

East coast rail

For the second time in a decade, the secretary of state for transport has been forced to bail out a private rail company running the vital east coast mainline. In 2009, the then Labour government took the line under public control after its private operator, National Express, couldn’t pay out the £1.4bn promised under the contract. The previous holder of the franchise, GNER, had already been stripped of the route after its US parent firm was struck by financial troubles. Last year, the government waived the majority of payments due under Stagecoach’s £3.3bn contract to run the London to Edinburgh route. Whenever the merits of rail privatisation are debated, the east coast line is a key argument for those in favour of nationalisation.

Dentists warn of child tooth decay crisis as extractions hit new high

NHS surgeons are performing record numbers of operations to pull out rotten teeth in children.

Hospitals extracted multiple teeth from children and teenagers in England a total of 42,911 times – 170 a day – in 2016-17, according to statistics obtained by the Local Government Association.

That is almost a fifth (17%) more than the 36,833 of those procedures that surgical teams carried out in 2012-13. Each one involves a child having a general anaesthetic and at least two teeth removed.

“These statistics are a badge of dishonour for health ministers, who have failed to confront a wholly preventable disease,” said Mick Armstrong, the chair of the British Dental Association, which represents most of the UK’s dentists.

He condemned “ministerial indifference [to] … the child tooth decay crisis”. Ministers were being “short-sighted” by not taking children’s oral health more seriously. Under-18s in England were receiving “second-class” services to prevent rotten teeth, in contrast to Scotland and Wales, both of which have a dedicated national programme, Armstrong added.

Tooth decay chart

The cost to the NHS of removing severely decayed teeth in under-18s has also escalated over those four years, from £27.3m to £36.2m.

Health campaigners said the “alarming” trend showed children were eating too many sweet foods and should prompt tough action to cut their sugar intake.

“These figures show that we have an oral health crisis and highlight the damage that excessive sugar intake is doing to young people’s health,” said Izzi Seccombe, a councillor and the chair of the LGA’s community wellbeing board.

Children’s poor dental health can limit their ability to eat, play, socialise and speak normally, she added.

The government’s main policy to prevent tooth decay in children most at risk, called Starting Well, was not given new funding and operates only in parts of just 13 local council areas in England, the BDA said.

“This short-sightedness means just a few thousand children stand to benefit from policies that need to be reaching millions,” Armstrong said.

Dr Nigel Carter, chief executive of the Oral Health Foundation charity, said the rise in childhood teeth extractions was “completely unacceptable” and was causing pain and distress for the under-18s undergoing the procedure.

Dr Sandra White, Public Health England’s director of dental public health, said: “Parents can reduce tooth decay through cutting back on their children’s sugary food and drink, encouraging them to brush their teeth with fluoride toothpaste twice a day, and trips to the dentist as often as advised.”

Prof Russell Viner, officer for health promotion at the Royal College of Paediatrics and Child Health, said ministers should ban television advertisements for foods high in fat, salt or sugar before the 9pm watershed and stop fast food shops opening near schools and colleges.

We need to raise taxes to fund our care needs | Letters

The obvious answer to saving the NHS is to train and recruit more care workers in both the NHS and social care – which would not only (alone) meet current crying care needs but provide good professional human-interface jobs in the coming hi-tech age (killing two currently worrying birds with one stone). This does, however, mean raising more public revenue by getting people to pay more taxes.

But to achieve this we must first counter the common idea that providing something that people want, and raising the revenue to provide it by appropriate pricing, is a clear case of “positive wealth creation” if done in the private sector – not only creating wealth for the sector in question (which may be private healthcare, as in the US) but stimulating activity in the rest of the economy – but is simply a “negative burden” if done in the public sector.

Providing separate healthcare budgets, linking specific tax increases to specific public care improvements (disinterring what we need to pay for care from more general taxation), which I think Chris Ham is recommending, may be the best way to get people to focus on the real issues. But until the debilitating myth of private good / public doubtful is scotched, we will not reach square one in solving our current healthcare crisis.
Bernard Cummings
Erith, Kent

It is now time for all opposition parties to combine to bring maximum pressure on the government to end the ever increasing and costly privatisation of the NHS and increase general taxation to pay for it. I think most people would agree to a tax that was hypothecated for the NHS and social care. Part of the problem the NHS is experiencing is due to bed blocking caused by such large cuts to social care.
Valerie Crews
Beckenham, Kent

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My charity sees the toll of job losses on mental health – we struggle to meet demand

As chief executive of a small mental health charity in one of the poorest areas of north east England, I don’t sleep well. We deliver frontline recovery services in Redcar & Cleveland and in 2011 our funding was cut by 61% in one fell swoop. We used to get £350,000 from the local authority; now we manage on £135,000.

Meanwhile, mass unemployment and financial pressure have taken their toll on people’s mental health and we’ve seen demand more than double. The steelworks used to be the lifeblood of our community and its closure in 2015 has been catastrophic.

Across the country, suicide is the biggest killer of men under the age of 50 and rates of depression and anxiety in young people are spiralling. We see the human face of those statistics every day, and although I am an eternal optimist, most days are tinged with upset and anger.

I regularly meet staff who work in search and rescue. We offer them resilience training and mental health support through our Blue Light Programme. We know that staff and volunteers working within the emergency services are at increased risk of suicide due to stress.

One instance that particularly stays in my thoughts is when a young volunteer from a local search and rescue team was involved in the harrowing experience of retrieving a body from the foot of Huntcliff, a beautiful and majestic landmark along our coastline. They had just had their first experience of the trauma of suicide and remained in my thoughts all day. It’s volunteers like that who potentially need our services.


Too many people need us, and our resources are limited. Very limited.

Later that day I received a call from my 19-year-old son. The body retrieved from Huntcliff was someone he knew. The sad irony is not lost on me: three young people of a similar age. One is dead, one may not sleep due to what they have witnessed, and the other is touched by sudden bereavement. What words do I choose that can possibly make this better? I am at a loss.

I do what I do today because of my own lived experience. In 2006, out of the blue, I suffered a life-threatening depressive episode. It lasted six months from onset to recovery. During that time struggling to understand my mental illness, I made repeated attempts to take my life. Back then I had no idea that services like Redcar & Cleveland Mind existed. I survived through the support of my wonderful children, a great GP and some very loyal friends. But I know some people aren’t so lucky.

I will do everything within my power to make sure our service continues to be there for anyone who needs it. But therein lies the problem. Too many people need us, and our resources are limited. Very limited.

Our Road to Recovery service is funded to support people with “mild to moderate” mental health problems. We are asked to categorise people depending on how unwell they may be, or how much support they may need. If they are too ill, we’re not funded to help them. But of course we do. We will treat them as real people and help them to realise that their lives matter.

We make a small income on the Well4Work training we offer employers to help them support their staff’s mental health – but this is all reinvested into the work we do. We increasingly rely on donations, often from those bereaved by suicide.

Mental health doesn’t have the appeal of other charitable causes, unless it touches people directly. We will continue to fight for those you may have loved and lost. And in the meantime I remain hopeful that in this new year we will see Huntcliff in its majestic glory rather than as a place where hopelessness claims more lives. As for me, I suspect 2018 will bring many more sleepless nights.

In the UK the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international suicide helplines can be found at www.befrienders.org.

This series aims to give a voice to the staff behind the public services that are hit by mounting cuts and rising demand, and so often denigrated by the press, politicians and public. If you would like to write an article for the series, contact kirstie.brewer@theguardian.com

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What I’m really thinking: the deaf parent

What’s going on? Am I missing out on something? Or should I say on something else: all the opportunities for small-talk that might make me feel more comfortable and confident in asking if your child wants to come to ours for tea, because our kids are friends. I am bamboozled. I feel the opening gambit has been lost.

My audiologist is great. He tries everything, but it’s about how the brain processes the reduced amount of sound I get, which is about half what anybody else might hear. Lip-reading goes only so far. I’d swap my arm for your hearing. Or my leg. It depends what day it is and how many times I’ve had to get someone else to answer my phone. Or how many times I’ve had to ask the woman in the supermarket to repeat herself, only to realise she’s asking if I have a loyalty card, as she has every other time I’ve been at her till. As a single dad, I’m in the shop a lot.

I think everybody else is friends, and even if I know this is untrue and ridiculous, it still bothers me. I can see fractures after a couple of years, anyway. People who have excised themselves from cliques, new ones brewing. I’m good at reading people’s faces, but I’d rather know what they were all going on about.

I worry I’m stopping my child from having the life yours have. I worry I won’t pick up on something he says, and he won’t repeat it because he’s embarrassed or tired. Could he miss out on a school trip because of me? Will he tell me about his work, because it takes so long? Maybe I’ll miss a clue that he’s being bullied, or not get the punchline to his jokes. It’s exhausting, because I’m deaf all the time. I even dream in mumbles.

Tell us what you’re really thinking at mind@theguardian.com