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
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
Cardiac nurse, King’s College hospital, London
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.
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
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