A health service dying on its feet

22/01/2000

This week the British Prime Minister, Tony Blair, was rowing back from his promise that he would bring health spending up to European levels. That was an aspiration, not a pledge, his spokesmen said. A hospital doctor in London has heard it all before. He writes here under a pseudonym.

WE told the neonatal unit last week that the baby would need an intensive-care cot. What do you mean, they?re full?

Prof. looked furious. He had managed this case with great care and in person. There had been various unusual problems during this woman?s pregnancy, and now she had succumbed to pre-eclampsia (a serious condition characterised by raised blood pressure). It was no surprise, as she was in her mid-forties: the older you are, the more likely you are to get it.

There must be a cot, he said.
There isn?t, Prof. A baby was born last night and started having fits. We had to give it the last one.
Well, where is the nearest cot, then?
The senior house officer is phoning round the London units, but as usual everyone says they are full. So far, Brighton is the nearest.
Prof. looked defeated: It?s so unbelievably frustrating!
We had arrived at her labour room. He knocked on the door, and her husband opened it.
He went in. Prime Minister, I am afraid ...

I do not wish for anything other than an uncomplicated and very happy birth for Cherie Blair. Were she to have a real experience of the National Health Service, however (as the Prime Minister?s wife, it is unlikely that she ever would), the above scenario, even at a flagship hospital like the Chelsea and Westminster (should she actually be booked there) would surprise no member of the obstetric team. The budget for the women and children?s directorate at the Chelsea and Westminster is hugely overspent. Cuts are having to be made in the service: things are very tight.

Since I qualified in 1988, I have worked in only one London hospital which had an attractive physical environment. For only one of those 12 years have I found the space in which I work enjoyable. In some years I have worked in nondescript buildings which were, in general, structurally and decoratively sound, but the vast majority of my working life in London has been spent in hospitals in a state of miserable decay. I have worked on two wards which had to be closed down by the health and safety department for lack of working toilets. I have worked in casualty departments where people are laid out in trolleys like pigs in a pen. Sit in the casualty department at the West Middlesex on a Friday night and try to imagine what it must be like to work in such an environment, let alone attend it if you are a frail, frightened old lady who is sick. Try the Central Middlesex, or the North Middlesex, visit Whipp?s Cross when it is busy.

It is routine to work on labour wards where midwives have to look after more than one woman in labour at a time, often more than two. Staff numbers can be so low that student midwives caring for women have hardly any supervision. Labour wards throughout the country run permanently on the edge. Who knows how many obstetric disasters could have been avoided had there been a senior midwife, or an on-site consultant, to supply adequate cover? Can you imagine what it is like to review a case which has ended in the death or handicap of a baby and know that, had there been adequate senior cover, it might never have happened? What would you tell the parents?

Every major study of obstetric care calls for more full-time supervision of labour wards by consultants. But for that to happen, either there needs to be an increase in the total number of consultants, which cannot be done because there is no money available for such expansion, or a reduction in other outpatient services, which cannot be done either, as it would make waiting-lists longer.

Post-natal care in hospital is often no more than crisis management. Try telephoning any London hospital and asking them whether they are fully staffed. Phone any intensive therapy unit, any neonatal unit, any labour ward and ask them when they were last short-staffed. They will tell you that they always are.

Come and visit a typical canteen in a London hospital to see what doctors who may be operating on you or the ones you love, or nurses who will care for you, can eat at night. When I qualified 10 years ago, food was generally available at any hour. In the hospital where I work now, the canteen is separate from the rest of the hospital buildings, and the canteen staff are afraid to go there at night because some have been attacked by patients from the psychiatric wing. The canteen closes at 8 p.m. and reopens at 7 a.m. What sort of employer expects huge numbers of staff to work at night and then fails to feed them?

Ask your consultant whether they feel valued. Stop a nurse, if you can find one free, and ask the same question. Ask any hospital chief executive whether they think government targets are reasonable. Talk to psychiatrists about the availability of acute psychiatric beds. Ask them how they feel.

Junior doctors in your local area are on the verge of industrial action over working conditions and pay. How can this be? What has happened to the health service?

Yet ever since I can remember, ministers from either of the two main parties have chanted a mantra about how they are increasing expenditure. How is it, then, that every year since I qualified, the local health authorities have had to shut beds, or stop operating or reduce staff at some point? To those of us who work within the service, it is perplexing.

I cannot explain all the sums but one area of deceit is pay, and working time. The government awards pay rises above the rate of inflation to NHS staff and then expects the hospitals to find a proportion of the new money from their existing budgets. If last year there were cuts in service to make ends meet, what precisely are the additional efficiency measures that can be taken to make this new money available? Operating on more people per day is a more efficient use of doctor?s time but it is not cheaper: you need more beds, more staff, more medicines. It is cheaper not to operate at all. The government encourages hospitals to reduce the number of hours that juniors work, but gives insufficient extra money to fund the obvious extra cost. Be more efficient, they keep on telling us. How much more efficient can one of the cheapest health services in the First World become?

Did you know, for instance, that despite the fact that Britain has fewer obstetricians per head of population than any similar country in the developed world, the number of training places is being reduced? Why could that be, considering that the government acknowledges the need for more consultant obstetricians? The answer is that it will not fully fund them. The health authorities cannot fund them either. As a result, in London at least, fully trained juniors are being encouraged to look for careers in general practice or elsewhere. The public pays for their training, the public needs them to ensure a safe environment for pregnant women to have their babies; yet they are being turned away for lack of resources.

It is true that as a rule, people can expect to be treated by the health service. It is not, however, an individual right. If my local hospital has a cardiac unit and my baby needs a heart operation, my baby has no right to the operation; no contractual obligation exists between me and the health service. The only requirement is that a service should be provided within budgetary limits. If there are no beds, no doctors, no nurses or just no funding, then that is tough. Usually this does not matter. Most people will get looked after. But an unfortunate few, who have paid their tax year on year in the expectation that they will be looked after well, will be let down by the system. They have no redress if the failure is related to resources. If your doctor fails, you can sue. If the Secretary of State fails you, tough.

It is absurd to blame the present Government for the state of all the hospitals, for the level of nursing pay, for the poor outcomes of those with breast cancer or heart disease. These problems began years ago, many under the previous Government and some, no doubt, from the governments before them.

Who is to blame, then? You and me, for allowing the connection between tax and public service to get lost. What is wrong with us, why are we as a nation so obsessed with the tax burden? Are the rich so greedy that they do not feel any responsibility for the sick, the dying and those in need? Are the middle classes so determined to have yet one more foreign holiday? Do they not care that when their grandmother is admitted to casualty, she may be the one to sit for 14 hours on a trolley somewhere? It is my fault and it is your fault that tax increases mean electoral suicide.

THE conservative forces calling for health insurance are siren voices. If we have to pay health insurance on top of our tax, why not call this a tax increase? Why is it more efficient for an insurance company to raise capital for the health service, than simply to use the Inland Revenue, who are doing the job already, to put a penny in the pound on income tax? The insurance company has to pay all its staff, as well as the health staff, and make a profit to pay to its shareholders.

It is also ridiculous to continue pretending that all things will be freely available through the health service. Cosmetic surgery, instant access to extremely expensive imaging equipment, any drug that comes on the market, perhaps even double-hand transplants, cannot be provided without limit. Otherwise we would end up spending not 5 per cent of the nation?s gross domestic product on health, but 50 per cent. Politicians must grasp the nettle and agree what it is that the health service should provide and provide well. If a particular cancer treatment for ovarian cancer will be available, then it must be provided to everyone who needs it, not just those who live in one health authority rather than another. If in vitro fertilisation is not going to be provided, then no one should get it on the NHS. The list of what is to be provided should be a binding contract between the health service and the nation, so that if my grandmother does not get her cancer operation and it is part of the contract, I do not have to listen to platitudinous political apologies without redress. I should be able to demand it if there is a clinical need, and the courts should enforce it.

It is evil to lead individuals to think that they will be looked after when they might not be. It is idiotic to believe that sufficient funds to make the NHS admired once more will come about if we all slavishly elect governments sworn to reduce tax. For heaven?s sake, stop thinking of tax as a burden and start thinking of it as a hospital bed.