When I started as a house officer in 1998, the NHS was just turning 50. I remember those early days and the endless nights; struggling on the huge open wards with breathless, blue-skinned patients in tiny pools of light cast by bedside lamps, desperately trying to do the right thing while waiting for the cavalry to arrive. I was sleepless and scared, feeling I was the weakest link in my patients’ chain of survival. In time, however, I realised that I was not, nor ever had been, truly alone; that I was instead part of something bigger.
The NHS is a complex success story. It has made enormous strides against disease over the past seven decades, through a blend of policy, public health strategy and medical research – coupled with the tireless endeavours of healthcare workers. This is how we have transformed our expectations of life and survival since 1948. It is about systems, not superheroes.
In search of lessons on how to improve safety in the NHS, we have looked to other high risk, high reliability industries; among them commercial aviation, automobile production and the space industry. Studies of these organisations have shown that senior executives with responsibility for budget and strategic vision must understand when to defer to on-the-job expertise and invest properly in both the staff and infrastructure that form the foundations of safe practice. Wherever these industries have failed to heed warnings from the front line, avoidable catastrophe has followed.
The NHS’s stories of failure are equally complex, and if we are to learn from our errors we need to be honest about why things go wrong. We must eschew the idea of individual heroism. Not out of false modesty but because if we create lone heroes then we must also invent villains; when in fact neither character exists in isolation.
Very few incidents are the product of the wilful or negligent actions of an individual. And we will not learn and cannot move forward if we treat them in that way. Whenever avoidable harm occurs it is everyone’s responsibility, from the people making decisions in the moment, to those shaping strategy and choosing how much resource to allocate. For the NHS to thrive all of us – politicians, the public, the media, as well as our healthcare workers – must be honest about what the NHS is, what it needs to guarantee its future, and how we will pay for it.
Kevin Fong is the author of Extremes: Life, Death and the Limits of the Human Body (Hodder & Stoughton) and is a consultant anaesthetist at University College London hospital.
For 70 years, the lifeblood of the NHS has been basic, glitz-free, humdrum humanity. Kindness isn’t loud, it doesn’t grab headlines. Yet all of us, NHS staff and patients alike, know that what heals is more than doctors’ drugs or scalpels. It is the quieter, smaller things too – being heard and shown you matter – that make patients feel cherished, and hospitals humane.
Right now, the magic string that binds the NHS together has never been more threadbare. Overstretched staff are burned out. Compassion fatigue is rife. If ever a birthday present mattered, it is sufficient frontline staff to preserve kindness at our NHS’s core.
Rachel Clarke’s Your Life in My Hands: A Junior Doctor’s Story is published by Metro.
Caring for others remains the most rewarding of jobs; to work in medicine or nursing is to engage your intellect, your curiosity, your compassion, yet we’re seeing crises in recruitment and retention. If the government refuses to fund the health service to the levels enjoyed by Denmark, France or Germany, there are still ways we might build an NHS to last another 70 years.
Gains have been made in ethnic diversity and gender discrimination, but in terms of socioeconomic diversity we’re going backwards. Bursaries for medical and nursing students from modest backgrounds would be a start, with admissions procedures that take account of the significant barriers those students face. Healthcare has been undergoing gentrification for decades, and it’s been shown that the more privileged your background, the less likely you are to want to work among the people who need you most. Both medicine and nursing need a return to faith in professionalism, ending systems of assessment based on adherence to centrally dictated guidelines which have seen a tripling of NHS drug prescription in 15 years, with little benefit for the patient and even some anecdotal evidence of harm.
Our most experienced doctors and nurses are retiring as soon as they can – to hold on to their skills and experience we need new patterns of flexible working and an overhaul of onerous and bureaucratic systems of appraisal and revalidation. These systems, introduced following the Harold Shipman affair, are weakening the services they were intended to support – and would have done nothing to stop a murderer likehim. Finally, commercial health providers have long benefited from an NHS that will pick up the pieces whenever they fall short – we need a reliable mechanism that bills them for their failures.
“Gawd bless the NHS” might as well be our national anthem. But – love the NHS as much as we all obviously do – just saying it isn’t enough; it’s conversational slacktivism, as pointless as canonising the dead. We need to do something. We need to lobby our elected representatives, we need to go on frequent, noisy protests and ultimately we all need to pay more taxes. Realistically, very few of you are going to do any of that. So here’s something you can do just by talking.
You all know someone who works for the NHS – a friend, neighbour, relative will be one of the 1.5 million people who keep the health service alive, keep us all alive. They might be a nurse working flat out on a ward with 50% staffing, a doctor carrying three bleeps, a physio whose clinics routinely end two hours late, a midwife who’s had all her holidays cancelled. Ask them how their day was. They’ll say “fine” and change the subject. But let them understand they’ve always got someone to talk to. Someone who understands that the days are never actually just “fine”, that the nature of illness means that more bad things happen than good, that they’re not superhumans with some kind of emotional force field.
Give them that opportunity to offload at the end of every shift, whether it’s a tiny irritation, a rant or a full-on sob. Chip away at the ingrained notion that healthcare professionals shouldn’t talk about these things – because that same ingrained notion is partly responsible for the huge rise in people leaving the NHS, the rise in stress-related absence and illness among those who stay, and the tragic rise in suicide among those who find it just too much. Don’t let them bottle it up. Let them know you’re there. Care for the carer.
Adam Kay’s This Is Going to Hurt: Secret Diaries of a Junior Doctor is published by Picador.
At a time when we need more nurses than ever, they are leaving the NHS faster than they join. We are short of 40,000 nurses in England alone – the highest vacancy level since records began. It is perhaps no wonder that nursing is in crisis. Our language is reflective of our wider values, or lack of them: nursing care, growing up in care, nursing homes, all provoke such negative imagery. Care has become a dirty word.We often hear the roar of doctors, see their visible representation across all forms of media, and rightly so, but nurses outnumber doctors in the NHS two to one. They are perhaps too quiet, too soft, too kind – whatever the cause, we don’t hear nurses’ voices. Nursing students have even less of a voice and yet are a vital part of the NHS. The removal of the student bursary was sold as a way to increase nurse training numbers, but since the government scrapped it, the number of applications has fallen by a third. Student nurses work twelve and half hour shifts, nights, weekends. They can’t get part time jobs to support their studies. They can’t pay off student debts on a nurse’s salary: (NHS staff are among the biggest users of payday loans). The biggest drop in applications following the scrapping of the bursary has been from mature students, with life experience, wanting to go into the areas that are struggling most of all with recruitment: mental health and the community. I would never have been a nurse without the bursary, nor would my most senior, experienced and brilliant nurse colleagues. I think of all the patients we must have cared for over the decades, those of us who – in this political climate – would simply have been unable to train in the first place. Perhaps governments depend on those quiet voices; they trust that the public won’t hear about the plight of nursing. How nursing is in real danger, and what that will mean for patients.
Christie Watson’s The Language of Kindness: A Nurse’s Story is published by Chatto.
Contrast the contemporary developments in medical science with what our precious NHS can afford. I was born in the backstreets of a northern steel town in July 1948. The splendid new NHS was a blessing for the poor but what it was asked to provide was limited. In 1958 I watched my grandfather’s horrific death from heart failure. His loyal GP came to the house and put an end to his suffering with morphine. At the time cardiac surgery was new and exciting, so I decided to pursue that career to find a solution. Heart transplantation began in 1967 but never fulfilled its promise. Annually in the UK 15,000 patients under 65 could be helped, but there are only 150 donors.
Six years ago my Greek trainees saved a dying heart attack victim with a temporary circulatory support device. When he relapsed into severe heart failure I joined them to implant a permanent LVAD and inject the scarred heart muscle with genetically engineered stem cells produced by a British Nobel laureate. This patient remains symptom free. We discovered that the cells remove scar tissue, which offers enormous promise for heart failure prevention in the future. It distresses me that none of these three components of heart failure treatment are available for NHS patients. Sixty years later NHS patients still suffer my grandfather’s fate. When my charitable funds expired so did many patients whom I could have saved.
The NHS is run by politicians so smoke and mirrors are to be expected. It may well be cost effective and free at the point of delivery, but it is not patient focused. Who can justify spending a fortune publishing surgeons’ death rates while denying us the equipment to save lives? Things must change. The 70th anniversary is the end of the beginning. We must be honest about what the NHS can afford and allow insurance to cover important innovations deemed unaffordable. It is wrong to pretend that they do not exist.
Stephen Westaby’s Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table is published by HarperCollins.
The success of the NHS has had an unanticipated dark side: reducing deaths in childhood and mid-life established a public expectation that sending even our frailest people to hospital would always save their lives. Death became a “medical failure”. People experience escalating hospital treatments despite likely futility. Without discussion of or preparation for dying, patients endure multiple, often unhelpful hospital admissions in the last year of life. We mistake medical prolongation of dying for appropriate care.
The prescription may be difficult to swallow. We should de-medicalise dying. For practitioners to recognise diminishing returns of medical treatments, and offer timely discussion with compassion and honesty, we need to challenge both societal denial and medical paralysis. This is not only a prescription for the NHS, then: it involves all of us recognising our mortality.
A skills set for NHS staff training includes conducting end of life discussions and understanding the process of normal dying. They should establish what care the patient finds acceptable, and put in place a coordination system to enable access to the patient’s preferences whenever a decision must be made, so they receive the right care quickly, and are not repeatedly subjected to unhelpful interventions or distressing end-of-life conversations. This may result in less medical treatment, but will encourage more appropriate, skilled care and real patient choice.
Bad deaths follow poor planning. And that is a failure. We need to re-establish that dying is simply what happens at the end of every life, and recognise that a peaceful death is a good outcome worth striving for.