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11 December 2006

A doctor’s scream

As the Prime Minister defends reforms in the health service, morale is at an all-time low. And yet m

By Lucy Chapman

No one is at their best at the 5am trauma call. It is the sound everyone dreads. It is the hour of the night shift when doctors begin dying on their feet: and then the emergency bleep – the drunk driver who’s in a coma after colliding with a lamp-post, the schizophrenic who has jumped from the seventh floor, the stabbing or the post-nightclub gunshot wound. “Trauma call . . . trauma team to A&E resus,” wail the pagers. Bleary-eyed, we assemble in casualty under the strip lights to wait for the ambulance to deliver the patient. We chat while we wait.

Today the subject is the overhaul of training and careers. The surgical registrar, an entertaining Irishman, is adamant that if he weren’t at the end of his training, he would leave. Only a mortgage, a baby and a lack of suitable alternatives for a man with ten years’ experience and a PhD cause him to hesitate. The patient arrives in cardiac arrest, having been shot through the stomach and chest with a single bullet. The crew are giving him chest compressions as he is wheeled in. I watch the same registrar slit open his abdomen and crack open his chest to stem the bleeding from his heart in less than three minutes. His skill, speed and dexterity are awe-inspiring, but they are no longer enough to make him want to continue. The patient dies an hour later anyway.

Morale in medicine is at an all-time low. Doctors of my generation have never worked harder, and yet their pay is being cut, while colleagues who leave are not replaced; they face an uncertain future and possible unemployment as hospital services are broken up and privatised. Most depressing of all is that our work is dictated by irrelevant and conflicting targets that render us impotent to deliver the care our patients need. This week, managers decided that 26 surgical beds must be closed to save money for the trust. This was implemented overnight and the beds physically removed from the ward.

These same people oversee the waiting lists. At no point did anyone see fit to inform the patients who had been asked to come in for surgery that there would be no beds for them. The patients duly turned up at an ungodly hour to have their blood taken and their consent forms filled in by me. They then had to wait for hours before being told that their operations had been cancelled because no beds could be found. Naturally, it is the doctors and nurses who have to explain and apologise. Managers are never on the wards and never take calls: “I’m sorry, she’s in a meeting. Can I take a message for you?”

When I worked in neurosurgery, I had to clerk for cancer patients with brain tumours who were being admitted for scheduled surgery. The psychological build-up to something like this – having to sign a form acknowledging that you wish to proceed despite a substantial risk of dying on the table – is something that few can appreciate. Every week, one such patient would have their operation cancelled on the morning of surgery because their bed had been filled overnight by a drunk or by a nervous wreck with a headache admitted from A&E, courtesy of the priority given to admitting patients from casualty, however well, because they were in danger of breaching the government’s four-hour-wait target.

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Undervalued and overworked

Doctors feel undervalued and overworked because they are. We are routinely coerced into submitting false time sheets to underpay ourselves, in order not to breach the legal limit for working hours on paper and so incur fines to the hospital. Trusts across the country, including my own hospital, have cancelled study leave and funding for training courses for medical staff. Whole wards are threatened with closure even though no bed is ever empty for more than a few hours.

It is not only doctors who are affected. Nurses on my ward are being made to reapply for their jobs. We have two excellent ward secretaries, both facing redundancy after 20 years of efficiency and goodwill. One of them arrives on the ward at six in the morning, so that the notes and scans can be put in order. Doubtless their places will be filled by new, temporary, expendable people, with no pension or rights attached.

In this strange new world we are also inundated with expensive and time-consuming private sector initiatives, imposed by the government with no thought for whether there is any need for them and any infrastructure in place to support them, or if there are any staff trained to implement them. One example is the electronic patient record, which must be used for requesting investigations. The forms still have to be printed, thereby using exactly the same amount of paper, but there are only two working printers in my hospital. This requires a doctor to make a six-flights-of-stairs round trip to collect the forms every time a patient needs a blood test.

Meanwhile, billions of pounds of taxpayers’ money touted as funding is poured into the building of PFI hospitals, and diagnosis and treatment centres. Or it is spent on consultants. The money ends up in the hands of private firms by way of glistening new buildings and headlines about modernisation, but with no discernible improvement in the quality, or quantity, of healthcare provided.

Indeed, the only obvious effect, apart from the haemorrhage of money, is an increase in the waste of clinical time. To get anything done for our patients – a chest X-ray, let’s say – doctors go to extreme lengths: they have to make phone calls, negotiate with people who couldn’t care less, usually find and handwrite the forms because the printer doesn’t work, and then wheel the patient to the X-ray department and back so that he or she doesn’t die waiting for porters. My rage is not your concern: it becomes relevant only when you consider that sometimes my choice is between staying with a patient who is haemorrhaging, or going to another building to collect the blood they need, because no one else will go.

Protests start

Then there is the ludicrous débâcle of payment by results. The policy applies only to the remaining public hospitals, while contracts for elective operations are guaranteed to private treatment centres, regardless of work done. We audited our own performance managers and found that the figures they use to obtain funds from the government under the new system underestimated the medical treatment given by almost one-third. In any case, we have no need to advertise our wares, because, as hospitals around the region are scaled back, we are oversubscribed.

The first large protests came last month, as patients, nurses, doctors and members of the public gathered outside parliament to express their frustration. But the horse has already bolted: this government is ideologically committed to fragmenting and privatising the NHS. Poll after poll has shown that the public opposes private sector involvement. The British Medical Association has repeatedly stated its opposition. The Royal College of Nursing is against it. Who, except the CBI and private health corporations, supports it?

I started training the year Tony Blair took office, and I quickly became disillusioned. I could not understand how students could be so conservative. I wondered who was left to defend the blueprint for a comprehensive, tax-funded, health service. Last week, on my way home after my 17th consecutive 12-hour shift, I had cause to remember the answer I received back then as an undergraduate, when I typed the words “left” and “medicine” into Google and found more than 3,000 items themed “Why I left medicine”.

The author is a junior doctor at an NHS hospital, writing under a pseudonym