It is a dark winter morning at Ipswich hospital in east Suffolk. Caroline Mortimer, a consultant surgeon, is doing the early round of patients brought in overnight. She specialises in breast cancer but, under new National Health Service guidelines, every patient who has been admitted as an emergency has to be seen by a consultant within 24 hours. It’s her turn.
As usual the hospital is full, with 60% of beds occupied by emergency cases. Mortimer, a sympathetic woman whose demeanour conceals a hard edge, meticulously examines dozens of patients and, as she and her entourage troop around the wards, she recites the problems produced by changes in the health service.
Like many other senior doctors, she is dismayed by the rampant consumerism that now colours patients’ attitudes — and which leads to many hospital beds being occupied by people who should not be there.
This began when GPs abandoned their out-of-hours responsibilities because they were being called throughout the night by patients with trivial ailments. In came locum clinicians.
“They don’t use any clinical judgment,” said Mortimer. “They often just call an ambulance and send people to hospital. We see more and more patients who should not be here. It costs more and clogs up the system.
“Apart from that, I think we are getting more unpleasant as a society. I had to put up with streams of violent abuse and threats from the obese parents of an obese 11-year-old who kept being admitted with severe stomach pains. When I suggested that maybe he didn’t want to go to school, they went mad.
“Eventually I rang the school myself. He was being bullied because he was fat. Now he’s going to another school and everything is fine.”
Ipswich is an average 800-bed district general hospital that handles 2,300 deaths a year, 4,000 births and the ill-health of 400,000 people. It used to be my local hospital; I was brought up around here. I have come back to assess the impact of the extra £35 billion — a huge increase funded by our taxes — spent on the NHS since Labour took office in 1997.
Is it just feeding the insatiable demand for healthcare? Who decides the priorities? Who decides how the money is spent? The answer is, it seems, nobody. The money is easily spent — even on something as simple as a crèche.
Simon Christie is a specialist paediatric nurse married to a teacher. His toddler attends the new £250,000 nursery for the children of staff, housed in a prefabricated building.
“It is very nice and has lovely equipment, but how on earth can it possibly cost that much?” he said.
THERE is much that is impressive about the hospital and there is no question that extra money has brought improvements. However, the injection of cash has not made anything like the difference one would expect.
On this evidence, Downing Street’s claims that the NHS’s new riches are being spent with “commercial discipline” are laughable. Nor are medical needs the absolute priority.
Performance targets are all- important. Ipswich hospital spent £2.6m last year chasing NHS targets. This 500-long list includes such lunacies as national instructions for the concentration of floor cleaning solutions. But the most important — those that affect hospital league tables and consequently the career prospects of NHS administrators — number just four.
These are: seeing 98% of accident and emergency (A&E) patients within four hours of arrival; seeing urgent cancer cases within 14 days of referral by their GPs; seeing outpatients within 13 weeks; and keeping nobody waiting more than nine months for an operation.
There does not appear to be a doctor in Ipswich who is happy with the list. In common with other cancer specialists, Mortimer complains that the two-week deadline for “urgent” cancer referrals has made things worse.
It has led GPs to stop using their own judgment, she says. They now clog up the system by referring low-risk young women with benign breast lumps and 90% of the two-week referrals are a waste of time. “Before this edict, 80% of the urgent referrals were appropriate and we would see them in two to four weeks. The result of this (two-week deadline) is that the waiting times are just prolonged further along the system where there are no ‘targets’. Little old ladies who do have cancer but don’t make a fuss are just made to wait longer.”
It is a difficult issue. Any woman suspecting cancer wants an instant diagnosis. Those who now get one are delighted, as the patients in Mortimer’s post-operative clinic tell me.
“When I found the lump in my breast I just felt the floor open up and swallow me,” said Diana Ranner, 64, who was seen under the two-week wait scheme. A malignant lump the size of a golf ball was removed just after Christmas. Her outlook is now good. “I can’t tell you how relieved I am. The care was fantastic.”
“Have you seen our nipple service?” asks one of the nurses. And off we troop to find it.
There I meet Julie Calcluth, an innovative senior nurse. A 35-year-old mother of three, she shares her job with another nurse. They were concerned that even with a breast-shaped implant, nipple-less patients were left with a perpetual reminder of their surgery. The nurses have learnt how to cut a nipple-shaped mound from the patient’s skin and use a tattooing kit to get the pigmentation right.
The nipple service is not the only sign of change. In an operating theatre, shards of tissue are shooting off the remains of a shin bone. Behind a flimsy surgical drape, Doreen Lewis, 78, is unaware of the carnage being wrought under local anaesthetic to her left knee.
Lewis is receiving a mechanical knee for the second time. A former fashion buyer for Burberry who lives in Suffolk with a much-loved persian cat, she underwent her first replacement in 2000.
“The new knee was never right,” she said. “I fell and broke my leg. I was in agony but it took them eight months and four x-rays to realise. By then it had healed with a great big bend in my leg.”
Near the operating table is a display of metal knee components supplied by John Creighton, a salesman from NexGen Complete Knee Solutions.
He regularly carts high-tech joints round the operating theatres of southeast England.
I ask Clare Marx, the surgeon performing the operation, how much she thinks the parts for Lewis’s knee will cost. She estimates £2,000. Creighton says nearer £5,000.
With other costs, including 10 days’ hospital recovery, the total will be nearly £20,000. This is not unusual. Demand for upgrade of joint replacements has rocketed. Ipswich hospital will spend the best part of £2m this year on joint hardware alone, compared with £900,000 in 2002.
IT IS not just the old who need new joints, but also the fat. Reflecting the national obesity epidemic, patients weighing 23 stone or more regularly appear on surgical lists. Ipswich is now operating on teenagers so massive that their hip joints have to be pinned to prevent dislocation.
Being a joint surgeon is a bloody, physical business. Marx tells me that one day recently in the operating theatre, struggling with hammer and chisel deep in a gaping surgical wound, her mobile phone rang and she asked the anaesthetist to take the call.
“Your friend’s mother says she’s still got the old- fashioned meat mincer you were after,” the anaesthetist said. “It’s a bit rusty but it would clean up.”
The rest of the surgical team froze. Was this some absurdly dangerous new technique? In fact, Marx was planning a pâté for a dinner party.
There is a less jolly side to the hospital, however. Louisa McLachlan, a nurse running an audit of what happens to heart failure sufferers, said that 144 such patients were admitted between January and April last year — and 61 were dead by November.
“The vast majority are never seen by a specialist cardiologist because there isn’t one there when they are rushed into hospital,” she said. “They are never followed up and there is a very high mortality rate. We need to treat these people properly.”
One of the first consultants I meet is Gerry Rayman, who runs the diabetes service. When his bungalow-style clinic opened 20 years ago, it was considered innovative and dynamic. Now investment in unglamorous diseases like diabetes has been left behind in the drive to tackle more headline-grabbing issues. Meanwhile, the diabetes problem has become a disaster.
Diabetes is linked to the spread of adult obesity. More than half the population is overweight through eating and drinking too much.
Rates of obesity-linked diabetes, with its attendant problems of blindness, heart disease and gangrene, have rocketed. Susceptibility to cancer and circulatory diseases is also raised if you are fat.
Rayman’s department deals with 13,000 appointments a year in a building designed to handle fewer than half that. Crammed into 11 rooms plus a tiny roof space, 30 staff try to deal with a burgeoning medical condition.
Diabetes damages blood flow and nerve supply. Many people are not diagnosed until their extremities, usually the feet, become diseased. Nerve damage means they do not notice injuries and infection. Gangrene can quickly follow, leading to leg amputation.
Rayman raised £120,000 towards an early diagnosis service through a charitable appeal four years ago. He is proud that amputations have fallen from almost 30 to about 10. He calculates that this has saved the hospital £600,000 a year, but added: “Have we seen any of that money? No we haven’t.”
He pores over architects’ plans for an extension to his unit. A hospital administrator, due to meet him to discuss the project, has failed to turn up.
“We have raised £600,000 ourselves towards extending the centre. The price of the scheme went from £200,000 three years ago to £1m. It seems to be vastly more expensive than a private building on the same scale,” Rayman said.
It is another example of extraordinary increases in spending at the hospital. But it is far outstripped by the rocketing budget for cancer drugs, which has almost quadrupled to more than £8m in four years.
“The hospital does try to be supportive, but they have to put money into meeting government targets and we are not a target,” said Rayman.
As he good-humouredly shows me round, we step over piles of patient notes and correspondence. Although the hospital is installing Patientline, which will bring television at £3.50 a day and expensive private phone calls to every patient’s bedside, it does not have computerised records.
The government’s vast spending has failed to provide what should be the fundamental strength of the NHS: full entry into the computer age.
More than 30 years after hospitals started getting electronic records, Ipswich is one of those still using a manual system. Managers have been waiting for the National Programme for Information Technology (NPFIT), a database that is meant to revolutionise healthcare but has run into ethical difficulties over doctor-patient confidentiality. Managers had been assured that it will be on stream next month. It might be a long wait.
SUFFOLK is a healthy area with an affluent population. The transformation since my childhood is striking. The tumbledown farmworkers’ cottages, which drew water from their own wells in the 1960s, are now comfortable commuter homes.
Yet demand for healthcare rises steadily because good health means high survival rates for the elderly; 40% of the hospital’s beds are occupied by people aged over 80. Every Monday there are about 240 elderly people to be admitted because they have deteriorated over the weekend.
Despite Labour pledges seven years ago to end “bed blocking” — the problem of chronically ill old people with nowhere else to go — it seems as bad as ever. I am struck by the sheer number of people in the department of elderly care medicine. Apart from the diabetes clinic, it is the most spectacularly overloaded part of the hospital.
Tim Lockington, the lead consultant, said: “These people can’t go home because carers who visit elderly people throughout the day are thin on the ground. Why do it when you can earn more stacking shelves in Asda?”
Excess patients get distributed to other departments and sometimes spend many months in inappropriate wards. The orthopaedic department frequently finds itself looking after bed blockers.
“It would be cheaper to put them in the Marriott up the road and get someone to bring them breakfast, lunch and dinner,” said Ivan Hudson, a consultant orthopaedic surgeon.
“You get families or local doctors sending old people here by ambulance and refusing to come and get them. They don’t want to sell the house to pay for care because they want to protect their inheritance.”
The cost of care in a hospital bed is £250 a day, excluding medicines. These patients are treated with great compassion by the staff. Although they are considered an impediment to the smooth running of hospitals you would never know, and neither would they.
Until the end of last year, elderly patients regularly clogged up Ipswich’s A&E department and made the key NHS performance target of seeing 98% of its patients within four hours impossible to attain. The hospital has moved heaven and earth to meet the target by paying £1.3m for an acute medical unit (AMU), where the elderly are now decanted. The idea is to arrange social service care for all but the most ill and to send them home within a day.
That has not solved the problem. Only consultants can discharge a patient. When Nicky Trepte, the sole consultant physician leading the new unit, is not available, patients are parked in whatever wards have space. It can take Trepte up to two weeks to clear the backlog.
The AMU has taken a huge strain off A&E, however. When I visit A&E, a crash team is making heroic but unsuccessful efforts to resuscitate the victim of a house fire. Others are dealing with a screaming depressive, a regular who (falsely) claims to have taken an overdose.
Elsewhere a paediatric team treats a two-year-old boy who swallowed methanol, a toxic fuel for a model car. The manager of the toy shop that sold the fuel rushes round, the Dutch manufacturers are contacted, the poisons unit at Guy’s hospital in London is asked to courier an antidote and a blood sample is sent by taxi to Cardiff. The boy later makes a full recovery.
While this is going on, a young man is rushed in unconscious. A CT scan quickly reveals he has suffered a potentially fatal brain haemorrhage. Staff work to stabilise his condition before he is sent to the neurological unit at Addenbrookes in Cambridge.
Nearby, 11-year-old Naomi Dunnett has a suspected broken arm examined. She is in and out in 75 minutes.
“They even took the time to explain to her how an x-ray machine works,” said her mother. “I was pleasantly surprised; the last time I was in here checking out a possible broken bone with another child it took 4½ hours.”
Chris Dooley, the hospital’s chief executive, said: “A four-hour wait is unacceptable for most people — and if you are waiting with an injured child, it is horrible.”
He has experience of this: he waited 3½ hours with his 13-year-old after a trampoline accident and 2½ hours after his five-year-old daughter was knocked out by a swing.
Perhaps the most agonising wait I hear about, however, was suffered by Maurice Lloyd, a 60-year-old prostate cancer patient. Scar tissue blocked his bladder after surgery and he waited almost 24 hours in torment, unable to pee, before a male nurse realised what needed to be done and summoned a consultant from home to insert a needle.
Lloyd, a thrice-married former windsurfing instructor, has recovered sufficiently to fret about the operation’s effect on his love life when I stop by to see him.
CRAIG BLACK is the hospital’s finance director. On paper, his budget has benefited hugely from government largesse.
Managers had an extra £14m to invest in new services in the past two years. Eye surgery facilities have received almost £3m. The radiography department has just received a £1.8m MRI scanner and a £1.2m angiography suite.
Other purchases include a new £2.5m C arm that enables the scanning machine to move around the sick patient; a new CT scanner; and a sophisticated gamma camera to track secondary tumour growth.
Black’s annual budget has almost doubled from £83m in 1997 to £164m now. Last year it received an extra £18m towards running costs, a budget increase of more than 12%. Yet more than £12m of this has gone on pay awards.
“There is no question we needed to pay staff more, but you don’t get an increase in capacity by paying more for a current resource,” Black commented when I met him in his modest office.
Of the remaining £6m, Black says, £2.6m went on reaching performance targets. Money also went on massive inflation in the cost of drugs and healthcare “consumables”.
As a result, Black claimed, the real increase in the hospital’s budget is only 2.5%. “Most of the money has been spent on simply standing still,” he said. “I have been in the health service for 13 years and I have never known it this bad in terms of financial squeeze.”
How does the hospital get by? “The NHS is built on altruism,” said Black. “People deliver the standard of care they think they should deliver. I don’t know how long that can go on.”
This is reflected in the confusion over the new national contract for consultants, the highest-paid medical staff. The contract is designed to take their average salary up to £80,000-£90,000 for a maximum 48-hour week. But Norman Irvine, consultant cardiologist and medical director at the hospital, tells me that most work much more than 48 hours because of a shortage of consultants.
There is also scope for profiteering. Last year the haematology department desperately needed a locum consultant to cover for maternity leave. It faced a huge bill. A locum consultant costs £75 an hour, of which £20 goes to the employment agency. If the locum does a week on 24-hour call this is clocked as 168 paid hours, costing £12,600 a week.
Luckily, a senior Australian consultant who wanted a bit of a change stepped in. He did not charge £75 an hour and did his on-call hours for free. “He just said it didn’t seem fair that he was going to be paid so much more than me,” says Nick Dodd, clinical director of cancer.
Altruism also sustains the hospital at the other end of the pay scale. I bump into Sheila Henry d’Almeida, a chic 84- year-old retired social worker who is escorting a patient down a corridor. She is one of 430 hospital volunteers who did more than 41,000 hours of unpaid work last year, feeding patients, filing, photocopying, running a library service and fulfilling dozens of other roles.
“People do voluntary work here because they enjoy it,” she said. “Most of us have been patients and we want to put something back.”
Ann Woolnough, who manages this huge voluntary force, receives £7,000 a year for a 20-hour week. “Of course I have asked for more money,” she said, “but, like lots of people in the health service, I do it because I love it — which is not the same as saying I wouldn’t like to be properly paid.”
The job pages of the Health Service Journal — essential reading for NHS managers — show she could earn about three times as much for the same hours working in a strategic health authority. But she would be a “service improvement manager” and instead of helping patients she would be chasing targets.
STRATEGIC health authorities (STA) are part of the new NHS bureaucracy. Their purpose, apart from gobbling up huge budgets, is a mystery to medical staff.
Norfolk, Suffolk and Cambridgeshire Strategic Health Authority has an annual budget of £105m, much of it spent on running clinical training and “workforce development” programmes. Its stated aim is “to improve the health of our population and reduce inequalities”.
To this end, it occupies much of an attractive Victorian asylum in the village of Fulbourn near Cambridge. Its 120 staff have spacious work stations in airy open rooms lined with modern art. The atmosphere in its white-painted corridors is tranquil.
“We performance manage organisations, run various clinical networks, spread good practice and anticipate demand for services,” explained Peter Davies, head of communications, as we undertake a leisurely tour. Davies lives in west London but camps in empty staff rooms at Addenbrookes hospital during the week. He is in charge of six communications specialists.
It is hard to see what is being done here which is not duplicating effort. Press releases are generated about the activity of local hospitals — in addition to the hospitals’ own press releases. One this winter was about the weather: “Health experts advise that falling temperatures can lead to a higher risk of people catching colds or influenza — or even dying.”
At Ipswich hospital, where it is normal for two consultants and two secretaries to share a room little more than 10ft by 10ft, senior staff fulminate about Fulbourn. In the past decade the strategic role has been passed locally from Anglia Health Authority to Oxford and Anglia regional NHS executive, then to county health authorities and now to Fulbourn.
“It is a joke,” said one of the doctors at a fortnightly management board meeting. “They suddenly decided it would be best to administer East Anglia from Milton Keynes rather than Cambridge, so they set up the Oxford and Anglia NHS regional executive there. People who didn’t want to move were made redundant.
“After three years they moved it back and reemployed all the people they previously got rid of.”
The dead hand of Fulbourn has disillusioned Fiona Webster, the hospital’s assistant director of performance and service planning. An Australian health economist, she arrived 18 months ago looking forward to working in the NHS. No longer.
“I can’t believe the level of bureaucracy and the meetings about meetings,” she said. “It is how you imagine the Soviet Union operated. What is the point of the strategic health authority?” She is also scathing about targets: “We have a list to achieve that is just a joke; a handful is reasonable, but there are more than 500 of them.”
Under Labour’s reforms, strategic health authorities were set up to supervise the primary care trusts (PCTs) that buy services on behalf of patients from local hospitals and healthcare providers.
The three PCTs covering east Suffolk and buying services from Ipswich hospital rapidly lapsed into squabbling and financial chaos after they were set up in 2002, running up joint debts of between £23m and £30m. Staff at the hospital complain that the regional STA has failed to intervene.
The three PCT chief executives, on combined salaries approaching £300,000, were not removed until last autumn. Peter Houghton, chief executive of the STA, said: “It is difficult to know how quickly to intervene. The financial difficulties were big, but they kept producing recovery plans. We gave (them) an opportunity to pull things round and put in support for them. But in the end it didn’t work.”
And this is the new commercially disciplined NHS? Carole Taylor-Brown, an NHS troubleshooter who has “managed” 26 failing health service managers out of their jobs, has moved in to supervise the three PCTs. She says she is confident she will be able to recover the debt they have run up, but it is difficult to see how she can without cutting services to patients.
DEALING with the three PCTs drives Tony Nicholl, a consultant anaesthetist and one of the Ipswich hospital’s medical directors, to distraction. “The old Suffolk health authority was broken up and replaced by this,” he said.
“There’s a hell of a difference between having to deal with one set of people and having to deal with three. If I wanted to offer a new surgical service, first I have to get agreement from the hospital, then I have to get someone to buy into it. In the past you would have simply taken it to the health authority. Now you need three sets of agreement.
“If two agree and the third doesn’t, you haven’t got the level of support you need.”
Apart from obstructing doctors and losing money, what do these three PCTs do? Without my even asking, their combined press office volunteers a list of 22 benefits achieved in the past two years.
Among these is a “first dressing initiative” that confirms my worst fears. District nurses are now given a stock of dressings to carry with them on their rounds. Previously, they assessed wounds before going back to base to fetch the appropriate dressing. The mind boggles. Can the NHS bureaucrats spending our money not tell the difference between “innovation” and long-overdue common sense?
As I left Ipswich I reflected that stuffing £10 notes into the widening NHS cracks, while relying on staff loyalty to keep things going, is not really enough to provide the “world class” health service that the government has promised.
Hospital anatomy
The Ipswich hospital is a fairly typical example of an ordinary general hospital in today’s NHS. Originally based around a former Victorian workhouse, it is now a sprawling complex of old and new buildings on the edge of the city. Its vital signs include:
- A 4,000-strong workforce, including 321 doctors, 1,373 nurses, midwives and other healthcare workers.
- It has 800 beds and serves a population of 400,000. The community now includes many affluent retired people and commuters who work in London.
- Local people are wealthier and healthier than national averages. Cancer deaths are below average and life expectancy is higher.
- Many of the wards date from the 1970s. The hospital is in the middle of a £34m investment programme to provide new wards and equipment.
- Notable success: in 1995 doctors performed life-saving cancer surgery on Bobby Robson, the former England football manager.
