A Day in the life of a CT1 Anaesthetics

By Zahra Essackjee

I arrive about 07:45, and after searching the shelves, change in to blues. On the theatre wall are all of today’s lists, so I pick up my list and head to the surgical admission ward. I start seeing patients, zipping in between the admission nurses, surgeons, specialist nurses and pharmacist.

I take an anaesthetic history; ascertaining if there were any issues with previous anaesthetics, serious co-morbidities and letting them know what to expect in terms of the anaesthetic. A quick “open wide”, getting the patient to nod and jaw thrust gives me an idea of their airway. Lastly, I try to answer any questions, “How long will it take?” Will I wake up during the operation?” and the surprisingly common “Could we film me going to sleep?”.

I bump into my consultant as I’m writing up the charts. “Straightforward patients on the list. Are you happy to just get on with it? I’ll stand in the corner of the anaesthetic room.” I’m about three months into my training. I know my basic doses for simple induction and emergency drugs, but there is a whole world of things that I don’t even know that I don’t know. Still, I nod as “getting on with it” with consultant help nearby is the best way to learn.

After team brief, I check my anaesthetic machine; making sure I can give my patient oxygen, use the suction and ventilate. I chat to my ODP discussing size of laryngeal mask, endotracheal tube, antibiotics indicated as well as drugs needed. I draw up my drugs in readiness.

First patient is fit young man. Of course, I fail to cannulate his rope-like veins that are visible from space despite my time in the Emergency Department competently cannulating all manner of frail, dehydrated ladies and IV drug users whilst sleep deprived. Thankfully the second cannula goes in smoothly. Now we make idle chat to put the patient at ease; “Have you come far today?” “What would you be otherwise doing today?”.

The induction starts with a dose of fentanyl then propofol. A whole syringe of the white drug goes by and he’s still awake. My consultant nods as I reach for another syringe and I’m beginning to wonder if he will ever drift off. Finally, his arm slides off his lap, caught by the theatre assistant. Time for the muscle relaxant. Once it’s in, I hold the mask to his face and lift his chin. I turn on the volatile and squeeze the bag, pushing gas into the apnoeic patient. It’s now a waiting game. I press the alarm pause on the anaesthetic machine, it’s exactly two minutes.

I smell the volatile despite my best attempt at a good seal, there is a reason why they say beware of men with beards. Luckily my friendly neighbourhood ODP is handing me an oropharyngeal airway before I begin yawning. Two minutes are up.

I place the laryngoscope into the patient’s mouth, and try to consciously remember to lift up towards the ceiling and not lever on his teeth. “Grade 1 view.” The endotracheal tube is put into my hand, and so I direct it towards the glottis. I see the tube pass the cords, but the proof is in the pudding. I connect the tube to the circuit, and hold my breath as I squeeze the bag. Chest rising, tube misting and C02 trace. Success. Tube tied in, 22cm at the teeth. First hurdle overcome.

We are ready to head in to theatre.

The patient is brought through into the operating room. I make sure that I have a constant grip on the tube during patient transfer, my nightmare is trying to deal with a misplaced tube. I reattach the tubing, turn on the oxygen and volatile. A test squeeze of the bag, reassures me that the tube is still working and so I switch to the ventilator. I recheck my monitors and settings once the time out checklist is completed.

“Are we ok to start?” asks the surgeon. Glance at the monitor, C02 trace good, blood pressure check, heart rate acceptable, oxygen sats good, MAC high enough. “Please go ahead.”

I watch carefully as the surgeon puts knife to skin. This is the test of my anaesthetic. Is my patient deep enough? My eyes swing to my monitor, looking for any sign of haemodynamic change. There are none. Second challenge met.

The anaesthesia flight has taken off and the analogy holds true. The main part of the operation is cruising from the anaesthetic point of view. Aside from the minor adjustment of volatile, gas flows and administering some IV analgesia, anti-emetic and fluids as required I can relax and complete my chart. My consultant relieves me for a break so I can grab a coffee (the lifeblood of all anaesthetists) but for remainder of the time is happy enough to leave me to it; making sure that both I and the ODP know where they are should we need any assistance.

“How much local can I use?” I’m not quite quick enough to figure this out in my head yet, but after some straight forward maths scribbled on my list I can tell the surgeon a safe dose for local anaesthetic infiltration of the surgical site. This is a signal that things are coming to a close. Time to check whether the muscle relaxant is safe to reverse. Four strong twitches. Good to go, I give the reversal agent.

I look over and they are closing the skin. I turn off the volatile, but keep my flows low. This is the bit I still find tricky, timing emergence. The final challenge. Thankfully he is starting breathe, so I turn off the ventilator.

Once the theatre assistants are starting to pull off the drapes, I take that as my cue to turn up the oxygen to encourage my patient to blow off the volatile. The patient is transferred onto a trolley, and I sit him up, watching his chest movement. All other monitoring comes off, leaving just the pulse oximeter. The rest of the theatre is tidying up, but amidst that chaos I’m watching for signs that my patient can now take over his own breathing fully again.

And it comes. First it’s a silent cough. Then a bucking. I untie the tube and suction his airway. Finally, the sign I’ve been waiting for: he reaches for his tube. “It’s ok, you are just waking up. Stick your tongue out so we can take out the tube.” The ODP deflates the cuff and I pull out the tube. I hold the Hudson mask to my ear to check the oxygen flow and then place it on his face. For the next minute I closely watch his breathing and sats. It’s regular and the sats are normal. Great, time to go to recovery.

After handing over to the recovery nurse, I congratulate myself on a successful and safe anaesthetic. In the early days, it is definitely a victory. Well, now it’s time to psych myself up for the next patient.

A Day in the life of an F1

By Zana Martin

As a newly qualified FY1, typically each day has something new to offer. I’m currently based in care of the elderly, spending my time with a fantastic team of people and facing new challenges daily…

Each day starts with a full board round of every patient, where we discuss recent results and more importantly discuss discharge plans. As the FY1 my role usually entails shouting out the significant blood results and chipping in with and titbits of information I have managed to glean from family members. From there, we divide and conquer, each taking a handful of patients, for which we are responsible that day (being on a well-staffed ward makes all the difference!). 

As the clinician responsible for those patients, it is our job to ensure jobs are done and discharged letters prepared in advance, with TTO’s written early to avoid delays. Often this means you have 4 or 5 letters to prep in a day, which seems a lot but makes your life easier in the future! We are also responsible for updating families and the nearest and dearest, and asking the difficult questions when there is no clear plan surrounding resuscitation. While it was daunting initially, being able to have these conversations early on does allow for a good rapport to be formed between patients and staff and makes the journey a lot more pleasant for everyone involved. Believe me, the difference it makes when you remember a relatives name is amazing. 

One of the biggest challenges I’m sure every FY1 faces is learning to trust your clinical judgement and having the courage to implement a plan for a patient. Things like prescribing laxatives will induce panic, as will the thought of being around a patient with a EWS of anything more than one. Despite feeling like you will never be able to do it, the confidence and competence will grow exponentially in those first few weeks and suddenly you will find yourself wondering why you worried in the first place. For example being called to an unwell patient on the ward with an increasing oxygen demand and tachycardia (that was just me, not the patient) and feeling like a fish out of water, I managed to call on the 5 years of training and issue some basic management until senior help arrived. Thankfully the patient survived. That is certainly a personal highlight. 

But the most enjoyable part of FY1 so far? (And no it’s not the wage, though that is glorious) Is being part of a team and being able to make a difference to real lives, even if it’s something as minor as holding a patient’s hand while you speak to them, or helping to make a bed when there’s a lull in the day. Those small interventions that we don’t consider to be of value are often the most valuable to patients and their families, and are what make the job special. 

Life as a locum doctor

There’s a lot of pressure on young doctors to go straight into specialty training and tick certain boxes for fear of damaging their career chances.

I never planned on having a conventional career in medicine. I always wanted to do relief work and work in the international healthcare setting.

Earlier this year I travelled to Iraq to be part of a medical mission with a small NGO called Global Kindness Foundation. 

They set up dental clinics and optometrists in schools in Najaf and Karbala. These schools are mainly attended by orphans and disadvantaged children.  We set up a rudimentary clinic and as the only female doctor on the trip I provided primary care and health check ups to girls from between the ages of 6-18 years of age. 

 I’ve also visited Northern Greece with another NGO called Health Point Foundation as their co-ordinator on ground for 3 months. We were the main providers of dental care to over 15 camps within that region. Everyday we’d pack our clinic equipment into a car and set up in a new camp. I was involved with inducting, supervising and assisting the dental volunteers. I was also the main liaison for regional government and other NGOs in the health sector and worked hard to expand our efforts to the refugees in other camps or squats. 

After that I went onto study for a diploma in tropical medicine and hygiene. I’ve since been out to Lebanon to assist in the set up of medical clinics for refugees close to the Syrian border. 

Why did I get involved in these projects? It’s what I’ve always wanted to do. 

I worked as a locum doctor in between trips, which meant I had the choice of working or the freedom to leave the country for months at a time – something I couldn’t have done in specialty training. I was also fortunate enough to visit Sri Lanka, Turkey, Switzerland and Germany in this time. 

I know the experiences I have had are beyond value and have given me skills that will be an asset in the future.

To sign up with Holt Doctors and receive your bonus go to the locum page on our website https://www.whatthebleep.co.uk/holtdoctorsbonus

The Truman Show

By Catriona McNicol 

Please, please tell me that I’m not the only person that this kind of stuff happens to, because I’m beginning to think that I’m on some sort of Truman Show. 

The day started well. Unbeknown to me, it turns out that the very pleasant, but possibly mildly stoned youth who takes your orders at the drive-thru McDonald’s has come to recognise me.

“Hey, good to see you. You’re early today, one white coffee, the usual price!” he offered as he held out the contactless card machine. 

Wow, I spend a lot of time and money in here. Mental note to self, “Stop this”.

I threw back some friendly comment and he said, “You’re always so happy, that’s a nice thing”. I was quite taken aback, but flattered nonetheless. 

“What’s not to be happy about? I’m getting a take-away coffee! It’s my favourite part of the day”, I said, a little too jolly for pre-caffeine interactions. 

His eyes narrowed and he offered a half smile, “you’re favourite part of the day is getting a drive-thru McDonald’s large white coffee? That’s not a good place to be in, dude. You gotta start living a little! On to the next window! See you tomorrow”, he said as he closed the glass divide before my eyes. 

Oh. My. God. The marijuana-smoking, slack lining dude who works in McDonald’s just gave me lifestyle advice. 

I chugged on in my little red car playing an old cassette that I recently found in my neighbour’s bin (this is a true story…she’s a neonatal consultant and well aware that I’ve pilfered it). Turns out it was the Beautiful South, Carry On Up The Charts, and with the sun shining down it felt like a good choice. 

I rocked up at work and reversed my car in to the ‘doctor’ space outside my surgery, painfully aware of the worried looks of the patients who eyeballed my 18 year old car that sounds like a foghorn in light of the detached exhaust. I stepped from the car and dropped my doctor’s bag, the contents spilling everywhere. Why hadn’t I zipped it up? I looked like an incompetent numbnut, but I gathered it all up, scooped up my coffee and headed into battle for the morning. 

The morning surgery went well. I felt in control, I did some good doctoring and I left enough time to scrape together the relevant paperwork to dash over to the other side of the city to meet with my Educational Supervisor for the much needed ES Report. 

Right, got to go. I have 18 minutes to travel the 17 minutes it takes to get there. Just need my keys. My keys. Just need them. 

I looked EVERYWHERE. I almost recalled my patients to look in their shoes, pants etc on the off chance that they’d been waylaid during examination. I looked upstairs, in the toilet, in the staffroom, on the stairs. 

Eventually after 15 minutes of sweating I figured I should check outside around my car so I headed into the blazing sunshine to look around my vehicle. Nope. Nowhere. 

What the flock was I going to do? I leant against the car wondering how I could transport myself to the other side of the city and low and behold, the wee buggers were sitting on the driver’s seat with the front door open about an inch. 

Now, thankfully the good folk of the affluent North Leeds suburb in which I work must have recognised that any form of jail time for this old beat up car wasn’t worth it, and the vehicle and its contents were untouched. 

I hopped in and wound down the window, pressed play on the cassette player and drove the 200 metres to Sainsbury’s. It was short but satisfying journey. I knew I was going to be late for my ES meeting but I had to eat. I just had to. 

I parked up outside a pedestrian entrance to the precinct, keeping an eagle eye for any dead equine (see earlier post), wound up the window and then ran into the shop. I did a supermarket sweep (RIP Dale) and was out in no time at all. 

I ran towards the small path where my car was parked just beyond and as I approached the zebra crossing, just on the corner, my life flashed before my eyes. Round the corner, at speeds way beyond those that should be acceptable for pavement based vehicles, came an elderly lady with a glint in her eye and the wildest hair I’ve ever seen. 

We briefly made eye contact before she, yes true story, ran me over. I repeat, today I was run over by an old lady on a mobility scooter. As in hit by the scooter, knocked to the ground, and she ran over the end of my shoe, narrowly missing my toes. 

What the actual Chuffing Nora? 

I was slightly dazed for a second before I stood back up, and yes I could feel everything and nothing hurt too much. I was about to open up a can of Whoop Ass when she looked at me and said in a proper wonderful West Yorkshire accent, “oooo luv, are you ok? Ooooo, I’m so sorry. I think I was going too fast, I’m on my way to get some cat food for Neville, he’s got poorly kidneys and needs one of them reduced protein meat sachets”. 

And this is my life. 

Run over by a mobility scooter because Neville The Cat has got freaking CKD. 

I brushed myself off, calmed the lady down and made sure she was ok before strolling back to the car thinking, “I’m totes telling the McDonald’s dude about this tomorrow. I’ll show him living life!”.

Diary of an NHS Patient – 2017

Posted on 27th of August by JuniorDoctorBlog

2nd January 2017
New year, new diary! Just moved to our forever-family home. Nice area, good primary just round the corner for Charlie and we are only twenty minutes from Dave’s work. Only issue is they just‘downgraded’ our local A&E– but I’m not worried, although Dave thinks I’m a hypochondriac! GP is local and there’s a big hospital a short drive away. Anyway, back to unpacking!

3rd March 2017
Finally got round to signing us all up at the GP- it’s such a faff. They wanted to see all our passports, and could only sign us up between 1-2pm on Wednesday. Who can manage that? Charlie had a cough for a few weeks so that finally pushed us to join. Waiting time bit long though- two weeks! Oh well. He’s fine.

10th April 2017
Still haven’t got an appointment for the GP! Charlie is looking a bit peaky- it’s been too long now. Phoned up for emergency appointments but the GP never has a free slot. I heard from Linda next door they might have to close- can’t maintain the practice on the funding they’ve got. Never mind. Plenty of other NHS GPs around. Even had a leaflet for a private GP through the door today- £40 an appointment. Bit steep. But booked one anyway. Dave didn’t mind.

17th April 2017
The private GP seemed very nice- referred Charlie for lots of tests though. Dave is worried- he thinks it’s a scam. I don’t. I saw the GPs face- he thinks Charlie is really sick. He asked us if we wanted to stay with the NHS- is that really a thing now? I don’t think we can afford any more private tests. He’s sending us to our local NHS children’s department.

24th May 2017
Waiting for an appointment is agonising. Lost our nerve tonight when Dave thought Charlie coughed up some blood. Everyone was a bit flustered so we went to local children’s A&E- except it was closed. Lack of staff. What the hell does that mean? I’ve never heard of a hospital being ‘closed’. What do we pay our taxes for if not the NHS? We got redirected to another hospital, had a minor divorce-level fight outside the A&E and then decided just to take Charlie home. Our appointment is next week anyway.

1st June 2017
Charlie has cystic fibrosis. I’ve spent hundreds of hours looking all over the Internet and everywhere about it. The specialist at the hospital was very nice- but we were still all in tears. We have another appointment next week. It’s still settling in- my child will always be unwell. I don’t know how to handle this. We tried to see the NHS GP this week- just to touch base. They’ve closed for good. I went back to the private GP for an appointment- looked a lot busier. Had to wait a few days this time. Saw a different GP for £50 this time. Wasn’t very helpful. What a waste of money.

10th Oct 2017
Charlie is managing on his inhalers and things. The NHS department at hospital is great- we have the mobile of Sandra, the nurse specialist for Charlie and any problems just call her up. Heard some mutterings about closing the hospital, ‘centralising’ services. Sounds like a good idea, but Sandra reckons many services like theirs will be cut in the reshuffle. Off the record she said the hospital might close entirely. I left pretty frightened, imagining losing such a lifeline for us. Wrote to my MP when I got back. Why are all the NHS services shutting down?

2nd Dec 2017
Sandra called- they are being moved to another hospital, and their service halved. More‘efficiency savings‘. She’s not covering anymore- it’ll be a duty nurse system now. I did the maths- our local specialist children’s hospital is now forty miles away. Just shy of 45 minutes by car. What we will do in an emergency? Dave is starting to get chest pains when he’s carrying Charlie up the stairs. We can’t afford to go back to the local private GP right now, the next closest NHS GP isn’t accepting new patients. Just ignoring it now, and hoping.

5th Jan 2018
More leaflets through the door- private health insurance companies offering discounts. Our local NHS hospital has just been taken over by a private firm. Me and Dave had a huge row, and then decided to look into private health insurance. We both believed in the NHS, but it’s clear that it’snot going to survive unless the government step in.  Plus Dave is self-employed and so am I- might be a bit trickier. We will struggle through.

20th March 2018
Got insured with Health Co. – few others in the street did the same. Quite steep for me and Dave – lots of cancer stuff on both sides of our family, plus we both run our own businesses. Dave went to  an appointment on the very next day- Health Co. GP sent him straight to the heart doctor at the private hospital. Long story short- Dave needs a stent in his heart- not a heart attack, but pretty close according to the doctors. Thank god we got the insurance when we did. Charlie has been good.

1st April 2018
Dave had his heart op today- says he’s feeling much better. Stayed in a nice room in the Health Co. ward- had to pay an excess though, £500. A lot more than we could afford. Really weird feeling as a 1970s child having to worry about money and healthcare in the UK. Anyway- no worries. Everyone’s at home and everyone’s well.

9th April 2018
Health Co. sent us a huge bill today. They say Dave isn’t covered for his op, because he had pre-existing symptoms. Altogether they want nearly £9,000. We were aghast. We tried contacting the NHS hospital to see if they would cover us – we still pay taxes. An hour of ringing got me to a stressed sounding secretary who just laughed in my face. We tried to move back to cardiology at our local NHS hospital- but they don’t do outpatients anymore. Have to raid the savings, probably add a bit to the mortgage too. Need to get the hang of this insurance business better.

15th June 2018
Charlie is sick again – looks like his cystic fibrosis. Went to a great Health Co. GP who wanted to send us to the Health Co. hospital. The hospital wanted to know is Charlie insured. We thought he was- – the hospital says not. An hour of furious tears on the phone turns out they are right- he was excluded because of his cystic fibrosis from a regular family policy. We could pay out of pocket, but the nice Health Co. GP said that might costs hundreds of thousands of pounds. We’d have to sell our house. So I called Sandra- she told us to drive to her NHS hospital, even though it’s an hour and half away. I never expected to be choosing between  money or my family’s health. How did this happen? Anyway, we drove to the ‘central’ children’s hospital – and they rushed Charlie to their high-dependency bay. He’s stable now. Dave and I can’t seem to talk to each other, every conversation turns into blaming the other for the insurance rubbish. Bad night for everyone.

17th June 2018
The NHS has really changed- much of the hospital is actually just private companies that have taken over different sections. I’m signing all sorts of documents about insurance and waivers and declining ‘optional’ extras. Whole wards of the NHS buildings are empty. It’s scary.  The NHS staff haven’t changed though- Charlie’s paediatric team are the same amazing, hard-working angels they’ve always been. Sandra has been in every day- she looks awful. I’ve never seen her so stressed. I caught her for five minutes to catch up and thank her- I asked her how’s work- and she started crying. Most of her colleagues have left the NHS side, she’s the last cystic fibrosis nurse left in the county for the ‘uninsured’. She gets heartbreaking phone calls like mine every five minutes. She has to turn many of them down. She can’t cope. Every month they get less funding and are told to be more ‘efficient’. She’s close to retirement she told me, so she said she was determined “to see it out”. Her career? I asked. No, she said, “the NHS”.

21st Aug 2018
Charlie is back at home. We did two months driving an hour and a half a day to be with him. We took it in shifts, so Dave and I haven’t really been in the same room for more than twenty minutes for 8 weeks. Our relationship is struggling, but at least Charlie is better. I managed to get him back on a Health Co. policy- but the costs are phenomenal. We had thought about a second baby, and if my business had done better maybe even a third. Now we will settle for Charlie. Health Co. gave us a card to show private ambulances to get to our local hospital. Our GP is private, all of Dave’s cardiology appointments are now private, at huge cost, but at least we are covered.

10th Jan 2019
Dave’s mum had a stroke. She’s 92 and the first we heard about it was a call from a care home telling us she can’t pay. We were shocked. She’d been sent to a ‘central‘ elderly care ward fifty miles away, and then sent back to a care home near Dave’s brother. Obviously Dave’s mum was still on the NHS. Apparently there is supposed to be free coverage for the elderly, but it doesn’t cover care costs. We went to the care home- it seemed nice enough. It’s all private though- the manager was a lovely man, who explained we basically had two options; sell Dave’s mum’s house, the house he grew up in, or move her to the NHS subsidised home a few towns away. We went to the NHS one- bit shocked by how run down it looked. Social care apparently has been cut just as hard as the NHS was– it’s all basically private now unless you can’t afford it. We are selling Dave’s mums house.

3rd May 2019
I found a breast lump today, in the shower. It felt like a hard rubbery knot, just under my right breast. Scared and anxious the first thing I did, still in my towel, was go to the Health Co. policy documents in my office. I read them three times over- trying not to linger on the ‘C’ word, but also making damn sure that if I go to the doctor now, we won’t lose our house. Only when I was sure did I go tell Dave. I felt sick watching his face as he felt it too. We booked into a private GP appointment- have to wait a week now, and still have to pay £60 excess.

30th May 2019
Had all our scans, tests, appointments, re-appointments. It’s a low grade breast cancer. Hasn’t spread- it’s an operation, then chemotherapy for a few years, then done. Sort of relieved, sort of mind-bogglingly terrified. All private staff, all the way through. Dave and Charlie have been very supportive. Hasn’t cost too much in excess payments etc. No holiday this year but let’s get some perspective. Op will be next week.

12th June 2019
Op went well, back at home on tablet chemotherapy. The doctor offered me radiotherapy as well- I thought that was a good idea. Booked in next week.

3rd August 2019
A bill arrived today. Another bill. I can’t cope with this. It’s for some aspects of my cancer treatment- apparently the company made an ‘error’, a lot of treatment was ‘extra-contractual’, bottom line; they won’t pay for it now. The CT scan that gave me the all-clear was ‘extra’, the radiotherapy treatment was ‘extra’, all of the nights in hospital with side effects were ‘extra’. The ‘extra’ cost is £192,000.
I keep looking at that number, wondering how it ever came to this.
My mum had cancer- she had a thyroid lump ten years ago. I went to all her appointments, in and out of NHS hospitals, specialists, scans, surgeons. She’s fine. And she never once paid a penny more than her taxes. What a different world we live in now.

5th November 2019
If I sell my stake in my accounting firm, Dave sells his business and goes back as an employee, and we sell our house and downsize we can just about make the payments without declaring bankruptcy. Charlie’s insurance is gonna hit us hard though.
I saw Sandra in the paper today- I spotted her face protesting in a crowd outside her NHS hospital. Shut down, no funds and not enough staff they say. I text her. She’s retiring now. She’s seen it out, and for her the NHS is over.
For the rest of us as well it seems.

3rd Jan 2020
I did some research. We were all told private companies came to ‘save’ the NHS, that healthcare was no longer ‘affordable’.
But compared to our neighbours the NHS didn’t cost very much- just under 8% of GDP in 2015, well below what Germany and France were spending. We were told that more money was being given to the NHS, but it never really was. Compared with demand the last ever decade of the NHS was also it’s most austere. 
Now we can just get by without the NHS- but only just, and we were fairly well off. I worry for those that aren’t. Every day I worry about the next treatment for Charlie or what if my cancer comes back? How will we afford the co-payments and excess charges?
Now the NHS is still around, but it’s gone in all but name. It’s for emergencies and the unemployed and poor only. Basic healthcare. I don’t pay any less tax- more money goes on my family’s hospital bills than ever before.

1st July 2020
A new government is about to be elected. I’m going to campaign hard for the NHS to return. Too many of us are suffering its loss. But no mainstream party has a realistic plan to restore it. It’s simply too late.

I’d wish I’d done something when I had the chance.

Juniordoctorblog.com

The NHS Is Collapsing. Part 3: The Collapse Is A Choice Not A Necessity

Posted on 17th of July by JuniorDoctorBlog

It’s my job as a doctor to interpret trends and analyse hodgepodge information to predict an outcome. I look at the NHS and see a single direction of travel: collapse without rapid and drastic intervention.
In a series of posts we will look at exactly why and how this is happening. This is what I see- you can decide yourself what you see.

In the part 1 here, we looked at why the NHS budget must rise 3-4% per year just to stand still.

In part 2 here we saw exactly how this isn’t happening and the catastrophic effect it’s having on the National Health Service.

Now we examine why.

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It’s clear the trend of rising demand and falling budget is not compatible with a sustainable health service, and after six years, the NHS is about to collapse. The question we have to ask is why would our leaders stand by and ignore, even exacerbate, the demise of the one of the safest, most efficient and equitable healthcare systems in the world?

Medicine is all about making choices: when you are faced with two courses of action, how do you decide which to take? What do I think the diagnosis is? What is the probability it is? What is the benefit of treatment? What is the risk if I don’t treat? What is the risk if I do? Standing by and allowing the collapse of the NHS is a choice, not a necessity.

The popular myth about the NHS, and the words certain elements are already chiselling into it’s tombstone, is that it is ‘inefficient’, ‘bloated’, ‘out-dated’, and we simply ‘cannot afford it anymore’.

The entirety of that belief is simply untrue. The NHS is ranked as one of the industrial world’s most efficient healthcare systems, and amongst the sleekest in terms of money spent/individual. Far from ‘out-dated’, NHS researchers and hospitals have pioneered some of the world’s greatest medical advances;  Tuberculosis treatments and the first successful kidney transplant*, we invented surgical robots and participated in the world’s first lab grown organ transplant. Most recently we are the first country in the world to vaccinate against Meningitis B.

So the real question is “Can we afford it?”. The short answer is Yes.

The long answer is more complex. Every pound spent on a public system is a choice; it is an ideological choice, a financial choice and a political choice. When the NHS was first created in 1948, the political and financial situation was dire: the UK debt was twice the size of the economy (214% GDP), and politically Nye Bevan faced extreme opposition, including, shamefully, from the professional body of doctors at the time. Here a difficult financial and political choice was trumped by an ideological one; the idea healthcare provision should be available to all. Flash forward to 2008 and the global economic crash required another financial choice; to bail out the banks – at a total potential cost to the UK economy at the time of £1.162 trillion, which meant UK debt doubled from 39% of the economy in 2008 to 84% in 2016. 

So the choice to fund the NHS today is actually three choices: political, financial and ideological.

Financially, if we compare 2016 to 1948 – our countries debt is a third of what it was when the NHS was created. Our international counterparts in similar financial circumstances have made a financial choice to spend more of their economy on healthcare. By 2020, that gap will be much more, and we will be spending amongst the lowest in Europe. And remember spending on healthcare isn’t an economic black hole – in areas such as public health every £1 spent to prevent disease saves as much as £5 on future health costs. More on this below.

Politically the NHS remains very well supported. It was even a part of the Olympic opening ceremony. However, the last government made a political choice to stake their reputation as leaders on reducing government spending, for no good financial or economic reason. Many economists and the IMF reject austerity as a means to increase growth in a country.

So what’s the issue?

It’s ideology. George Osbourne and Cameron believed in a small state, and that private competition is the most efficient means to achieve the best allocation of resources, a principle of economics that has no evidence base in healthcare. Despite politically promising no ‘top-down’ reorganisation of the NHS, in 2012 the largest ‘top-down’ reorganisation in the history of the NHS was pushed through in the guise of the Health and Social Care Act. This made it much, much easier for private companies to take publicly funded contracts away from public hospitals. Privatisation of services increased 500% last year.

As public services decline due to lack of public funding, further private companies will come in, and without intervention will eventually take over the entire service. Re-nationalising our hospitals and GP surgeries once this happens will be nigh impossible.

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So what can be done?

Well the choice to maintain a publicly funded NHS isn’t as simple as “are we willing to keep spending more money on the NHS?”

There are many areas in the NHS where vast amounts of money could be saved and redistributed, without an extra pound from the Treasury. I’ve written about this before.

The two predominant areas of waste in the NHS are not how care is given, but where care is given. Currently private finance initiative deals provide £11 billion pounds of worth to the NHS, in the form of buildings and maintenance, but will end up costing the taxpayer £80 billion in interest. Hospitals like Barts Health in London pay £2.7 million a WEEK in interest on these deals. Why hasn’t this been addressed? Again it’s a choice not to. An alternative choice would be to nationalise this debt and renegotiate it – even restructuring it to paying 1/3 less would save the NHS £23 billion – enough to fund it fully for the next ten years.

Similarly the cost of administrating competing private companies and contracts in the NHS has a huge cost – estimated at around £5 billion/year. Reverting back to a purely state-funded and public model isn’t an ideological dream of left-wing liberals – it’s a sound money saving effort. Again, it’s a choice not to do this, because ideologically the government has chosen to create a system that prefers private competition, without any good financial, economic or scientific reason.

And if we don’t plan in the long-term to prevent diseases; diabetes, obesity, falls in the elderly, stroke and heart attacks – we are shooting ourselves in the collective foot. But a political choice was made to save short-term money on public health. Cutting social care costs us 2-3x much as it saves: I regularly have patients waiting for relatively cheap social care in highly expensive hospital beds, or contracting easily preventable conditions in inadequate social situations that develop into hugely expensive and life-threatening disease.

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This is what happens when an unstoppable force meets an immovable object. Demand for healthcare is currently unstoppable; it rises 3-4%/yr, and without taking preventative measures, will continue to do so. The government is apparently immovable; they steadfastly refuse to meet this demand, which every year creates larger and larger problems as patients suffer in underfunded and understaffed hospitals. Between the two the strain on the NHS has reached critical mass – it will collapse without drastic intervention.

Neither of these forces are truly immutable; we can curb health inflation with proper prevention and better social care, and we can both fund the NHS to an equivalent level for a modern industrialised country, and save vast amounts of money through removing deals that are criminally expensive and wasteful.

I hope you now see the NHS is collapsing, and in dire need of help. This doesn’t have to happen. It is a choice.

What will you choose?

juniordoctorblog.com

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Read the other parts in this series: The NHS is Collapsing.

Part 1: A Life in a Day of the NHS

Part 2: If the NHS were a patient, I’d be pulling the emergency alarm

Part 3: The collapse is a choice, not a necessity.

The NHS Is Collapsing Part 2: If The NHS Were A Patient, I'd Be Pulling The Emergency Alarm

Posted on 16th of July by JuniorDoctorBlog

It’s my job as a doctor to interpret trends and analyse hodgepodge information to predict an outcome. I look at the NHS and see a single direction of travel: collapse without rapid and drastic intervention.
In a series of posts we will look at exactly why and how this is happening. This is what I see- you can decide yourself what you see.

In the first post here, we looked at why the NHS budget must rise 3-4% per year just to stand still.

In this post we will see exactly how this isn’t happening and what effect it’s having.

Imagine the NHS is a person- and it is very sick.

When I first see a patient we are trained to go about their assessment systematically. We first check their airway is clear of obstruction and they can breathe.

What do health systems breathe? Money. Everything has a cost, even in a free at the point of service system like the NHS.

So let’s look at our patient’s charts- as demand has risen the NHS has suffocated without proper oxygen to feed it.

Already an alarm is flashing; hospitals went from £0.6 billion surplus in 2010, to the worst deficit in NHS history- £2.3 billion in the red. 

If I saw this nosedive in the hospital I would pull the emergency buzzer. We have second and third opinions here too- The Kings Fund called this

the most austere decade in NHS history.

Professor Don Berwick, patient safety tsar, said

 “I know no nation that is seeking to provide [modern] healthcare at … 8% of GDP let alone 7% or 6.7%, that may be impossible “

The government spun this crisis as hospital ‘overspending‘- but that’s the equivalent of telling a gasping patient that they are ‘overbreathing’. It’s estimated the NHS needs £30 billion to keep afloat by 2020- the ‘extra’ £10 billion promised by government hasn’t appeared, is actually just £4.5 billion and is nowhere near enough. A deflated armband for a drowning man.

Next we look at the circulation, which is how the blood flows through the body and delivers life to the vital organs. What is the lifeblood of the NHS? The staff.

And we are haemorrhaging out. Just like our real blood the NHS system is made up of lots of essential components; doctors, junior and consultant and GP, nurses, midwives, paramedics, pharmacists, health visitors, radiographers, physio and occupational therapists, clerical and secretarial staff, cleaners, security. The list goes on. Every single staff group is suffering.

In the last two years the number of vacant posts for doctors has increased 60%, the number of gaps in nurse’s posts 50%. GPs are contemplating mass resignation,community pharmacies face mass closure, and the cuts to student nursing bursariesmean fewer nurses will be enticed into training. And junior doctors? Alongside most NHS staff junior doctors have already taken a 25% paycut in real terms since 2008, and certificates to leave the country are on the rise.

Now thanks to a toxic contract dispute they are leaving training in England; first choice applications to Scotland and Wales jumped 30-40% vs 2015, and first year training was under recruited in England for the first time in history.

The NHS needs a rapid and skilled workforce transfusion, and to stop bleeding staff burnt out by demoralising leaders and working environments.

The next step in a real patient is to assess their brain- so who are the brains? Well, Jeremy Hunt is still Secretary of State for Health, a man who looked at the above gasping and bleeding patient and declared “the NHS needs to go on a ten-year diet“. I think we need a brain transplant.

Then we assess the vital organs. What are the vital organs of the NHS? A&E, GP and cancer care. Let’s look at some test results. A&E is crashing- wait times over 4 hours just hit the highest in history, with just 81% of patients seen in target time compared to 98% just 8 years ago.

A&Es are closing and downgrading due to lack of staff and funding and no plan to cope with demand when other local departments close.

GPs are closing at record rates– and some being sold privately for more money, and for the last two years we are consistently missing cancer targets.

And let’s not forget the huge problems in social care funding. Even if we resuscitate our dying patient, we can’t forget that their house is caving in as well.
In the midst of all of this the government want to launch a ‘seven day service’, and deny there are any problems at all. Some NHS leads are even starting to leave reality altogether and claim ‘we don’t need safe staffing levels’.
Imagine a crowd of very concerned doctors and nurses around a very sick patient, tubes and wires and monitors blaring, and in jumps Mr Hunt, trying to shoo attention away and declaring “He’s just overbreathing and needs a good diet is all!”. As a doctor I would be within my rights to have him thrown out of the hospital. I can’t seem to get him thrown out of government though.

And as our leaders withhold the vital oxygen our patient NHS needs, as they fail to address the profuse haemorrhaging and the multi-organ failure, we have to ask why? Why would a responsible government be so wilfully ignorant of such catastrophe? And can we hope to resuscitate?
Find out in our final instalment;

The NHS is Collapsing Part 3: The collapse is a choice, not a necessity. 

Juniordoctorblog.com

The NHS Is Collapsing. Part 1: A Life In A Day Of The NHS

Posted on 14th of July by JuniorDoctorBlog

So May is in, Hunt stays, Brexit means Brexit. It’s all change in a crazy week of politics. But what hasn’t changed is the NHS is still about to collapse. May will likely be the last Prime Minister to oversee its demise. 

It’s my job as a doctor to interpret trends and analyse hodgepodge information to predict an outcome. I look at the NHS and see a single direction of travel: collapse without rapid and drastic intervention.
In a series of posts we will look at exactly why and how this is happening. This is what I see- you can decide yourself what you see. 
In this part we will simply explain why the cost of modern healthcare rises every year just to stand still, which is fundamental to understanding the funding needs of the NHS. 
This is difficult, but I think best explained if you simplify the entire health system as treating a single person, let’s call her Beverley.

Beverley is born in 1948- her birth is at home, with no healthcare professional, midwife or monitoring. Several of Beverley’s siblings are also born this way- unfortunately two die before they are one. Sadly an uncle has a heart attack at 52 and passes away.

Beverley grows up, and fortunately remains healthy. She marries, Bob, and she has her kids in 1968. She has every one in a hospital, with a midwife. One requires surgery. Beverley’s own mother has a stroke and dies at 63. Bob decides to stop smoking.

Beverley gets older. Her first grandchild is born in 1988, in hospital with electronic monitoring and emergency caesarean. Beverley’s second grandchild is born at 25 weeks, and spends three months in the new intensive care baby unit. Stressed grandparent Bob has a heart attack- he is rushed into hospital and has an emergency procedure to open the blood vessels in his heart. He is at home in time to hold his new granddaughter for the first time. 

Beverley and Bob stride on, both retiring at 65. On their 50th wedding anniversary Beverley feels odd, can’t find the words to toast, and can’t raise her left arm. Her daughter dials 999- Beverley has a stroke, just like her mother. Fortunately she gets to hospital and 30 minutes later she has had a brain scan and a clot buster is being infused into her arm. She makes a full recovery, and goes back home a day later.

The junior doctor looking after Beverley spots a shadow on the routine chest X-ray she has. She is diagnosed with lung cancer.

Bob is going spare. They meet the specialist, the cancer is treatable and they start right away, six rounds of radiotherapy then weekly chemotherapy. It’s hard, and Beverley goes into hospital twice with complications.

Halfway through Bob has lots of abdominal pain and throws up some blood. Rushed to hospital he has an emergency camera test into his stomach – he’s developed a stress ulcer, which they clip and repair. He’s in hospital for a few days. Gratefully Bob and Beverley return home.

Beverley goes into remission, but is very frail now and is falling a lot at home. Now in their 80s, Bob gets chest pain trying to look after them both, and Bob needs three more stents put in to open blocked heart vessels. Bob and Beverley ask for some social services support at home- a carer comes once a day. 

Overnight one night, Bob passes away in his sleep. Beverley is distraught, but at the funeral she asks her daughter; “Where’s Bob?”. Concerned, her daughter takes her to the GP. It’s clear Beverley now has dementia. She is moved first to a sheltered flat, then a residential home, then a nursing home. 

She dies in hospital of a severe pneumonia at 83.

This isn’t a sad story- this is modern life and modern healthcare.
Why did i tell you this story? To show you how healthcare has changed. Let’s look at some facts.
In 1948 the average female life expectancy was 71. In 2016 it’s 81.5. 

Beverley’s mum died at 63, while Beverley lived into her 80s. People are living longer.

Why? Better healthcare, better immunisations and prevention, better nutrition. 

But also diseases that were previously fatal are now treatable. Mortality for conditions such as coronary artery disease have halved in fifty years- Beverley’s uncle died of a heart attack, but Bob survived two. Stroke survival and stomach bleeds are now readily survivable where fifty years ago they were not.

But these treatments are very expensive- the technology to open blood clots through vessels is super high tech and costs £3000 a go, advanced chemotherapy and radiotherapy treatment costs can run to hundreds of thousands per person, and intensive baby care costs £12,000 a week.

In short- we can do more every year, so we do. And those that we save live on as survivors- but this comes at a cost.

The cost of healthcare per year for an 85 year old is around 4x that of an under 65. The proportion of the population over 65 will rise to 25% by 2040. And alongside that the population is growing, by around 30% since the start of the NHS- so there are 30% more Beverley’s and Bobs than we started with.

So more people, who need more treatment, are treated with more medicines and survive more to need more treatment in the future. And let’s not forget they will need more social care.

This is why the NHS needs 3-4% more funding every year.

That seems like a lot- it’s a tremendous challenge. But we aren’t rising to it as our neighbours are. Of the G7 countries we currently spend the 2nd least on healthcare, well behind the US, Canada, Germany and France. 

With the current healthcare budget under the Tories, we will be spending just 6.7% GDP by 2020- lower than Lithuiania and Hungary. 

Despite that the NHS is still consistently ranked as one of the best healthcare systems in the world. In 2012 the US commonwealth fund found it the most efficient, safe and accessible system out of all countries ranked, and also spent nearly the least.
Whew. 

So now you now that the NHS needs a rising budget to meet rising demand, like every other modern country. Yet we aren’t funding it anywhere near that level, and we aren’t meeting that demand.
In short, the NHS is about to collapse.

Find out why in Part 2: the NHS collapse is a choice, not a necessity. Due tommorrow.

Juniordoctorblog.com