Dear Friend,

You’ve asked me for my experience with my recent hospital visit. I’m not sure how much you know about the National Health Service here in the UK, so I hope I haven’t made too many assumptions in what follows.

Introduction

Inevitably, what follows is critical of some of the ways that the NHS works; I hope that those who read this who work for the NHS would recognise that no organisation is perfect, not least the NHS, and any organisation can learn to improve. During my recent time in an NHS hospital, I met some staff to whom I would award an A* – competent, friendly, committed, compassionate, knowledgeable and enthusiastic about their work. Sadly, I also met some who were none of those things and who would struggle to hold down a job in any other organisation. One of those scarcely spoke English; this is a very serious weakness in an organisation in which it could be life-threatening to misunderstand what someone said.

I’ve listed at the end of this document some of the things that could be done to improve the NHS. This comes from someone with no medical background, but several decades as a ‘Company Doctor.’ Some issues are complex and not easy to solve, but my experience suggests to me that there is also a large number of simple problems that could be very easily improved. The NHS could be massively improved by looking at the simple issues, which would make everyone’s lives easier and more comfortable, for both staff and patients. I get the impression that, currently, many staff feel that the NHS is actually incapable of improvement. It’s clear that morale is very poor among many staff. This isn’t surprising; disappointingly there’s not much to love about the current NHS.

Gratitude

I would be the first to acknowledge that the NHS used all the skills and equipment at its disposal to find out what was causing my symptoms, and then treat me appropriately. It might not be an exaggeration to say that without finding the cause of my symptoms (by CT scan), I may have died of sepsis. For that I am, I hope it goes without saying, very grateful. However, I don’t believe that this statement should exempt the NHS from criticism. Organisations only improve through criticism and root cause problem-solving analysis. The NHS cannot afford exempt itself from criticism, if it wishes to survive and prosper. I’m afraid that I don’t buy into the argument that it’s an act of disloyalty to criticise the organisation that has possibly saved my life. Complacency stalks the corridors of much of the NHS.   

How easy is it to access treatment?

The first thing to say is that you may have heard that even getting to see a doctor is challenging in some parts of the UK. This is true; I’ve experienced it for myself. The experience of many people is that the service rapidly deteriorated during COVID and there has been no real attempt to reinstate the service that was routinely provided before the ‘pandemic.’

Admission to Hospital

My experience of being admitted to hospital was, overall, quite good. It included contact with an ‘out of hours’ facility and a home visit, prior to the decision being made to hospitalise me. A short time after the home visit, made by a paramedic and a medical student, my doctor rang me to tell me that I could go to the hospital and was expected there. My symptoms were an ongoing potentially dangerous high temperature, and many of the symptoms of ‘flu, but which had lasted for weeks on end. The out of hours doctor had diagnosed a ‘pyrexia of unknown origin.’ – a euphemism for a ‘high temperature the cause of which is unknown.’ I’d been prescribed antibiotics, but after a few days my condition had deteriorated, rather than improved as expected. When I was admitted, I was in a bad state – probably the most unwell that I remember in my life, and my family was most concerned for my welfare; I owe them a huge debt of gratitude.

On arrival at the hospital, I was shown to a waiting room that was full of other patients, presumably all also awaiting admission. I was seen by a nurse (I use this term throughout as meaning anyone who administers front-line help; I’m aware that many of them have never qualified as ‘nurses’). Within a short period, she took my personal details, measured my blood pressure and asked me to return to my seat. An hour or more later, I saw a second nurse, who asked me about my condition and my symptoms and fitted a twin ‘canula’ in my arm (for administering intravenous fluids and drugs later). I then returned to my seat for a second time. It was approximately two hours after my arrival at the hospital that I finally saw the admissions doctor. I was delighted that he was extremely thorough and understood the situation well. An hour later, ie about three hours after arrival at the hospital, I was admitted to my first hospital ward. I don’t know how ‘average’ this is; there are stories of people waiting for far longer than I did, but you’ll see later on, that the admissions process is heavily affected by the way discharges are handled.

Situation in the ward

I would like to be able to say that I was content with where I found myself. I was in a bed next to the window. The window was ajar and through the gap, the hose from a portable air conditioner had been placed. The air-conditioning unit at the foot of my bed was very loud, 24 hours a day, and did little to reduce the temperature. My bed was ancient and broken in more than one place. The window overlooked a loading and unloading bay for deliveries to the hospital by articulated lorries; it resulted in constant noise, made worse by the window being open. However, even if I hadn’t had the additional noise to contend with, sleeping would have been impossible because of the noise from inside the ward. Some of this came from fellow patients, one of whom was screaming like a wild animal throughout the night, and seemed to be completely ignored by the staff (I later discovered the reason for this and had to give the staff some sympathy.) There was also a patient who would get up and walk around the ward at night, occasionally falling over and having to receive medical attention. By this stage I was on intravenous antibiotics and also on a fluid drip to prevent dehydration. The nurses and auxiliaries were well aware that if the patient moved their arm with the canula even very slightly, it set off an alarm on the machine that persisted until a suitably qualified person could reset it; sometimes half an hour or more later. The medical staff seemed to be the only ones who didn’t care about the constant noise from several alarms, which continued right through the night, every night.

My daughter said that she wanted to visit me. I had to ask my wife to talk her out of this. I had a (hopefully remote) chance of not coming out of hospital alive, and I couldn’t bear the thought of her last memory of me being in a place that was akin to hell on earth. And no, that’s not much of an exaggeration. No one should have to suffer such a place in modern Britain; it reflects very badly on those who run the NHS that such standards are tolerated. I’m extremely sorry to have to write this.

I discovered later that this ward has an appalling reputation with staff elsewhere in the hospital. I witnessed a nurse being physically attacked at night by a patient who had ‘escaped’ from a neighbouring ward. I was told that events where medical staff were assaulted by those who were being treated for drug addiction were not uncommon. I feel for those who have to work in such an environment.

Basic Hygiene standards

I am no medical expert, but it wasn’t difficult to be worried about fundamental hygiene standards in my first ward. I was too tired to unpack my small overnight bag on the first night. When I did so the following morning, I discovered that the bag and its contents were saturated with foul-smelling fluid. I had no idea where this had come from. My wife had to deal with the contents and reached the conclusion that the bag itself was beyond rescue and had to be discarded.

My condition meant that I needed to urinate several times during the night, into disposable cardboard ‘bottles.’ I remember having several meals with three full ones still in place on my ‘bed tray,’ right next to my food and water, despite several requests to have them removed. This is surely not acceptable? I was aware by that stage that my urine was badly infected.   

The hygiene and noise situation in the ward was so bad that after three days, I suggested to a Consultant that I wished to discharge myself. I was quite genuinely concerned that I would pick up some additional serious infection, if I stayed there any longer. Someone obviously got the message, as in the middle of the following night, I was moved to a new ward, on a different floor. The new ward was mainly post-operative and conditions were such that I felt that I’d been moved into a different hospital; it was clean and quiet and at last, I managed to get some sleep. How can two such different wards exist in the same hospital?

The involvement of Consultants and Senior Doctors

I am old enough to remember clearly a British actor called James Robertson Justice (see picture) playing the role of a fictitious Medical Consultant called Sir Lancelot Spratt, in several early British comedy films about life in British hospitals in the 1950s and 1960s. ‘Sir Lancelot’ would do his ‘ward rounds’, doing his best to intimidate and humiliate the gaggle of medical students that trailed in his wake. Sir Lancelot was loud, arrogant, impatient, irascible, superior and he left disaster and confusion in his wake. The most commonly displayed characteristic of the great man was to treat the patient in the bed in front of him as if he didn’t exist. Or, perhaps more correctly, as if he were an inanimate object, there for the sole purpose of testing the ‘Great Man’s’ huge medical intellect.

It would be unkind to suggest that Sir Lancelot is alive and well in the modern NHS, but it would also be impossible to ignore that some of the six consultants that I met did display an arrogance that was unmistakable, and in one case, I was treated as if I didn’t exist. In contrast to Sir Lancelot, each of my ‘Great Men’ (for men they all were) had just one junior doctor with him (also all men), whose sole purpose was to say nothing and hang onto the ‘Great Man’s’ every word, writing things down longhand, when so instructed. On one occasion, I heard one Consultant, that I’d never met before, state something about the history of my case that I didn’t think was accurate, so I asked him if I could tell him the history of what I’d been experiencing. He turned to look at me and the sharp reply was: ‘I know the history.’  Six Consultants in a week might seem excessive to you. I have absolutely no objection to a ‘second opinion,’ but that does rather rely on the assumption that the six had discussed my case with each other and swapped notes. If they had talked to each other, I could not discern the fact. Very unhelpfully, not only did several Consultants disagree with those who’d seen me before, but they didn’t attempt to disguise their contempt for what I’d been told, up to that point. Thus it was that I was given more than one diagnosis (see below). In one case a couple of days after my arrival, I was told in no uncertain terms that what I’d been told was wrong and that the ‘Great Man’ had therefore decided to start the process of blood testing and diagnosis from scratch. I was told on the penultimate day that I needed to have one further blood test, to confirm the trend of falling infection levels, and that if that test continued the previous trend, I could be allowed home the following day. However, the following morning, another doctor I’d never seen before (in this case, not a Consultant) told me that what I’d been told the previous day was incorrect and my infection levels had been static, and not falling, for several days. As a result, I would have to remain in the hospital for another few days, until the levels had fallen. When I said that I’d been told the exact opposite about my infection levels the evening before, the response was: ‘I have no idea where that idea comes from; I have all your results here.’

The first Consultant and his junior examined me shortly after my arrival on the first ward. During this examination, the Consultant was trying to persuade his junior that he had detected a heart abnormality through his stethoscope. This conversation didn’t involve me at all. The junior said he couldn’t detect anything, which resulted in the Consultant telling him that he needed to buy a new, better, stethoscope. He decided that I should have a chest X-Ray. I have no idea whether his notes showed that I had already undergone a chest X-Ray in the same facility only a couple of days before, which had revealed nothing. I accordingly underwent another chest X-Ray (at 03:15 the following morning, of course) that also revealed nothing. Reflecting on the conversation between the Consultant and his junior, I can now only reach the conclusion that ‘willy-waving’ about the quality of the stethoscopes had resulted in an unnecessary procedure being carried out. However, this Consultant and his junior were actually mostly very sensible and after discussion, they agreed that they would ask for blood tests to be carried out in the middle of the night, when my fever was known to be at its worst. This made sense to me. Two days later, I asked one of the six other Consultants what had happened to the results from those blood tests, as I’d had no feedback. I was told that the blood samples had been lost. They were eventually found, 36 hours later, and proved to be important in my diagnosis. I heard similar tales about lost tests and results from several other patients. There is clearly something wrong here, but I’m not sufficiently aware of the procedures, to identify what that might be. This is surely not ‘rocket science,’ when the test laboratory is in the same building?

My diagnosis

As I’ve pointed out, when I was admitted to hospital, the site of my infection and the cause of my high temperature was unknown. It was day three before I was admitted for a CT scan, which identified an infection in the area of my left kidney. When the results came in, I was told that the infection was in the ureter – the duct/tube that connects the kidney to the bladder, but I was very clearly told that there was no infection in the kidney itself. The following day I was told by that day’s ‘Great Man’ that I had been told nonsense and the infection was primarily in the kidney itself and the ureter infection was therefore secondary. Without the CT scan, I’m unsure how the seat of the infection could have been identified, which shows how important this technology is. Once the diagnosis had been made, however, (“pyelonephritis and ureteritis”) and treatment targeted accordingly, my improvement was rapid. If rapid access to a CT scan had been possible when I first presented to my local surgery, I wonder whether hospitalisation could have been avoided? Perhaps not, but surely my stay in hospital could have been significantly shortened?   

Quality and Competence of Staff

As I’ve mentioned, several members of staff that I met couldn’t be faulted for their care, compassion and competence. Others, sadly, showed a complete lack of interest in what they were doing. When I was in business, through hard-won experience, I eventually reached the conclusion that attitude, commitment and enthusiasm were more important than qualifications, when recruiting people. The NHS now only accepts nurses from the UK if they’ve first completed a University degree. Today I’ve read that some of those who’ve obtained their UK nursing degree, and built up the associated eye-watering student debt, can’t find vacancies within the NHS for nurses, because of the huge numbers of overseas nurses who have come to the UK for work. I don’t believe that overseas nurses have to show the same qualifications as the home-grown nurses, to be accepted? If this is correct (it’s quite difficult to find out the truth) then it would seem to be an own-goal of epic proportions. There are suggestions that the same applies to doctors, with those from some overseas countries being far less qualified than those who have trained in the UK. Why do we allow this?

I had one experience in hospital that underlined these concerns. The canula that was fitted to my left arm on arrival in hospital eventually needed replacing (typically they need replacing after four days). The replacement was attached to the back of my left hand, ignoring my voiced concerns. I’d objected because the ancient skin on the back of my hands is now very fragile, and I was not surprised when the canula fell out of my hand within an hour. Its replacement was attached to my right arm. It seemed to be secure, but when the nurse came to inject the night-time antibiotics, it was clearly not allowing the fluid to enter my bloodstream. The night-time nurse had to call a central department to get a new one fitted, as she didn’t have the necessary skills to replace the canula herself. This took two hours, and in the meantime, the same nurse had to take my blood pressure. I was half asleep when she did this, and it therefore took me a while to realise that she had attached the pressure sleeve from the blood pressure monitor over the top of the faulty canula in my right arm. I suspect that this error could have been serious – when I told a doctor what had happened the following day, he grimaced. A different nurse was appalled, and told me that often those who were least committed to the job worked nights, as they got more money for doing less work. Is vocation not assessed as a vital part of recruitment to these positions? Incidentally, this was not an isolated incident – the following night the same nurse tried to do the same again, but I was aware enough to stop her. She showed no remorse whatsoever. I would recruit nurses based solely on their vocation and desire to serve. Many generations of nurses were thus recruited and then trained ‘on the job’. Are standards actually now better from having degree-qualified nurses? I doubt it.

Handover procedure from night-time nursing staff to daytime nursing staff and vice-versa

This is carried out by the outgoing staff at the foot of the bed. More than once, I heard my symptoms and condition being mis-reported to the incoming team. It was another scenario where the patient was not part of the process, but was expected to sit and listen to errors without comment. I seem to think that not many years ago, notes were held at the foot of the bed? This procedure has been abandoned. Why?

The Procedure for Discharge from Hospital

It’s a well-known fact that access to beds is one of the biggest issues in NHS hospitals; in many hospitals the corridors are full of patients on trolleys awaiting beds. Again, as a ‘Company doctor,’ I rapidly learned how critical it was to ensure that bottlenecks were identified and eliminated. But in hospital, one of the worst procedures I witnessed was that for approving the discharge of patients from hospital, which in my case resulted in a delay of several hours in my bed becoming available for the next urgent patient. The procedure of agreeing that discharge should occur was not a problem. Although that was out of my sight, it seemed to work smoothly. What didn’t work so smoothly was getting the paperwork ready for discharge. The paperwork is needed to cover the ongoing need for drugs, writing up the history of the case, etc.  Those responsible for the paperwork production (not the nursing staff, but the ‘Consultants’) did not prioritise this work, which was only completed when they had cleared their other work. The result of not prioritising this clear bottleneck was that the bed was ‘blocked’ unnecessarily for several hours. In my case, I was told to inform my wife that she could come and collect me (I didn’t need an ambulance at any stage during my week, so I can’t comment about that service). My wife then had to wait for two hours, whilst the person responsible completed the necessary paperwork. This drove the senior nursing staff crazy, as they were in effect prevented from carrying out their job efficiently. And the ‘Great Men’? Well, I cannot say whether they are all as lackadaisical as mine was, but it seemed to emphasise that they were more important that anyone else – the patient, the nursing staff, those responsible for admissions and so on. Again, sorting this would not be ‘rocket science’ and would lead to huge improvements. What is getting in the way of this blindingly obvious need for improvement? Is it really just hierarchy?

What happens after the patient is discharged?

The question that seemed to draw a blank stare every time I asked it was this: ‘What was the cause of my kidney infection?’ The system either does not know or, maybe, does not consider this to be part of their remit? Everything in the NHS seems to be geared towards identifying the problem and treating it, rather than identifying what the root cause may be, so that a repeat can be avoided? Or have I missed something?

Possible Root Causes of the problems that I witnessed in the NHS

I would not like to suggest that I could solve all the NHS’s problems, based on witnessing the organisation at work over one single week! But the first step to improving any organisation is surely to start by properly identifying the problems, and their contributory root causes? My list would include the following (not in order of priority):

• Research shows that a new CT scanning machine in the UK costs in the region of £840,000. This sum is much smaller than I had expected. I wonder whether anyone in the NHS has tried to identify what the cost of the delays in accessing the crucial diagnostic machine might be costing the NHS, on a daily basis?
• When hospitals are dealing with post-operative patients, the Consultant surgeon continues to have responsibility for the patient after they have been returned to the ward. Why are other, non post-operative patients treated differently? What is the total cost of handing over responsibility daily to a new Consultant? What are the costs of mis-communication inherent in such a system? Why cannot Consultants call for a second opinion only when they consider it necessary? The current system seems to maximise discontinuity and repetition.
• Decades ago, there were nurses present on wards through the night. This no longer seems to be the case, and leads to delays in dealing with problems, as well as presenting additional security risks? Nurses now seem to have their own private spaces outside the ward whilst on duty, that patients do not enjoy. Why?
• Why have basic hygiene standards, followed over generations, been abandoned?
• What is causing blood test samples and results to be ‘lost in the system’?
• When I left hospital, my ‘paperwork’ included a link with the words ‘Please fill out our inpatient survey and let us know how we did.’ When I completed the survey, I was shocked to find that all they wanted to know were my details (age, ethnicity, etc) and my comments on how well my admission to hospital had been managed. There is no ‘Trustpilot’ for this hospital and the only review site I can find, (iWantgreatcare, which I’ve never heard of before) shows over 231,605 reviews, with an average of 5 stars out of a maximum of 5. Really? Why the reluctance to subject yourself to proper scrutiny and criticism?
• There is little doubt in my mind that the NHS is now an organisation that is too large to be managed sensibly. For most of my lifetime, there has been a change towards combining hospitals, closing smaller ones and making the ‘new’ ones huge. I would not like to have the responsibility for managing such an enormous and multi-faceted facility. Why is the NHS committed to increasing size in everything? In a recent email to me, you said: ‘The smaller and more numerous the providers, the easier it is to try different things and tailor protocols to desired outcomes.’ I could not agree more!

Conclusion

There is, however, one final and most important point to make in connection with what is wrong in the NHS. When seeking to improve the performance of organisations, it’s a well-known fact that continuous improvement only comes from each ‘customer’ and ‘supplier’ in the internal supply chain identifying and agreeing their requirements and measuring their ability to satisfy their internal customer. Why could this not work in the NHS?

More than 30 years ago, I had a friend who was contracted to train an NHS hospital in such a process. His problem was that on day one, looking at the facility as a whole, not one member of staff, from juniors up to and including senior Consultants, could agree who the end-point customer was. It could not, they reasoned, be the patients; clearly they were not paying and therefore could not be the customers. When pressed, therefore, to identify what position the patients occupied in the supply chain, if not that of customers, after several hours of discussion, they decided that patients were ‘free issue material.’

I remain far from convinced that this view has improved in the last 30 years. Everything that I experienced in hospital leaves me with the impression that for the organisation as a whole (I do not say every person in it) the patient is of no real importance. Until this changes, we should not be surprised to see performance in ‘our beloved NHS’ continue to deteriorate to standards expected of medical services in Third World countries.

The sixty four thousand dollar question is, of course, is there any sign of anyone having the political will to tackle what is becoming a major problem? I don’t see any signs of it. Sad.

Heavenly Father, bless and encourage those with a vocation to serve others in their time of need. And grant those who have the responsibility, the courage to tackle with determination the change that is now desperately needed in the NHS. Amen