I joined the NHS in 1991 as an optimistic trainee. It was a time when GPs still did home visits and knew all their patients and families personally. District nurses were available to help people in the community, and mental health units were accessible.
We doctors were supported to do our work with onsite accommodation, free parking and staff canteens; we discussed patients and cases while sipping the occasional free coffee or tea on a night shift.
Despite this, it wasn’t a utopia. Junior doctors worked 120-hour weeks and undertook every basic patient intervention on the wards themselves, and we experienced sexism without having the ability to speak up. But we learned so much in those hours, and in the intensive time spent with more senior trainee doctors and consultants. When it came time to step up ourselves, we were ready on the first day.
When I became a consultant in 2001, I had a good work-life balance. I felt respected, I felt empowered, I had a professional contract. I was excited. We were able to have influence, modernise and implement change. Where I identified areas that could be improved, I could make proposals and test pilot schemes that were supported and invested in. When some of these were then rolled out, I felt proud to have successfully contributed to progress in the NHS.
Today, things are different at all levels. For juniors, there are fewer training hours; less team-oriented work; more tick-box competencies. I am concerned about the calibre of medics being trained for the future. Innovation and transformation have been taken away from the people delivering the actual services. Centralised managers and departments do that, and clinicians are only brought in as token endorsements.
After the 2008 financial crisis, austerity kicked in and with it came cuts to public sector spending. The first thing to go was bed capacity. Community hospitals were privatised or closed down. Some innovation in surgery and recovery helped to reduce the time patients occupied beds. But despite these measures, the overall reduction in beds and the lack of community services to move people on meant bed-blocking became routine.
England now has half the number of hospital beds it had in 1987. The biggest drop has been in overnight mental health and learning disability beds, as mental health has been moved into the community. Routinely, overflow beds are relied on, but not recorded in occupancy numbers: beds placed, for example, in inappropriate areas such as store areas and corridors with temporary screens for privacy and no suitable toilet or bathroom facilities.
Austerity measures also present themselves in the gradual decline in hospital estates, especially affecting the old hospital buildings that make up so much of the NHS. In 2011, the cost of maintenance issues was published as £4.6bn, of which £1.4bn was related to issues classified as high or significant risk to patients. By 2018/19, the costs had increased to £6.4bn – but now, £3.4bn was associated with high or significant risk to patients.
Add to this that savings initiatives have resulted in bare-minimum levels of equipment. Older techniques are sometimes utilised, for example needing to return to open surgery for appendicectomy instead of keyhole surgery if the camera and equipment stack is broken and not replaced. And IT systems are simply not fit for purpose despite huge NHS digital investment. Systems often do not communicate with each other such that X-rays and scans from one hospital cannot be viewed in another when required for surgery or treatment.
Staff have worked to keep the level of patient care as high as they can, but this does not stop them also being seen as a savings opportunity. Pay rises have been absent, or not matched inflation. Nurses were subjected to “down-banding”, or reduction in pay for the same kind of work – many staff were required to reinterview for their now-downgraded jobs. Staff sickness rates have increased steadily since 2011. Staff sickness rates of 3.8% in 2018 in England rose to 6.7% in 2022, with the most common cause being stress, anxiety and depression. The total number of NHS vacancies in June 2022 stood at 132,139. As the patient waiting lists surpassed 7 million, the expectation is that the staff just “crack on”, much akin to “just hold your nerve”.
The norm has become to go to work and not know whether the operating list will start on time or the clinic be over- or under-booked. It is unknown whether the special order equipment for the complex procedure will be available or working, or the drugs you need to administer your anaesthetic will be available due to ever-increasing supply line problems. It has become increasingly necessary to become more accepting of “making do” with what is available rather than what is best for the task.
The end result is a demoralised workforce and an inefficient NHS. We are told the NHS has to change how its workforce functions. There is a preference for allied health professionals and more generalised and flexible middle-grade medics to be used. But this won’t fix the material problems facing the service, and does not value consultants, the highly skilled specialists with the breadth of knowledge required to be the progressive medical experts in their fields.
Consultants now feel disempowered, unvalued, no longer treated as medical leaders. It is incredible that these workers are not recognised for the years of training that enable them to work with microscopes in the eyes and hearts of babies, with robots in the brains and organs of cancer patients, and to medically manage countless diseases or undertake cutting-edge research.
At one time we felt like we had a hand in steering the health service. It was a communal effort, but one that valued individual contributions. Now, we increasingly feel like cogs in a broken and sputtering machine. We are told we are valued but that’s hardly validated when everyday working practice is compromised.
I cannot blame the hospital trusts that try their best to deliver services within unrealistic financial constraints: the cause of the decline lies firmly on the doorstep of No 10.
This is why 86% of 24,000 consultants balloted in England have voted to go on strike: their very clear message is that enough is enough.
Claudia Paoloni is a consultant anaesthetist working in Bristol
