It’s 6am on a Saturday in November, and most sensible people are still asleep. My alarm clock rudely reminds me that I am not one of them. I am down for a 12-and-a-half-hour shift, and I have slept poorly. I get dressed and drive to work. I don’t have time for breakfast. It’s still dark, and there is no traffic to contend with, but I feel as if I could nod off at any moment. I arrive at the hospital, a large regional hospital in the east of England, and put on my uniform – a shapeless blue polycotton tunic with ill-fitting trousers and a pair of old running shoes. I walk on to the ward at 7am to find the night team still busily rushing around. The night has been terrible, they say – patients have been up and down constantly.
I glance at the staffing board. The orthogeriatric ward, for elderly people with fractures, has a capacity of 28 patients, spread across bays and side rooms. For staffing purposes, the ward is split into two roughly equal halves. On my half of the ward, there is a nurse and two healthcare assistants – I’m one of them – to help with basic patient care. I feel the tension in my shoulders dissipate slightly as I see that I’m due to work with a friendly and capable colleague, and I feel today might not be as bad as yesterday. No sooner has this thought formed, however, than her name is crossed off the board. She’s being moved to another ward, which is even more short-staffed than ours.
We take handover from the exhausted night team, jotting down basic information about each patient, and begin our shift. The ward I’m on is supposed to be for people with broken bones, but we have had to take several neurological patients, after one of the neuro wards was closed due to a Covid outbreak. Several of these patients have survived brain haemorrhages but sustained damage to the part of the brain responsible for motor coordination. This means that they are prone to losing their balance and falling. Another of these patients has dementia and wanders around the ward talking to anyone who’ll listen to him, and is also at risk of falling. The ward is neither equipped nor staffed to accommodate these kinds of patients, and many of the staff feel as if they have been offloaded into our care without consideration for their safety. The upshot of this is that the bay housing the fall-prone patients must be “tagged” – that is, someone must be there at all times to prevent them coming to harm. On the ward, we refer to this as the “falls bay”.
The situation is further complicated by the fact that it often takes two people to wash some of the geriatric patients and change their bedding, which is frequently soiled during the night. The nurse and I decide to split up in order to maintain a presence in the falls bay, even though this means we may be unable to wash some of the patients. The plan is to get them all washed and dressed by the afternoon, then to fill out a slew of paperwork to certify that we have done so. The nurse remains in the falls bay to watch the vulnerable patients.
On my assigned bay, I find a patient who is covered in his own excrement. His sheets are sodden and his clothing is ruined. He apologises profusely. Despite having advanced dementia, he seems to understand his situation, and I feel as if I’m about to cry. I have no choice but to clean his hands and face, cover him over in a clean sheet and move on, as he requires two people to wash him, and time is of the essence. I promise myself I will return and help him as soon as possible. I move on to the next patient and begin his wash instead. Just as I do so, I hear a shout from the direction of the other bay, a piercing “Can I have some help please!” A patient has climbed out of bed and hit his head on the floor. The nurse watching the bay wasn’t able to get to him in time. He is a sweet man who reminds me of my grandfather. Today is going to be difficult, and there are still 12 hours left.
I never planned to work in medicine. I was doing a literature degree. Then, in my second year of university, I fell ill and required hospital treatment. It was a routine medical issue, a streptococcal skin infection, but one that can quickly become serious if untreated. I was nervous, because the GP had missed the diagnosis, and the problem was getting worse. Luckily, I was treated by an excellent registrar who understood what was wrong and prescribed the correct treatment. I was struck by how much he seemed to enjoy his job, and the care he took over such a simple case as mine, and I realised this was what I wanted to do with my life. I hadn’t taken science A-levels, but luckily there is a route open to people like me, known as graduate entry medicine. A graduate entry course in medicine lasts four years as opposed to the usual five or six, and is designed to prepare graduates of any discipline for a career in medicine. It is highly competitive. I applied last year and didn’t get in, so I decided to get a job in the NHS and reapply the next year.
Becoming a healthcare assistant (HCA) was a straightforward process. It consisted of several seminars, a half-day course in moving and handling and various online classes about care work. Within two weeks I was on my first shift. The job of the HCA is to do the manual and administrative labour that nurses and doctors don’t have time to do. This means taking care of patients’ personal hygiene, taking observations at regular intervals (blood pressure, heart rate, oxygen saturation and so on), and helping patients to eat, drink and use the bathroom. We are also trained to administer CPR, and to operate a defibrillator in emergencies. The role is paid a basic rate of about £19,000 at entry level, and there is limited scope for career advancement.
The eight months I spent on the wards has enabled me to understand what it was like on the frontline of the NHS. It has shown me how much patient care suffers in a system in which underpaid, overworked health workers are forced to deliver care without proper staffing.
By 9.30am, things seem to be slowly improving. Progress is being made with the washes, and the team has rallied around us. The senior nurse in charge assures us that we can abbreviate the washes to save time, by only washing the patients’ armpits and groins. One of the student nurses from the other side comes across to help me with the washes that require two staff. She is good company, and already very good at her job, even though she isn’t paid for her work. We manage to wash the man who had soiled himself, who shakes my hand vigorously, and informs me that I am “a very good boy”, before telling the student nurse she is a “lovely girl”. We both smile.
Washing patients is a laborious business, but doing it does make me appreciate my own independence. If you’re bedridden, you have to be washed by hand by carers, and you often never feel truly clean. There are occasions when patients refuse to be washed. I recall one shift when a nurse and I were tasked with washing a highly aggressive patient with dementia. We approached him quietly while he was sitting in his chair and asked him if he would like a wash. His response was not overtly negative, so we started with his face and hands. Within about 30 seconds he’d managed to give the nurse a nosebleed, and set about hurling everything within reach across the room, including a cup filled with spit. The nurse and I had to duck and cover behind a vacant bed on the other side of the room and wait for the objects to stop flying.
At about 10am, I get my first break. We get three breaks a day: two of half an hour, and one of 15 minutes. The time we spend on break each day isn’t included in our hours and we don’t get paid for them, despite being at work for the full 12-and-a-half hours. Food options are limited. There is a canteen, but it is on the other side of the hospital, and walking there and back takes 10 minutes, leaving only 10 anxious minutes in which to eat once you’ve waited in line for your food. The other option is the hospital shop, which is just down the stairs, but the prices are exorbitant. Most of the staff bring their lunch in from home, but I often forget. I understand the principle of captive markets at airports, petrol stations and sports stadiums – but at a hospital? It strikes me as a little crass to take advantage of people in this way.
When I get back from break to relieve the nurse in the other bay, she tells me that one of the patients is deteriorating and has been classified as “end of life”. His breathing is fast, his blood pressure is low and his pulse is irregular. The family have been called in to say goodbye, but there’s no telling if they will arrive in time. The student nurse and I give him a wash and reposition him to make him more comfortable. I decide to give him a wet shave as well, which he seems to enjoy. Things appear to be under control for now, so I tell the student nurse I’m going to catch up on paperwork. She nods and tells me she will stay with the man who is passing away. She removes her gloves and holds his hand.
The paperwork I am required to fill out for each patient is extensive, and sometimes feels excessive given the workload. There is one document that certifies the patient has been checked on, which must be filled out every two hours, and another, to be filled out daily, that assesses the patient’s body for bedsores. The purpose of this paperwork is partly to provide information about a patient’s care in the event of a legal claim or complaint being lodged against the hospital. The problem is, as I quickly found, that we are so busy and understaffed that by the time I get around to filling out the paperwork, sometimes at the end of my shift, I have forgotten most of the information I am supposed to provide. I am required, for instance, to remember what the backside of each patient looked like, and whether each patient’s heels were pink or red and, if they were red, whether they blanched under pressure or not. These documents are supposed to be filled out at the bedside, but the pace of the job makes this impossible. You can’t leave a patient in difficulties or in danger of falling while you fill out a form.
By 11am, the patient with mixed dementia has wandered out of the bay again, and is talking to the staff in graphic detail about his marriage. He approaches one of the consultants, who looks annoyed, so I lead the patient over to where I’m doing my paperwork and he sits with me while I’m writing. He is interested in what I’m doing, so I give him a piece of scrap paper and ask him to help me with my work. He puts me in mind of a lecturer I had at university. As far as I can understand, he was a scientist, but although he can tell me the relative atomic mass of lithium, he can’t work out how to tie his shoelaces, or understand what sort of building he’s in. I manage to persuade him to go back to bed, but feel sure that he will be up and about again shortly. I later find out from his family that he used to be a neurologist.
By midday, I have managed to catch up with the paperwork, and the call bells have abated temporarily, but as it is a weekend, there is nobody to answer the phone, which has been ringing all morning. It’s always a risk answering the phone, particularly from an external number. Patients’ relatives – though in the main understanding – can be unreasonable and at times abusive. I decide to take the risk. The lady on the other end of the line wants an update on her mother’s condition, and is angry that she has been kept waiting all morning. I assure her that we aren’t doing this on purpose, and tell her we are very short-staffed. She says something like: “That’s not very good, is it?” I agree with her, but her tone suggests that this is not an expression of solidarity.
While on my lunch break, I get chatting to one of the nurses. She is complaining that she only gets two hours of sleep per night because she’s so anxious before every shift. She tells me she thinks the profession she entered 15 years ago feels like a distant memory, and that she no longer enjoys her job because she is so overworked, and the ward so understaffed. I struggle to know what to say to her to make her feel better. After all, she’s right. More or less everyone who works in the NHS thinks the same. I reassure her that she is an excellent nurse, and that she is clearly in the right job. She laughs.
People who work in care do so because they take pleasure in helping others. But if they are forced to work in places where there aren’t enough staff to properly care for the patients, a vicious cycle takes hold. It becomes harder to offer good care, and the work becomes even tougher and less satisfying. In the worst cases, people are forced to work in a way that is unsafe, and patients’ lives are put at risk. Care staff begin to lose faith in their profession, and in the institutions where they work. So more people take sick leave, or seek other types of work, which leaves even fewer staff, stretched even further, and patients getting worse and worse treatment. It’s not that carers are lacking in motivation, it’s that they don’t feel able to do their jobs properly. It’s not the fault of the management either – indeed, the ward I worked on had excellent leadership, and uniformly dedicated staff. There just weren’t always enough people.
Fortified by strong tea, I return to the ward at 1.30pm. The patients seem to have settled down for lunch. The lady who dishes out the patients’ food is angry again. She always seems to be angry with us. She’s upset because nobody has helped her distribute the food. She often does it herself, but isn’t supposed to, as she’s employed by a private catering company and isn’t insured to interact with patients. Ridiculous though this may sound, she has a point, so I help her hand out the last few lunches.
This is an issue with privatised aspects of the health service that people seldom discuss – the friction created by having different employers. I spend the next half hour attempting to feed an elderly lady with advanced dementia. She seems to have forgotten what food is for, and how she’s supposed to eat it. She interprets my attempts to feed her as some sort of elaborate joke, and laughs each time the spoon approaches her mouth. I manage to trick her into eating some of her meal by laughing along with her.
When I walk out of the bay into the nurse’s station, I’m told by a colleague that a patient at the other end of the ward has passed away. The death was expected, but the patient died alone in a side room. My colleague asks whether I want to learn how to perform “last offices” – the final act of care we provide once a patient has died. I recall being told about this during my induction, and the pang of fear I felt as the process was described.
When we enter the room, the patient looks as if he is sleeping, yet there is something missing when we enter, as though whatever force animated his body has dissipated into the air. Another carer asks my colleague whether we should try to close the patient’s eyes. He tells her she’s welcome to try, but it might not be easy as the muscles that control the eyelids go rigid shortly after death. Before we wash the patient for the last time, my colleague reminds us of the importance of treating deceased patients with the same courtesy and respect as one would treat the living. When we’re finished, we wrap him in a sheet, and my colleague opens the window slightly to let in some air. I find the whole experience very difficult and, saying I’ve forgotten to do something in the other room, I leave.
Things take a turn for the worse around 4pm. Everything suddenly seems to be happening at once. Two patients are now wandering around the ward, and the call bells are numerous and deafening. There is a phenomenon known as “sundowning”, which affects patients with dementia during the evening, making them more agitated. It’s a badly understood concept, but it seems that the change in the light outside as the sun sets affects their neurochemistry and causes their behaviour to change, sometimes quite dramatically. One of these wandering patients has taken to picking up random objects and throwing them at staff. Security is called, and two of the largest blokes the hospital can send arrive to put the patient back to bed.
The NHS has a very particular problem in caring for such patients in a humane and dignified way. We are caught up in what’s called “health inflation”: the increase in costs of medical treatment, as technology and medical science advance. The combination of two factors – an older population and the growing capacity to keep elderly patients alive for longer – presents a dilemma not just for the NHS, but for society as a whole. There is, sadly, a point at which continuing medical intervention ceases to be in the patient’s interest, but deciding when to withdraw treatment is very difficult for everyone involved. We need to answer the question of when to stop. People often worry about dying too early, but having worked with demented patients, I am just as terrified by the prospect of dying too late.
I spend the next few hours answering call bells: this usually means getting commodes, repositioning patients to avoid pressure sores, cleaning patients who’ve opened their bowels, or asking the nurse to provide pain relief to those who need it. At one point it feels as if I’m running between bays, and it seems that whenever I enter a room to answer one call bell, another patient collars me and asks for something else. In all the excitement, we have failed to tag the bay with the fall-prone patients, and I arrive just in time to prevent an elderly man from clambering out of bed.
Just as I’m leaving the bay, a stony-faced relative approaches me and demands an update on her father’s most recent MRI scan. I explain to her that I’m not qualified to comment on it, but will inform the nurse of her query. A man I understood to be her son stands up and says, “Well, what are you here for then?”, his face ablaze.
Towards the end of the day, the pressure has intensified to the point where we aren’t able to get even basic aspects of care done. An elderly lady who has asked for a bedpan several times ends up wetting the bed, and I find her in tears. I know it is my fault that I didn’t manage to reach her in time. The ward sister pitches in to help us. She is extremely experienced, and strikes the right balance between seriousness and compassion, with both her staff and patients.
Sometimes I wonder what will happen to the NHS when this old guard of nurses eventually retire. Despite the hours, and the physical cost of the work they do, they battle on to lead the troops, still quite prepared to get their hands dirty themselves. When the night team arrive, just before 7pm, we know we’ve made it through the shift. The nurse hastily fills out all the paperwork while I watch the falls bay. The shift has been so hectic that by the end I feel as if I’ve been in a car crash.
Night has fallen by the time I walk out of the hospital towards the car park. I pause for a moment and look up at the maternity block – a 1980s monstrosity thrusting into the sky. I think of how strange it is that I was born in that building – in some hot little room that has seen the arrival of thousands of babies. I can’t help but wonder how things could have deteriorated so much in such a short time. I feel an oblique sense of guilt at not having been able to help everyone as I should have today, and as I reach my car, I think of my own grandmother. She’s in her 90s, but still living independently. I worry about the idea of her being an inpatient on a ward like mine, unwashed, unable to sleep and surrounded by staff unable to properly care for her.
Working in healthcare shows you a side of it you sometimes wish you hadn’t seen. My experience of the NHS as a patient has been largely positive: I was born into it, and it has saved my life on one occasion since. I also love working in it: the people who staff the NHS restore my faith in humanity. But while I don’t have children of my own, I worry that the NHS I was born into simply won’t exist by the time I do.
If we stay on the current trajectory, the NHS will become more and more dysfunctional, and the private sector will increasingly step into the breach. This is already happening, and one wonders if this hasn’t been the government’s intention all along: to slowly crash the health service and to let people opt for a private system of their own volition. People should know that there are alternatives to this future. The NHS can be properly funded, or it can be reformed to keep it afloat. Either outcome would be preferable to the current situation. People should feel angry about the way the NHS has been neglected over the years. That’s certainly how I feel. But what I feel above all else about the NHS – above my anger at the government, above my sympathy for my colleagues and their patients – is grief.