SQUALID, IDLE, DESPERATE: WELCOME TO THE NHS

The government knows that the health service is imploding but won't

admit it. Christopher Silvester talks to a surgeon who is quitting

because of low morale and misery on the wards

AFTER several years of medical training, Jeremy Burnham, a 31-year-old surgeon who is a Fellow of the Royal College of Surgeons and has been appointed to a registrar's post at a London teaching hospital, has decided to leave medicine and work in the pharmaceutical industry. His defection goes to the root of what is wrong with the National Health Service. Burnham — his name has been changed for this article — comes from a conventional, middle-class background in Oxfordshire, where he attended a minor public school. He has no political axe to grind but he does have some disturbing stories to tell of the front line.

Burnham trained at Barts, the London teaching hospital that has since been closed. It was impressed on us how we were very privileged to be given this training. Certainly, the consultants who were teaching us enjoyed a good standard of living and all seemed to enjoy their work — and again they seemed to get a lot of respect from patients and from the community at large. As I reached the clinical stage, probably about the third year out of five, I started talking to junior doctors and realised that these guys were doing 120 hours a week. But I still had another two years of medical school and I was quite interested in doing a BSc.; which I did, in genetics. This was in 1991, and none of the Tory NHS reforms had worked their way through yet. At that stage, you never heard disillusioned consultants criticising colleagues or talking about how pleased they were to be retiring, which is the case now, every day.'

The introduction of the internal marketplace in the NHS was, in Burnham's estimation, a turning-point. Departments had to compete for budgets and empire-building became far more conspicuous. 'All of a sudden, consultants began to criticise each other in public, in front of juniors, in front of medical students — you'd never have found that happening previously.' Since those Tory NHS reforms were introduced, the tendency has been for doctors to adhere to the letter rather than, as before, to the spirit of their contracts. 'The NHS, historically, has had a fantastic deal from doctors, based on team spirit. They stayed late, largely unpaid. Operating lists that were due to finish at four-thirty or five routinely carried on till six-thirty or later, on goodwill, because the surgeons wanted to get the job done. That team spirit suffused the whole hospital. Nowadays, come four-thirty, the anaesthetists say, "We're not being paid, we're not doing the last two or three cases on your list." The nurses say, "We're not getting paid." The surgeon might want to do it, but you're

often losing two or three hours a day. The impetus to get through the workload is no longer based on goodwill; it's based on wanting to get out of the hospital at fourthirty. If you add to that the gradual decline in doctors' wages in real terms, the hours issue and the negative press, then you have far more doctors questioning their lot.'

Burnham first thought about leaving the profession during his early months as a senior house officer. He still finds surgery academically interesting, and the key factor in his decision is not the money so much as the unsatisfactory working environment. 'There's been an extraordinary haemorrhaging of nursing staff, and the decent nurses are all leaving because their relative pay has deteriorated. They introduced a degree system for nurses, Project 2000. All the good nurses enrolled, were taken away from the wards for the duration of their degree, then moved into management or left nursing altogether. So you actually trained all your good nurses to leave! All the nurses now are on Bank, which is an agency, because that way they're getting paid two or three times the money of permanent contract nurses. There are times on my ward when you do not have a single nurse who is trained in the speciality. More than that, there are times, usually at night, when they are all agency — i.e., you've never met any of the nurses who are on duty and they've never met the patients before. Continuity of care simply no longer exists.

'As a surgeon, that's pretty demoralising, because your surgery's only as good as your post-operative care. I know consultants who used to do ward rounds as a matter of course three or four times a week, and who now won't do them because it upsets them to see so much that hasn't been done, and they've just given up complaining as they know they're wasting their breath. Similarly, half of the nursing staff are from the Philippines or from Australia or wherever, so you have this very transient population, and you know that their next step will be to move to the United States. Without some training they won't get accepted in the States, and we give them that training.'

Burnham is sick of the squalor on the wards. Surgeons' logbooks are now stuffed with reports of wound infections, which was not the case five years ago. 'I wouldn't want to be an in-patient on many of the wards I work on,' he says. And this is in a teaching hospital that's supposed to set the very highest standards.' He is also sick of the way doctors are treated. The on-call rooms in his hospital, where the doctors on duty at night grab a few hours' sleep, have filthy floors and the beds often haven't been changed. About 40 doctors share unisex loos, some of which don't have doors.

Compared with his peers in either law or accountancy, he has fallen so far behind in salary terms that there is something like a

50 or 60 per cent difference. Within the NHS, doctors pay differentials have been eroded, 'A newly-appointed consultant 20 years ago was on four times a newly-qualified nursing sister's salary. Now it's just under two times. Their relative training is this: a sister is probably at nursing school for two or maybe three years, and then probably has six years before qualifying. To become a consultant, it's six years' medical school, tenure, then eight to ten years' post-medical-school training, with a vast number of exams in between, and also you're taking ultimate responsibility for the patients. Please understand that I think nurses, too, are vastly underpaid. As a result, you can't attract the people, and if there's no one to fill the posts, you can never fire anyone for being bad,

'There is an immense amount of good in the NHS and many of the people who work in it are undervalued and taken for granted, but there are also a lot of crap people there who couldn't get jobs elsewhere. You walk into the medical secretary's office and there are notes literally reaching the ceiling, all over the floor and all over the desks. Why? Because they're paying medical secretaries, which is a real skill because of the technical terminology that's used, £12,000 or £13,000 — so far below what a legal secretary gets, which is a comparable skill, that the good ones are all leaving.'

Burnham reserves particular scorn for the Health Secretary Alan Milburn's proposal that NHS consultants should be prohibited from doing any private work for the first seven years after being appointed, because he sees this as another way of undermining their professional autonomy. 'You feel as if you really are just a number working in the system. Milburn says that it's about time consultants gave back to the NHS some of the cost of their training. But if you look at how hard you work as a junior doctor for eight to ten years, for a salary which is way below what your peers are earning, and at some point you catch up a little bit with some income from private work, then to be told that you've not paid back to the state what you owe for your training — it's just so insulting.'

Consultants' salaries start at £51,000, rising to .£66,000 within five years, but remain pegged at that level until retirement, although there are cost-of-living increments and discretionary merit points and merit awards. Only 300 out of 24,300 consultants will be on the top merit awards, taking their NHS salaries up to £128,000 in the last few years of their careers, but most of them are in academic posts and are restricted from doing private work.

'I don't actually mind about the money,' says Burnham, 'Far more important is the respect issue. My understanding of what it meant to be a professional was that you had autonomy, and, while I accept that there has to be a service commitment, I think that to be told when you can or cannot do private work is completely unac

ceptable. It's the total lack of respect, the total anti-doctor feeling that this government has, that I find upsetting.'

For Burnham to pursue a career as a consultant, even with three or four sessions of private work per week, he would have to take a drop in his standard of living compared to that which his parents enjoyed. He wouldn't be able to afford the kind of home in which he grew up, or private education for his children, and his wife would definitely have to work.

'It's politically led rather than patientled, more so than ever before. The surgeons say, time and time again, we can only have, say, six patients on the operating list. It used to be that you'd get the correct number of patients on the operating list and the registrar and consultant would select them. Now, to try and meet these waiting-list targets, the managers say it's got to be ten. They've no clinical knowledge, yet they override doctors. Those ten patients come into hospital. You know that four will get cancelled. They'll be starved from midnight the night before, they'll be kept waiting all day, and at five o'clock you'll spend the first 40 minutes of your ward-round apologising to people, with them screaming at you, in tears. And it happens week after week, until they have a waiting-list drive to do all the people who've been cancelled because, once you've been cancelled three or four times, the hospital will get fined. The managers wave their chequebooks to meet their targets, offering to pay nurses three times what they'd earn on Bank, then it's back to normal. After a while you don't feel any empathy for those people who've been cancelled, who've sat there all day and put their lives on hold, because it's just part of coming into hospital. Then you think back to what it used to be like and what it should be like — and you realise what a hard bastard you've become.'

Burnham doubts whether the current generation of surgeons in training are being trained to the same standard as in the past. 'It used to be that people came from all over the world to our private sector,' he explains, 'whereas that will certainly not be the case in future because if you're not trained in the techniques you can't use them. With treatments and diagnostics and surgical techniques that are routinely available in other parts of the world not being available here on the NHS, and with doctors in private practice not being trained to perform them, it will start to have an impact on the chattering classes, who now feel protected by their private health insurance. Also, the older generation of nurses, who are very good, are all in private hospitals, but they're coming up to retirement age and suddenly the private sector is going to be exposed to the nursing crisis that is facing the public sector. Once that starts to happen, people will begin to see what a state we're in.'

There will definitely be a two-tier system, he believes — only the lower tier will represent not merely the NHS but British medicine as a whole, both public and private; while the upper tier will represent those treatments that are available in other developed countries for those who can afford to shop abroad.

'I think New Labour are fully aware that the NHS is imploding but they can't afford to admit it yet, so there's got to be a period when they are seen to be throwing money at it. All the bad news in the media, all the anti-doctor sentiment, is having its effect on the public, and the respect you once had is no longer there. It's a genuine thing to want to be respected in your working life. And you can see where these patients are coming from when they're sitting there talking to you and there aren't any notes because they haven't been typed, and they end up coming to a clinic appointment on an operating day which is cancelled, and that's already happened to them twice before. The person they see on each visit is the doctor. You can see why the lack of respect is reinforced,'

Burnham is not alone in his disenchantment. The line that he frequently hears among the better surgical registrars is this: 'I love my job. I love the subject. But I'm outta here.' They're sitting exams to go elsewhere — Canada, the US, Australia. 'There's nothing to keep young surgeons in a city where we can't afford to live, let alone afford private education for our children, or whatever other middle-class aspirations we might have. I went to a christening the other day and three doctors said that about 15 per cent of their medical-school contemporaries have left. The sentiment among the other junior doctors is "Good on you!" And that, I think, is more shocking than the statistics. What is even more shocking is that their consultants are saying that, if they were at our stage, they'd be leaving too.'

Christopher Silvester edits the Brutus column for the Daily Express.