Distant Voices (7 page)

The analogy with war crops up in casual conversation. In reply to my question about who suffered most, the nursing sister on duty in casualty said, ‘The elderly. This is a war zone, and you can't have elderly people lying about near the front line, now can you? You can't have them occupying a trolley when an emergency comes in; anyway, the trolleys play havoc on the delicate skin of the old. And you can never be sure when something's going to go wrong with them.'

Julia Branch, aged 79, a cancer patient, strayed on to the front line and spent nine hours dying and in pain on a hard trolley before being transferred to Dulwich Hospital, where
she died. She was put ‘on hold' during a ‘red alert', which is a period when only emergencies have priority, and planned admissions are cancelled without notice because no beds are available. Michael Mulhall, aged 52, with life-threatening heart disease, was turned away from King's College on the day he was due to be admitted. He died at home in the early hours of the morning, while his daughter Maria and son Gary struggled to resuscitate him.

‘It is a matter of deep regret', wrote the hospital's general manager, Julian Nettel, ‘that before we were able to make new arrangements for his admission, Mr Mulhall collapsed and died.'
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Said Maria, ‘Although they made clear my father died because the hospital had been starved of resources, they tried to cover themselves by saying he might have died on the operating table anyway. The point is, he was never given the chance. And, the pity is, he could've gone private: but he said doing that would only help to undermine the National Health Service. “I'll support the NHS,” he used to say, “until the day I die.”'
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This is reminiscent of
triage
, the French military policy during the First World War of deciding who among the wounded should be helped and saved, and who should wait and die. In the Health Service, a modified version of
triage
has been operating in certain British hospitals, especially during the winter months when the old are brought in, often as a last resort. ‘If you have one bed and two customers', said Dr Glucksman, ‘and one of them is middle class, has a hernia and can be sent home in twenty-four hours, while the other has pneumonia and lives alone, the temptation is to give it to the first.' That way the hospital makes more money. ‘Financial incentives', he said, ‘can overwhelm the quality levers. There are no longer enough safeguards to protect the patients.'
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Malcolm Alexander, secretary of Camberwell Community Health Council, which covers King's College, is in no doubt. ‘We believe that the concept of “institutional negligence” could be applied to this situation,' he said, ‘because when the district health authority closed 100 beds last year in order
to save £8 million, the managers either knew that their action would lead to 20- or 30-hour waits on trolleys in casualty, or they did not.'
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The point is that managers follow political orders, some more enthusiastically than others; and the assault on the Health Service, which began under the Callaghan Government of the late 1970s, has reached such a stage where the Major Government is vulnerable on that issue alone. Having written a great deal about the National Health Service during my time on the
Daily Mirror
, I am struck by the conspicuous absence of a coherent Opposition campaign.

This is not to underrate the interventions of Robin Cook and the hard work of Harriet Harman, Labour's spokeswoman on health whose constituency covers King's College; but something is clearly wrong when the National Health Service, an institution valued across class lines (and used mostly by the middle class), is being effectively dismantled by a government that could be re-elected in spite of its destructive agenda. Why is this so?

The question demands attention on arrival at King's College casualty. Near the entrance there is, or was, a pigeon's nest and pigeon droppings. ‘We feel it is inappropriate', says a Community Health Council report with fine understatement, ‘for debilitated patients to be exposed to this on the way into casualty.'
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The same report described filthy lavatories, overflowing dustbins, an out-of-order drinks machine and the humiliation of sick and troubled people. These people sit or lie so close to each other that, as you enter, there is a perspective that they are actually on top of each other. Some, slumped near the door, smoke and clutch a can of strong lager; the nurses are wise to let them be. Where medical treatment is unattainable within a decent length of time, and a hospital bed out of the question, a can of Tennent's and a fag is just the job.

There was an old man who came in the other night and who already had had quite a few Tennent's, or suchlike. His head was gashed open and blood spilled on to the floor. He shouted; and the children waiting looked at him in
apprehension; and he paced and shouted some more; and he finally left, only to return with another gash on his head. On the same night – which wasn't ‘too bad', said a nurse – Lillian Cornford lay on her metal-hard trolley, her eyes held tightly shut from the severe pain in her chest. She is 86. She had been there since eight o'clock that morning; after twelve hours she was found a bed.

On another night the main area and corridors of casualty were filled with people lying on seventeen trolleys. There were no beds available, because beds had been cut so that the hospital management could achieve ‘cost effectiveness'. On several of the trolleys were people suffering sickle cell disease, an hereditary ailment. Their screams expressed the degree of their pain. Others held their heads down and said nothing. During a crisis they need Pethidine administered to them every hour. The nurses in casualty, whose numbers are down because of their own ill-health, have the responsibility of keeping this up, knowing that a sickle cell sufferer can die during a crisis. Some of these people have lain on trolleys, side by side, nine inches apart, with the elderly and the inebriated and the bloodied, for up to thirty hours.

One of the nights I was there Jim Armfield, a 74-year-old retired postman, was admitted with a stroke after waiting more than two hours for an ambulance. He lay six hours on a trolley before he fell to the floor and fractured his skull. He later died from his injury. At the inquest the Coroner criticised the bed shortage, and the doctor who tried to save him said, ‘People don't go to hospital to fall off trolleys.'
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When people are brought into casualty at King's College one of their first sights is the padlocked doors of the children's casualty ward. For something to do, those waiting the hours peer through the glass at the empty beds, and the toys, and cheering pictures. ‘Two years ago we were told to balance our books,' said Dr Glucksman. ‘If we didn't balance them, we had to sacrifice the quality of treatment for 20 per cent of our patients in order to keep the quality for the remainder. The 20 per cent were the children. This was a real pity, because the ward allowed us to keep the kids away from the
sights of casualty; and for nurses to observe children in a small environment with their families and for us to be able to identify clinical problems that are more difficult to understand when kids are part of . . . well, you've seen it out there.'
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Camberwell has a high incidence of child abuse; for junior doctors and nurses to spot certain types of child abuse in the conditions that exist in the war zone would be, it seemed to me, quite impossible.

The casualty department was built in 1912 to accommodate 30,000 patients a year. It now sees 80,000 a year. Forty per cent of these are people who either cannot get on a general practitioner's list, or are transient, or homeless, or desperate in some way. King's College stands at the epicentre of the Britain of the nineties, in which structures of civilisation, long taken for granted, have been and are being torn down. The doctors and nurses know this. Several have left because, they say, professional standards will not allow them to continue.

The nurses who run casualty are a marvellous mixture of professional carer and brilliant make-doer. They speak out with nothing to lose; and they encourage the patients to do the same. ‘I tell them,' said one, “You have rights. Don't let yourself be treated like this. Write and write again.” I think we've got through to them. People are funny; they take it all, then suddenly they don't. It's difficult to describe the aggression we feel here, not directed at
us
, but at what they feel is being done to them.'
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King's College's management is probably like most post-Thatcher National Health Service regimes. Terms such as ‘purchasing services' and ‘customers' are the ingrained jargon now. When I asked Dr Glucksman if his use of ‘customers' instead of patients was ironic, he smiled and said, ‘No, unfortunately, I've got used to it. All those meetings have done it.' The top managers in health authorities are paid more than £60,000. The pay of most administrators is ‘performance-related', so that if they can balance the books – that is, close a children's ward – it's likely they will be marked for promotion, or get a ‘discretionary lump sum'.

Some of the managers are excellent professional administrators; yet the system has its way with them. The medical staff describe an authoritarianism that, they say, compounds the conditions under which they have to work. Some of the letters I was shown demonstrate this, demanding that doctors make cuts. In the haematology department the number of beds has been cut by half to four; and if a consultant wants to treat a leukaemia patient from outside the hospital's district, he must get permission. So whether the patient becomes a ‘customer' and is given a bone-marrow transplant, and lives or dies, can hinge on the decision not of a doctor, but of an administrator.

‘We have been threatened', said one doctor, ‘that if we go against these diktats – if we decide to treat people purely on medical and ethical grounds – our admitting rights will be taken away. We shall be allowed to teach, but not to treat sick people.'
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When doctors ‘sneaked in' sixty-one seriously ill patients, they were threatened with disciplinary action. When consultant Linda Cardoza spoke out in the national press about conditions at King's College, she was publicly upbraided by officials for ‘behaving in this way' and ‘damaging morale'.
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Yet one official told me he regarded much of the bad publicity as ‘important in the circumstances . . . but don't quote me'.

Secrecy is reinforced by the new order. Should King's College be allowed to opt out, as its management wants, the legal right of the Community Health Council to act as the public's watchdog may be withdrawn. According to a confidential Health Department document, trust hospitals need to be freed from ‘petty consultation', and there should be rules that ‘diminished the ability of CHCs to obstruct'.
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As a trust hospital, King's College would regard certain ‘customers', like those suffering from leukaemia, as ‘assets or liabilities'. ‘The system', said a consultant, ‘says that we take on certain surgery because it brings in more revenue, and that we neglect the Cinderellas.'

The managers deny this, and say they have fought for the well-being of patients along with the medical staff. They say
the problems ought not to be minimised, but ‘horror stories' are unusual. The chief executive, Derek Smith, told me that ‘the casualty and out-patient departments would be completely rebuilt, beginning next summer'. He said that the South East Thames Regional Authority had agreed, in principle, to release £34 million after consultations.

This is good news. Unfortunately, it will not be paid for by new money from the Department of Health, but will be part of an ‘acute services strategy' about which there is much scepticism. Although this has positive features such as the establishment of paramedical and trauma units, it will mean the closure of a number of London and near-London hospitals. As a result, people will have greater distances to travel to a casualty department, placing even greater strain upon the ambulance service. As the Community Health Council has pointed out, children suffering broken bones, head injuries and pneumonia sometimes have to travel more than an hour to Kent or Surrey before getting a bed. If this is the exception now, it could well become the rule with more closures.

During the general election campaign John Major showed us Brixton, his childhood home, from his chauffeur-driven, bullet-proof Daimler. As he drove along Denmark Hill the camera picked up King's College Hospital, over which the commentary extolled the government's record on the Health Service. It did not say that the previous October the health secretary, William Waldegrave, had announced more cuts to London's hospitals. Waldegrave was also in the area at that time and was asked by the Community Health Council to visit King's College. He did not acknowledge the invitation. ‘The secretary of state', said an official, ‘cannot possibly be everywhere at the same time.'
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Nor could Julia Branch, Michael Mulhall and Jim Armfield before they died.

January 3 to March 25, 1992

ON A DURHAM
beach in the early morning a figure approaches, etched against a grey veined sky, buffeted by a freezing wind. The sea is so black that the breakers are incandescent. The beach is black, a quarry of polished black stones and scabrous mud. There is no colour. The whites of his eyes peer from beneath a sack of coal so heavy he is doubled.

‘Coming back is worse than going,' wrote George Orwell of miners in
The Road to Wigan Pier
, ‘not only because you are already tired out but because the journey back to the shaft is probably uphill. You try walking head down as miners do, and then you bang your backbone. Most of the miners have what they call “buttons down the back” – that is, a permanent scab on each vertebra.'
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