"Premium Patients" and the septuagenarian NHS: a rant by Julia Jones

My partner Francis has just emerged from a brief stay in hospital to have a hip replacement. It’s one of those blessed operations, like cataract surgery, that have become almost a rite of passage for us over-sixties. “Oh I’ve had three of those,” people say and one looks for the extra bulge that has turned them into a tripod. A successful hip replacement wipes out months of debilitating pain, sleeplessness, inability to walk up or down stairs without howling agony. Living in a country where such a major operation is relatively freely available is an absolute blessing. So thank you, fellow citizens, for continuing to fund our NHS, 70 this year ... and with aging problems of its own.

As we baby-boomers move through the system that is almost our coeval, we block beds, stretch resources and look likely to show our appreciation of our lifelong free-at-the-time-of-need health care by continuing to live longer and longer. (Sorry, everyone.) Francis was among the increasing number of NHS funded patients who are diverted into the private system for these “elective” operations. The NHS eye operations I had last year were described by one sassy young surgeon as my “lifestyle” choices – pandering to my self-indulgent wish to be able to continue to see, rather as Francis would greedily like to be able to walk, sit, lie down, sleep... (Sorry again?)

He had a well-equipped single room in this nice private hospital but we were put properly in our place by the visiting arrangements.  I wish I’d taken a photo of the notice in this hospital reception. Here’s the website version, copied verbatim.

NHS Patients

Lots of noise and groups of people can cause upset for some patients, as such we request that the following visiting hours be observed 2pm to 4pm and 6pm to 8pm.  We also ask that there are no more than two visitors at the bedside at any time and that all visitors report to the ward reception first, so that we can ensure visits do not disturb patient care.

Premium Care Patients

Friends and relatives are welcome to visit at any reasonable time of the day before 9pm.  We ask that all visitors report to the ward reception first, so that we can ensure visits do not disturb patient care.

Francis and I arrived just before 7 am on the morning of his operation and sneaked past the ward reception, which was empty. He'd been told that I was only “allowed” to drop him at the main entrance and then I should leave. “She can’t come down to the ward, you know.” But I came anyway and sat quietly in the corner of his single room, not upsetting anyone, I hoped, with my wild NHS-funded propensity to riot and to party. 

The first nurse who arrived asked Francis (quite correctly) if he minded talking in front of "this lady”. When he confirmed that this was okay she seemed pleased to let me learn how to help with the surgical stockings – this would after all be one of my duties for the next six weeks (though no one from the hospital had actually asked me if I was available and willing to do this). Next to drop in was the surgeon. Did he mind me being there?  He looked mildly surprised. “Not at all. It’s rather helpful. I need to be going through the issues of risk and consent again.” The anaesthetist was similarly friendly and I hoped that I justified my presence by mentioning how difficult the "intubation" had been when Francis had had a previous operation at this same hospital several years ago.  (There wasn’t anything recorded in his notes.)

Francis, of course, could have managed all of this alone (except for the stockings) but where was the harm in me keeping him company so early in the morning? Why the blatant unfriendliness of the phone call and the notices? Thousands of our contemporaries may be flooding though the healthcare system to have hip replacements but, for each of us the first time is an individual experience, in which we are likely to have invested great hopes, but about which we might well be privately scared.

And being scared has a practical impact. When Francis and other patients were in the recovery room later that day there was a man in great distress, trying to pull out his cannulas, shouting and crying, completely confused, needing the attention of several staff members to keep him restrained and safe. Perhaps he’d simply had "a bad trip" (as we might have said in our unregenerate 1960s and 1970s) more likely he had dementia. A blog on the Johns Campaign site this week confirms that many people living with dementia are unable to have their pre-booked operations when the day comes because they are already too frightened to be anaesthetised.  Many more people living with dementia, especially those having hip repairs, suffer post-operative delirium. Delirium is a hospital-stay-lengthener (bed-blocker!) and a patient-life-shortener (that's premature death, to you and me). .

People as old as I am (b 1954) can remember what was like waking up after an operation as a child without the reassurance of a parent present. An anaesthetist friend a little older than me can remember the difference it made to her job when parents were first involved to support their frightened children. She was one of the first professionals to support John’s Campaign as Nicci Gerrard and I attempt to ensure that our parents have the same opportunity for loving companionship through hospital admissions that they obtained for us so long ago. The hospital where Francis was being treated boasted two dedicated parent-child rooms but made no provision at all for patients with dementia.  Perhaps they assumed they wouldn’t have any? Yet, unless they were NHS cherry-picking (which their website strenuously denies) they should expect approximately 20% of their elective joint replacement patients to have at least mild cognitive impairment (MCI). In a hospital performing emergency surgery the % soars (it's up to 80% of the over 65s).

But let’s return to hospital as a place of rest and recuperation as well as treatment. My family make it a running joke that I only signed up for my four eye operations during 2016-2017 as an excuse to lie in bed and read – actually it was so I would still be able to read, which without the brilliance of the Moorfields surgeons who repaired macular holes in both eyes (yup, age-related once again) I would no longer be able to do. Closer to personal survival than “lifestyle” i m o.  This was day-case surgery; rest and recuperation took place at home. When I spent a week as an inpatient in my local hospital with a badly broken leg a few years ago, I waved away most offers of visits in order to keep up the three-book-a-day average that, for me, constitutes a perfect holiday. I’m sure my leg healed the better for it.

Francis entered this hospital with a nicely topped-up Kindle, a phone-full of audio books and the inclination and mental capacity to enjoy them.  Restricted visiting was not going to be a problem for him – apart from the implicit insult that we NHS types need corralling into 2 hour slots as we can’t be trusted to behave with proper consideration for others. In fact it was the hospital itself that consistently interrupted his rest: a bewildering procession of nurses, therapists, doctors, pharmacists and “hostesses” came in and out of his room, usually without introduction,  scarcely ever the same face twice and seemingly with little internal communication or access to his notes. Some knocked as they entered and closed the door behind them: others didn't. Nevertheless they were all of them essential and dedicated to the single aim of getting him fit enough to return home and crank up that Kindle whilst continuing with the exercise regime and trying to keep our relationship in good repair over the next six weeks as we struggle with those stockings. They succeeded and we’re happy – and yes, fellow citizens, we're very very grateful.

Yet what if Francis had been that poor chap shouting in the recovery room, what if he’d been one of the 1-in-5 who will already be living with MCI when the pain of arthritis urges them to consider a hip replacement? “People with cognitive impairment should receive the same standards of and access to healthcare as people without cognitive impairment.” (This is a quote from a draft document setting new standards in anaesthetics. I can't cite it as it's not yet published.) I believe access and provision need to be a little better than the norm for people with cognitive impairment. Dementia is a disability, like vision loss. Equality and human rights legislation surely require that special arrangements should be made for these citizens' access?

I did check whether an NHS patient with cognitive impairment could be upgraded to “premium” status in that private hospital -- and their family carers therefore entitled to visit  without restriction -- but no. Currently “open visiting” is  only related to the funding source not the individual need. I haven't named the hospital as I'm hoping, when their position is pointed out to them, that they will change. 

Meanwhile. here’s a bit of my favourite reading – probably not on your Kindle, though it probably should be: it's the NHS Constitution. 

The NHS belongs to the people.

It is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of our lives. It works at the limits of science – bringing the highest levels of human knowledge and skill to save lives and improve health. It touches our lives at times of basic human need, when care and compassion are what matter most.

The NHS is founded on a common set of principles and values that bind together the communities and people it serves – patients and public – and the staff who work for it.

I know I've said this before but this is a document we should ALL read. Here are its principles: 


1. The NHS provides a comprehensive service, available to all

2. Access to NHS services is based on clinical need, not an individual’s ability to pay

3. The NHS aspires to the highest standards of excellence and professionalism

4. The patient will be at the heart of everything the NHS does

5. The NHS works across organisational boundaries

6. The NHS is committed to providing best value for taxpayers’ money

7. The NHS is accountable to the public, communities and patients that it serves

and its values: Working together for patients: Patients come first in everything we do. We fully involve patients, staff, families, carers, communities, and professionals inside and outside the NHS. We put the needs of patients and communities before organisational boundaries. 

Respect and dignity: We value every person – whether patient, their families or carers, or staff – as an individual, respect their aspirations and commitments in life, and seek to understand their priorities, needs, abilities and limits. 

Commitment to quality of care: We earn the trust placed in us by insisting on quality and striving to get the basics of quality of care – safety, effectiveness and patient experience – right every time. We encourage and welcome feedback from patients, families, carers, staff and the public.

Compassion: We ensure that compassion is central to the care we provide and respond with humanity and kindness to each person’s pain, distress, anxiety or need. We search for the things we can do, however small, to give comfort and relieve suffering. We find time for patients, their families and carers, as well as those we work alongside. We do not wait to be asked, because we care.

Improving lives: We strive to improve health and wellbeing and people’s experiences of the NHS. We cherish excellence and professionalism wherever we find it – in the everyday things that make people’s lives better.

Everyone counts: We maximise our resources for the benefit of the whole community, and make sure nobody is excluded, discriminated against or left behind. We accept that some people need more help, that difficult decisions have to be taken – and that when we waste resources we waste opportunities for others.

As the NHS gets older -- and so do we -- these principles and values matter to us all.