Life at the sharp end

Everyone knows that the health service is in crisis and needs reform. But how much do we know about the realities of life on the medical front line? Julia Stuart spends five days in hospital watching one of Britain's biggest NHS trusts in action

Monday

11am In the treatment room of ward PPW3 in University College Hospital's haematology department, senior staff nurse Claire Carter, 27, is calmly loading her tray, which she has meticulously cleaned with an antiseptic wipe, with syringes and drugs. She started work at 7.30am and is due to finish at 9pm. She doesn't mind as she's got tomorrow off and will spend the morning sleeping. The radio is playing "Have a Nice Day" by the Stereophonics.

11.25am One of her patients, Patrick Harkin, 60, is sitting in an armchair in his single room. He was diagnosed with non-Hodgkin's lymphoma (cancer of the lymphatic system) in 1996 and had a bone-marrow transplant from his sister two weeks ago. "It's been a walk in the park so far," he says, brightly. "I haven't picked up an infection, which, considering I haven't got an immune system, is pretty amazing." He squeezes a roll of flesh on his stomach and injects himself with growth factor while looking out of the window. "The hospital is fantastic. I can't praise the staff enough. Despite what everyone says about the National Health Service, the treatment I've always received is second to none."

11.45am One of the nurses is muttering about the cleanliness of the patients' rooms, despite the fact that independent inspection results released by the Department of Health last week gave the trust a green rating for cleanliness, denoting high standards. "They are just about clean enough," she says. "We use private contractors. The hours in the contract don't reflect the hours that we need. It's a bit of a worry considering bone-marrow transplants take place in there. One patient who's been here for two or three years on and off said the standard of cleaning has got worse. I had to talk to her, and on one hand not bullshit her, and on the other try to reassure her before her transplant."

11.50am A doctor listens to the chest of Nigel Knight, who is sitting on his bed in shorts in a four-bedded room. Nigel has multiple myeloma and underwent a form of bone-marrow transplant three days ago. He is still smiling. "My treatment's been excellent. I've got no complaints at all. The nurses are really top class. Even the food has been good. In fact, I've put on 4lb in a week." Nigel, 35, is a contract cleaner. He judges the standard of cleanliness in the wards to be "fair". "If I ran my finger along the top of the curtain rail up there, there would probably be dust, but that's me being picky," he says.

12.35pm Senior staff nurse Alison Finch, 31, is chatting gently to Nancy Lambert, 24, while she is taking her blood. Nancy, who has been on the ward for three weeks, just wants to go home. Four weeks ago, while in North Cyprus, she fell ill and was diagnosed with acute myeloid leukaemia. "I'd only been there 10 days. I was selling up and going to live there with my family. I'd already sold my business - a party shop - and the cars." But that was not all. Last week her husband broke his leg playing football with her seven-year-old son, and he now has eight bolts and a plate in his leg. "I'm a positive person," Nancy insists. "And the nurses are really good in here. If you don't laugh, you cry."

4.40pm It is very quiet on Galaxy, an acute medical/surgical ward for under-17s, also in University College Hospital. It can take up to 17 patients, but at the moment has eight. Nevertheless, there is still plenty of work to do, and staff nurse Sue Robbins is tired. She came in at 8am and will finish at 8.30pm. Some nurses have only just had their lunch. "Sometimes you get to the evening and you haven't been to the loo because you don't have time to drink throughout the day," says one.

5pm The mother of an 11-week-old girl, who has been having fits, is in tears. "They haven't diagnosed it yet. It's just depressing," says the 29-year-old care assistant. The pair have been in for five days. The mother, who is breastfeeding, says the food is so bad that her mother is bringing in supplies for her. The baby starts to fit, and she presses a button that brings over a nurse, who gives it oxygen. "I'm getting used to it, but it still frightens me," says the mother. "I just read the Bible while I'm here. I don't like to sleep." She has never heard of the term "foundation trust".

6.10pm A smell of popcorn drifts out of the adolescent unit at Middlesex Hospital, and The Blues Brothers soundtrack is playing loudly on the CD player. Patrick Barry, 31, the activity co-ordinator, is preparing a Las Vegas night for patients, complete with roulette table, in the day-care unit, now shut. The first partygoer, Joe Sharp, 15, who has arthritis, arrives in a wheelchair.

6.25pm There is a relaxed atmosphere on the ward. The nurses are dressed in purple T-shirts and black trousers and Star Wars and Harry Potter posters cover the walls.

6.45pm Toni Neufville, 19, who has juvenile arthritis, is lying on her bed in the girls' bay. She has been in for three weeks, following a flare-up. "It's so nice here, it's like being in a family. You come here so often that the staff get to know you and your illness," she says.

7.45pm Gareth Hughes, 16, is declared the winner of the roulette evening. Gareth, who has spina bifida, is recovering from an operation to straighten his legs. His prize is a pizza of his choice from Pizza Hut. "I'll get a big one to share. A couple of people will want a piece because the food is so bad. The mashed potato is the worst," he says.

Tuesday

8.45pm "If you get rained on, that'll be the air conditioning because it leaks," warns Kate Tomlinson, charge nurse in A&E at University College Hospital. There is one air-conditioning unit for the whole department. By mid-evening, it is more than 27C in the cot room.

9.30pm Dave Starkie, a mini-cab controller, is sitting slumped and topless on a trolley attached to various monitors in the major incident area. He came in at 8pm. "I started feeling tired and was sweating and my colleague advised me to call NHS Direct, and they advised me to call an ambulance. It seemed a bit over the top to me. They're waiting for my blood results. I feel a bit guilty. I just felt a bit unwell."

9.35pm The board in the major incident area lists five patients, their ailment, the time they arrived and the time the Government would ideally like them to be dispatched. According to NHS targets, 90 per cent of patients should be seen, admitted or discharged, within four hours. Staff have 50 minutes left to deal with an 87-year-old woman who suffered a head injury in a fall. But there is no bed available on the wards to admit her. "There are concerns that we are trying to reach targets, and that patients' care wouldn't have been as good if we could have had that extra half an hour. But as it is you have to ship them out," says one nurse. Another admits that he doesn't understand what foundation trust status means.

9.45pm A pizza delivery arrives for Dr Rob Henderson, 24, a house officer who has been working since 7.45am, and senior house officer Dr Jay Smith, 28, who started at 7.15am. "There's a hovel in the corner called a mess where we'll eat it until we're bleeped. I'm off at midnight," says Rob, who performed his first epidural today. "This is the best job in the world," says Jay, with utmost sincerity. "You talk to people all day and make them better." Neither says they're particularly tired.

10pm "We've run out of suture packs; we've been stitching all day," announces Kate to her colleagues. Eyes roll. She suggests asking the Whittington Hospital for some. "If there's a trauma, there are packs on the trauma trolley," she adds.

10.05pm An ambulance arrives with a blue light flashing, and a 33-year-old man who has been hit by a bus is rushed into the resuscitation area. A paramedic dressed in green, with blonde hair in bunches, reads out a list of injuries that includes a possible fractured hip, which could be life-threatening. Jay, who has been bleeped, comes in eating the remains of his pizza and puts it in his top pocket. A surgeon and anaesthetist arrive. The patient, who is surrounded by staff, is moaning. His trousers legs are cut open.

10.10pm The man admits he's a heroin and crack addict, which explains the difficulty they are having putting in an IV drip. X-rays are taken.

10.20pm A police officer comes in. The man allegedly shoplifted from a store and then ran under the bus. "When did he say he last used?" demands Dr Emma Young, the specialist registrar.

10.35pm The X-rays reveal there is no fractured pelvis and the man is moved to the high-dependency cubicle in the major incident area for observation. A police officer starts interviewing him. "This is the bit when you pretend you're on ER, but you're not, sadly," Emma says. "We were all completely obsessed by it as medical students."

10.50pm Kate and Emma are having a fag break outside. "The NHS is one of the best things about this country," Emma says. She doesn't, however, see the benefit of foundation trusts. "I think it will create a two-tier system. Most people in the NHS don't really understand the issues."

11pm An extremely drunk man is brought into the major incident area. "You didn't do two years' training to pick up drunks, and for the public to make snide comments when you're firm with them," says one of the paramedics who brought him in. "People have no qualms about dialling 999. I've been sent to a paper cut, and to open a front door. The other day control sent a crew to a person who had a straw stuck between their teeth. We had to respond with blue lights." The paramedics hang around the nurses' station and banter with them. Everyone seems in a good mood.

11.15pm A girl has come in complaining of "itchy bits". Pubic lice are suspected.

11.20pm The drunk gets off the trolley and starts staggering around. Nurses remove the trolley and he's put on a mattress on the floor. "He's got something down his pants!" exclaims Kate. The curtains are drawn. The mystery object turns out to be a box containing a rosary.

11.25pm Kate reviews the admissions register. The old woman with the head injury made the four-hour deadline with eight minutes to spare. But quite a few cases have busted their deadlines. Kate says she won't worry. "Patient care and staff are foremost." She started work at 8.45pm and is due to finish at 8.15am. She won't be paid for 45 minutes of her shift, which is meant to be a break. "We are told it's our responsibility to take breaks, but if it's really busy you just can't." All the nurses do agency work to improve their standard of living, sometimes even for the trust. A charge nurse earns about £23,000.

12.05am Rob, the junior doctor, leaves after a 16-hour day. On a scale of one to 10, he rates his tiredness at seven. He will start work again at 8am. A junior doctor earns about £39,000 in the first year.

12.15am Kate is trying to make two suture kits out of the last one.

12.30am A man who regularly fakes his symptoms, and has 15 aliases, is in the majors area. He says he has been vomiting blood. Kate takes a blood sample.

12.55am Jay, who started work at 7.15am, is going to bed in a room upstairs. He will have to be up for a 7.15am ward round, though he could be bleeped before. "I'm not too bad," he claims.

1am Some of the nurses are sitting around their station chatting while it's quiet. With them is Dr Will Wraight, a young senior house officer. "The camaraderie of working here is one of the best bits," he says.

2.05am There are seven people in the waiting room. One, Polly, 36, a barrister, has stomach cramps that started two days ago. The pain has been so intense she has been vomiting.

3.05am Electrician Paul Moran, 30, fell down his back step and cut his knee open. He has been in the waiting room since 12.30pm. "There's hardly been anyone here since I've been here. It's a bit slow. I wouldn't want to come on a night when it's very busy. The drinks machine doesn't even work."

4.05am A nurse offers the drunk man some toast from their own bread supply.

6.20am Staff believe that Polly, who is complaining of stomach cramps, has constipation. "They've showed me the X-rays, my gut is completely blocked up," she says, before being given a laxative. "It's the most painful constipation I've ever had," she says, laughing. However, she is still waiting for a blood result.

Wednesday

7.30am The night shift is doing the handover on ward PPW2 of the haematology department. They discuss a patient with myelodysplasia (which, if not treated, can turn into acute leukaemia), who now appears also to have a flesh-eating bug attacking his arm. It may have to be amputated. His relatives are coming in to give blood and staff have been trying to get the car park downstairs to allow them emergency parking for £5 a day; otherwise it's 20p for four minutes. One nurse expresses his frustration over some of the junior doctors, who have only been in the department for nine days. "They should sit down with a pharmacist and find out what regimes we do [before they start]," he says.

8.25am A nurse walks down the corridor singing: "Hello sunbeams! How are you today?"

8.35am Silvana Hayden, 47, whose husband, Michael, a bricklayer, is the patient with the suspected flesh-eating bug, is in the day room with relatives. Michael is now in intensive care. "I said to the surgeon, just do it [amputate his arm] if it saves him. He's a real fighter. I've never met anyone like him. I would be hysterical. I can't put into words the professionalism of the staff. They've been fantastic. Even if Michael doesn't make it, they'll have given him a hell of a chance. They've given it 150 per cent," she says, looking drained.

9.30am Senior staff nurse Justine Mesaric is giving Sarah Perez, 35, who has acute myeloid leukaemia, antibiotics. Sarah had a bone-marrow transplant from her twin two weeks ago and has had four lots of chemotherapy. "It's been really hard, but the care and treatment have been absolutely brilliant," she says. But she has one complaint: "I had my purse stolen from my handbag while I was in the shower. They took out £180, and then the bank rang me after they tried to take out £800. Anyone can wander in and out even though there's a security guard. They could just say they were a visitor."

10.05am On PPW3, Nigel Knight is now in his own room as his immune system is temporarily suppressed following his treatment and he is at risk of infection. "I'm still eating a lot; it takes a lot for me to lose my appetite," he says. "A cleaner has even been in and checked all the high levels for dust."

11.05am In Galaxy ward, the mother of the baby suffering fits watches a video of her pastor giving a sermon. She says her daughter only had three fits yesterday and they're getting shorter. "I have to encourage myself to sit here and be strong. I know God heals, I've seen it. The Devil wants me to say, 'God, you are unfair'," she says.

12.10pm Toni Neufville on the adolescent ward is lying on her bed talking on her mobile phone. "I'm tired and pissed off," she says. "I'm tired because I've had physiotherapy and I suffer from fatigue. I had tablets this morning and they make you feel drowsy. I want to go home. I've been here for four weeks."

12.50pm Gareth Hughes's lunch has arrived. He doesn't know what it is, and can just about recognise the mashed potato. He won't touch it, and just eats the ice cream.

1pm A senior staff nurse, Becks Mortimer, walks past the nurses' station on her way to see a patient. "It's been nice and busy," she says. "There is horrible and busy, when there's pressure on beds and you feel that you're not giving a good standard of care. I feel we are today, so that's good."

1.10pm A nurse puts the radio on. Claire Hareven, the youth worker, walks past with a box of Jaffa cakes. "They're my secret stash," she admits.

2.10pm A doctor is taking blood from one of the nurses to be tested. The nurse has just accidentally scratched herself and a patient with the same needle. "I feel bad, but it was a mistake," she says. "I could have infected them or they could have infected me."

Thursday

8pm Night shift. Two heavily pregnant women and their partners are standing in the narrow corridor of the labour ward at the Elizabeth Garrett Anderson and Obstetric Hospital waiting to be checked in. One is carrying a pillow. Opposite the midwives' station is a pinboard covered in thank-you cards and photographs of babies. There are nine patients on the ward, one of whom has already given birth. Each patient has her own room. "If you call a midwife a nurse you will be in trouble. Don't make that mistake," warns Evelyn Boachie-Mensah, a sister, laughing. There is an air of calm on the ward.

8.30pm Senior house officer Vikram Davé appears spruced up and preparing to go out for dinner with his girlfriend, despite having started work at 7.30am. "You've got to unwind somehow."

8.45pm "Congratulations!" says Evelyn to a father walking down the corridor. Midwife Pepe Martin Blanco goes in to see Aide Crossa-Banzer, 22, a Bolivian who is having her first child. He says that some women do mind having a male midwife and request a woman. She has a drip in her arm to make her uterus contract.

8.55pm A Kosovan man helps himself to water from the fountain in the corridor. His wife has just given birth to their second baby. "I feel very good, the birth was fine," he says. "But it's too hard to see your wife in pain. I couldn't look when the baby's head came out."

9.15pm The night shift starts work and assemble at the midwives' station for the handover. Senior House Officer Dr Stewart Disu hands out Ferrero Rocher chocolates as they listen.

9.55pm Stewart goes to see a patient on a gynaecology ward. Opposite is Polly, the barrister who had been treated for constipation in A&E on Tuesday night. She is attached to a drip and has a tube in her nose. "The junior doctor [Dr Will Wraight] said that he wasn't happy releasing me because my blood pressure and temperature were out of sync, and he got the consultant to have a look at me," she explains. "The junior doctor had a hunch, and they did scans and goodness knows what. It turned out to be a 9cm cyst on my Fallopian tube sitting in a pool of pus. They operated yesterday. I feel pretty rotten, actually, but I was very lucky. The staff were bloody marvellous."

10.30pm Back in the labour ward, a midwife pushes a cot containing a baby wrapped in a yellow blanket down the corridor, while its father pushes its mother in a wheelchair.

11pm It's quiet, and the midwives are standing at their station in between looking into rooms. Most of them are from Africa, where midwifery is encouraged as a speciality. They roll their eyes at memories of Monday night. "It was only with God's help that we were able to manage," says one. "Every midwife had three women to look after. We enjoyed it, but it was all very stressful. Sometimes you don't have a break and you are absolutely knackered. Sometimes you don't know what day it is." Helen Nelson-Wilson, who wants to do nights permanently because of the camaraderie of the staff, says she laughs to combat stress.

11.20pm Alex Black, the specialist registrar, looks at the white board on which is written patients' names and observations, and asks why a woman's cervix is shrinking. It turns out that a different midwife has taken the new measurement and has smaller hands.

11.30pm Aide is informed she should have a Caesarean section. "She's not progressing despite our best efforts," Alex says. "It's mainly due to the fact that the baby is in an awkward position."

12am Aide is in theatre with a man she says is her brother. Her husband is in Spain, she claims. "If I cry, is that bad?" she asks the anaesthetist, who sprays her bump to see if the epidural has taken effect. They wait for the doctors.

1am Screams reach the corridor from one of the delivery rooms. "Breathe! Breathe! Breathe!" comes the instruction from another room.

2.20am In the operating theatre, Aide crosses herself. Her eyes fill with tears. The anaesthetist strokes her hair.

2.25am Stewart starts cutting.

2.30am Alex pulls baby Matilde from the womb. "Hello," Alex greets the infant. The brother is crying and Aide is laughing. "Hello, how are you?" the midwife asks the baby as she dries it. Though she has helped with hundreds of births, she appears delighted at the arrival of little Matilde. "Now let's see how big you are," she says.

2.45am "I'm so happy. It's the best thing in the world having a baby," says Aide.

4.35am Mary Paditey, 50, co-ordinating midwife, is sitting at the station, pleased that it's quiet for once. "There hasn't been much screaming tonight," she says.

5am "I'm ready to go to bed now," says one of the nurses. How many hours have we got?"

5.10am "It's my fifth night in a row, I'm tired," says Stewart.

"Only fifth?" asks Mary, not looking up from her paperwork.

"We do 58.1 hours on average a week," he says.

"We do 74," she replies. (Midwives can work seven nights on, seven nights off. 90 per cent also do agency work).

"And you get a rest," another nurse chips in. "You're not at it all the time."

Stewart rattles off the number of procedures he has performed over the past 20 months as he works towards becoming a registrar - 53 Caesareans, 52 laparoscopies, 31 evacuations of retained products, 22 ventouse deliveries and four forceps.

5.30am Mary puts down the phone. St Mary's in west London has called; it is full. She tells them that she can take two "normal, straightforward" cases.

5.50am Stewart goes to bed. The midwives won't finish until 8.30am.

Friday

7.30am It's handover time in the nurses' office in ward PPW2 in haematology. One nurse has brought in croissants, pains au chocolat and smoothies for her colleagues. "It's Friday and it's been a bit shit," she explains to them. Another nurse tells the incoming shift that Michael had to have his arm amputated yesterday.

10.05am Angie Buxton, 47, who is an NHS healer trained by the National Federation of Spiritual Healers and a Reiki master, walks along the corridor on her way to give a treatment session to a patient. "The energy passes through me and into them. I work with my hands on the body on the way down, and over the body on the way up," she explains.

10.55am Silvana Hayden is sitting in the day room. Her husband, Michael, is still in intensive care. "I'm OK," she says flatly. "He's holding his own. He's heavily sedated. It's just waiting. When you're outside you can cope with it."

11.10am Nigel Knight is lying on his bed watching cricket. For the first time he is off his food. "I'm not quite as good as I was the other day. My immune system is nil. I got a temperature yesterday, which has increased to 39C today. I'm on three types of antibiotics. I'm not as chirpy as before. It was a shock for the nurses, they were used to me smiling." He does, however, have some good news. "Someone came in yesterday and cleaned the top of that cupboard, so we are 100 per cent spotless. The clock's even been taken down!"

11.25am Patrick Harkin wanders into the activities room to return some magazines. He's smiling, and there's good reason - he's going home tomorrow. "I haven't had a glitch or a blip after the bone-marrow transplant two weeks ago, thank goodness. I can't wait to have a barbecue on Sunday, it's one of my favourite hobbies. I'm going to do fillet on one side and tuna the other. Surf and turf, I think they call it."

12.10pm The woman with the fitting baby on Galaxy ward has gone home. There are only eight patients. "It's been really quiet. There are only three qualified nurses on, but it's been fine," says senior staff nurse Michelle Schofield, 25, happily.

1.15pm In the adolescent unit, Gareth Hughes is feeling happy. He'll be going home for the weekend and coming back to the hospital on Tuesday. He has also just received his GCSE results - an A, a B, a BB, two Cs, a D and an E - and has got into college. He says he had wanted to stay up the previous night and celebrate, but staff wouldn't let him.

1.20pm Joe Sharp is tired and sore. He's been having ultrasound, bone-density scans and hydrotherapy. He's looking for his swimming trunks as he's about to go to hydrotherapy again, after which he'll spend the day resting. He does, however, have something to look forward to: he's going home next week.

1.25pm Toni Neufville is lying on her bed in a flowery dressing-gown, feeling sick. "I've been throwing up all morning because of the medication. Because I've been taking it since I was 11, it has caused ulcers in my stomach that make me throw up. I'm trying to perk myself up. The nurses are really great and try and make me laugh or stroke my hair." She also has something to look forward to. "I'm going home today on conditional discharge. I just want to lie on my couch and see my family and friends. If I get ill, I will have to come back in. Sometimes I don't ring if I'm ill, but my mum will."

1.30pm Youth worker Claire Hareven walks into the girls' bay, chirpy as ever. "We're going to make some bread if you're up to it," she says to Toni. "Olive and sun-dried tomato ciabatta. If you're feeling less pukey you can come and be a taster."

Sometime after 10pm Michael Hayden dies in intensive care. Tests confirmed that he did not have a flesh-eating bug, but an overwhelming acute infection of the tissues, which claimed his life.

University College London Hospitals NHS Trust is, in common with 24 other NHS trusts, working on the second stage of its application to become a foundation trust. The successful candidates will be announced in January. Foundation status will be granted in April, subject to the passing of the Health and Social Care Bill, which will have its second reading in the Lords on Monday. The new trusts will manage their own assets, keep any surpluses, set their own pay and conditions within national limits, and have greater freedom to borrow.

Staff and patients at University College London Hospitals NHS Trust - which dealt with about 50,000 people in the five days I was there - will watch these changes with interest. Robert Naylor, its chief executive, believes foundation trust status will bring "freedom from bureaucratic controls and better access to additional resources. There's this funding coming into the NHS and we want to make sure we get at least our fair share to benefit our patients and staff." It will also enable them to "put the patients and public that we serve first, so they will become the decision-making body of the organisation, rather than Whitehall."

Views among the staff vary. Kate Tomlinson, charge nurse in A&E, is in favour. "It will give us greater flexibility to treat the needs of our client group. With the amount of money the trust generates, we can then direct it to areas and services that we need more than other hospitals because our client group is very specialised." Her colleague, Dr Will Wraight, said: "In theory, because the hospital will be able to control what it wants to do, it can target resources and use them more appropriately. But I'm sceptical as to exactly what it is going to achieve; is it just moving the goalposts?"

Time will tell who is right. But certainly, judging by the high praise from patients and the morale of staff, this trust, at least, appears to be in rather rude health.

THE NHS TRUST IN QUESTION

University College London Hospitals NHS Trust is one of 25 NHS trusts now working on the second stage of their applications to become Britain's first foundation trusts. Incorporating eight hospitals - Eastman Dental Institute, Elizabeth Garrett Anderson and Obstetric Hospital, the Heart Hospital, the Hospital for Tropical Diseases, the Middlesex Hospital, the National Hospital for Neurology and Neurosurgery, the Royal London Homeopathic Hospital and University College Hospital -

it is currently undertaking the largest NHS building project in the country. Its £422m new hospital, on Euston Road, is due to open in April 2005.

In 2002-03, UCLH NHS Trust employed more than 5,800 staff and had an income of £350m. A&E treated 67,152 patients; 386,667 out-patients attended the trust's hospitals; almost 62,000 in-patients were admitted; and 3,100 babies were born at the Elizabeth Garrett Anderson and Obstetric Hospital. Overall, the trust deals with 10,000 people a day.