Episode 3 Hospital

This programme contains some scenes which some viewers may find upsetting

Just move yourselves over to the side.

This winter, one of Britain's busiest NHS trusts

opened its doors...

We have to look after the patients whether they come

from Buck Palace or the park bench.

..to show us what's really happening inside our hospitals.

We've got lots of patients now competing

for an unknown number of beds.

Every week, more than 20,000 people are treated here...

-The pressure's just gone.

-What? Has it completely gone?

..and the numbers, as well as our expectations, are rising.

We just had our worst ten days on record.

There's nowhere in the hospital to move anybody.

At some point somebody will be telling us

whether we're allowed to do any work.

This is a place with some of the best specialists in the world...

-Tumour's out, job done.

-..where lives are transformed.

This is saving his life. It has to work.

But they are operating at a time when the NHS

has never been under more pressure...

-Any beds?

-No.

-No beds for anyone?

-No.

-OK.

It does feel to me like the elastic's

a bit nearer to breaking now than it ever was.

..its very future under scrutiny.

All right, I think we will go out on red,

cos we're under real pressure in the emergency department.

We are aware of the problems - anybody got a solution?

Following the patients from the moment they are admitted...

Anything I've done up to this point means nothing compared to

when you can, literally, give a bit of yourself to save someone else.

..to the moment they leave.

It's all good news. The cancer has gone.

-You don't need any more treatment.

-Fantastic.

Thank you so much.

Week by week, we reveal the complex decisions the staff must make

about who to care for next.

That patient is coming to me to be operated on

and if I don't do it, then there's only one inevitable outcome -

they're going to die.

-OVER RADIO:

-Did we trigger red overnight?

Cos we clearly should have done.

OK, let's go through the capacity, then, for Charing Cross.

For surgery, we've got...

all those patients to place, one intensive care bed.

So we don't really have capacity at Charing Cross.

Charing Cross is one of the five hospitals within Imperial Trust.

It's a centre of excellence for neurosurgery

and cancer treatment.

Known for pioneering new technologies,

it deals with some of the most complex

and challenging surgery in the country.

Demand for its services has never been higher.

This morning, the hospital is already at 95% capacity.

This month alone, it's been at this level for 28 days.

It's me, yeah. Course I am, I'm on my way, I'm on my way.

Kevin O'Neill is a world-leading brain surgeon.

His reputation has made him one of the country's

most in-demand specialists.

We do like to push the boundaries a bit here.

We've got a very good team,

people that work together, we get very good results.

We do stuff that sometimes other people don't want to touch.

Stuff that we consider doing that is complicated cases

that come for consideration from all over the country

and all over the world.

Today, Kevin has two scheduled operations.

His first case, 53-year-old Valerie is particularly challenging.

Seven years ago, she was diagnosed with multiple brain aneurysms.

I've got five, two of them have already been operated on.

I've had coil in, and this one has to be clipped,

so they have to go through my head, because of where it is in my head.

It is, I see what you mean.

It's like a trifurcation, almost, isn't it?

There's the actual aneurysm there, isn't it?

The way to think of this is, it's the inner part of the vessel

bulging through a weakness, rather like the inner tube bulging

through a split in the tyre.

And that poses a threat,

because that can rupture and cause a bleed, and that can be fatal.

So, it's a little bit of a ticking time bomb.

It certainly does have quite a wide neck, doesn't it?

And lots of vessels at the base.

Got to get it clipped all the way around this.

The difficulty we have is quite a weak-walled aneurysm

that's going to be at risk of rupturing during surgery,

plus there's something down here as well.

And so, it's not straightforward.

Valerie has been waiting for this surgery for nearly a year.

-I'm stressed.

-What's stressing you?

Is there anything specifically that's worrying you?

What happens if it's cancelled today?

I can't answer that, because as far as I know it's not.

And if it is cancelled, I think it's a discussion that's best to have

with Mr O'Neill, cos he's the person who's doing the operation.

-I'm not going home.

-I understand, I understand.

It's not easy.

I think it's very unlikely at the moment

that we're going to face that

and I know we've said this in the past and there have been problems.

Said it would be done January.

Ten months on, three cancellations, so I'm hoping it'll happen today.

-Getting worried about you.

-I'm sorry, I'm sorry.

'It's so important to her.

'My mum puts on a brave face,

'but knowing you've got a brain aneurysm is petrifying.

'It's heartbreaking to see a family member,

'especially your mum, go through something like this.'

The one thing they stressed to my mum is not to get stressed,

and this whole year has been nothing but a stressful period for her.

Hello, Valerie.

So, today, we've got you in a bed,

so we have a head start.

But it has been a bit of a struggle.

It's the fourth time I've been here.

We feel your emotion, we feel your pain...

I don't think there's any way we're going to cancel you.

I'm not going home.

You will have priority today,

we will go ahead, we won't cancel your case.

Even if we've got bed issues today,

we will really do everything possible.

-OK, so we'd better get cracking.

-OK.

-Any questions?

-No.

-Just get it over with!

Before Kevin can start Valerie's procedure,

the intensive care team must prepare for the worst-case scenario.

-Specialist surgery, and she needs a level 3 bed.

-A level 3 bed?

A level 3 bed, post op.

If her operation runs into serious complications,

Valerie will need a bed with life-support

and one-to-one nursing.

-How many nurses have we got?

-We've got 17.

We might be able to.

One, two, three, four, five, six,

seven, eight, nine, ten...

12,

13, 14, 15.

SHE SIGHS

-It's a bit tricky.

-Cos we've got no emergency bed.

No, no, no, exactly.

I just don't think there's any way

-that we're going to be able to do it.

-No.

Apparently she'd been cancelled a couple of times before.

OK.

Yes.

-But if you haven't got the nurses to do it, it's irrelevant.

-Yeah.

OK.

We don't like cancelling patients and, you know...

but sometimes that decision is out of our hands.

Every sort of decision impacts on somebody else, really.

Availability of intensive care beds is constantly changing.

The demand for the beds comes from departments including

neurosurgery, ear, nose and throat, or ENT, and stroke.

This morning, there is just one bed available,

and competition for it is already high.

Have you heard what's happening upstairs?

Yeah, I heard.

I think we're competing for the same ITU bed.

-Yeah.

-Is yours a hot aneurysm?

I think mine trumps yours.

She's been cancelled four times this month.

Mine's been cancelled twice, so...

It's a game of trumps, isn't it?

Because we all want to do the best for our patients.

-Absolutely.

-Best of luck.

Thank you.

Dr Kyriakos Lobotesis also has a patient

with a brain aneurysm who may need

the intensive care bed after surgery.

So, we're just waiting to hear.

I have every confidence that they will do the best they can.

Somehow, we need to fit our patients in.

-PHONE RINGS

-Hello, intensive care, can I help?

Hi, intervention, how are you? Good.

So, as soon as I know, I will give you guys a call back on 30777.

Let's see what the situation is.

-Hi, guys.

-Hi.

Any news?

Yeah. I spoke to sister Nicky.

She's saying I need to speak to Sarah Gordon.

Got to create beds for these patients.

Neither aneurysm operation can start until Sarah and Nicky

move patients out of intensive care onto a general ward.

But the general wards are full.

OK. Maybe if you can let us know.

PHONE RINGS

Hello.

Until a decision is made, two theatres are inactive.

Yes, right, OK.

In an ideal world, everybody would get their own bed

and everybody would get done, but it's not an ideal world.

PHONE RINGS

Hello, intensive care, can I help?

Oh, right, OK.

They will keep calling until we've got a bed available, really.

Cos they've got, obviously, so many people that they need

to proceed with. The longer the delay is,

you know, you worry about them not being able to do

all of the cases on the list.

Ten calls from IR there.

-Oh, yeah. They're texting me as well.

-God.

-Shall we just say yeah?

-I'm tempted just to say yes.

Rather than cancel patients,

Sarah gives the go-ahead for both operations to proceed.

I think just do it, because otherwise, you know,

it ends up later and later and, you know,

then there are other problems.

It's quite a common thing.

What you tend to end up doing is, you know,

we'll accept two patients when we've got one bed

and hope that one doesn't need to come and if, at the end of the day,

they do need to come,

then we have to work out another strategy.

So it makes things quite tough, doesn't it?

It's no fun at our end, but, you know,

otherwise patients get cancelled.

Valerie is called to theatre.

It's the end of a year-long wait for her operation.

They don't even know if they've got a bed for her after the operation,

which is so worrying, because if she needs to go to ITU after,

and they're saying there isn't a bed available,

who's going to look after her?

Who's going to give her that one-to-one care that she needs?

It's a big, invasive operation that she's having done.

It's scary.

It really is. It's scary.

It's a serious business.

We do have many challenges

and, I mean, Mr O'Neill is much more qualified than me

to speak about these issues, you know, the NHS is facing.

But, yeah, it is very stressful for us as well,

it's extremely stressful.

Giulio Anichini from Italy came to London to train under Kevin.

Giulio is basically my right-hand man.

Suction. Excellent.

Eccellente, Ambassador.

EQUIPMENT WHIRS

What's good is that we can share the struggle.

Get things done.

She's a lovely lady.

She's a very nice lady.

EQUIPMENT WHIRS

It can't be easy, knowing you've got all these aneurysms in your head.

The number of elective operations performed at Imperial

has grown 50% in five years.

Each month, at least 10,000 procedures are carried out.

John is the second patient on Kevin's list today.

For two years, he's suffered from a spinal disorder

which causes acute leg pain.

Yeah, exactly. Yeah. Hang on.

His operation requires four hours' theatre time.

It can only start once Valerie's is safely completed.

I'm a patient man.

The only reason I'm here is because of Kevin O'Neill.

He certainly could not guarantee that the operation

was going to take place today.

However, he's very conscious the operation has been already

cancelled once, so we'll wait and see.

The stats are just unbelievable.

"How long do Germans wait after seeing a specialist?

"Two to three weeks."

How does this compare to your waiting time?

Mine, what, here?

Yeah...

I've been waiting since March.

You know, the time it took to get the appointments done,

the time it took to get the MRI scans,

the time it took to get those things done was just ridiculous.

It's still a good system, I suppose, compared with lots of countries.

What, Third World or...

-HE LAUGHS

-..Western world?

-Western world.

-Western world.

Looks very, very unstable.

The problem is that she's got a very fragile-looking aneurysm

that's about to pop.

To get that requires some complex clip.

It's more complicated than we thought.

Valerie's surgery is into its fourth hour.

The longer the operation runs on,

the more impact it has on other patients.

Hi, Sarah.

This is not as straightforward as these things can be.

How long is it going to take? ..Right.

The chances of Valerie needing an intensive care bed are rising.

A clip across here.

Yeah.

OK. We need the bed.

Right.

The situation with the bed is, there is one ITU bed available,

two complex cases, including ours,

and I'm in the middle of a complex operation.

Yes, it's constantly juggling, actually. Yeah.

Although your focus is here, and has to be here,

there are things going on in the background.

OK.

So the neuro case does need a bed.

-Valerie?

-Yeah.

Do they try and put pressure on you?

They do a little bit, but it's swings and roundabouts, you know.

We put pressure on them, they put pressure on us.

So, it can be a little stressful, but it's OK.

Yeah.

So, we were thinking about this one, weren't we?

Because I was thinking more of something like this.

That's very curved, isn't it?

Kevin must fasten a metal clip around Valerie's aneurysm,

a procedure that could cause a bleed on her brain.

It's the most dangerous stage of her operation.

-Let's just see what this looks like.

-OK.

Aneurysm clipped.

And the clip is all over, right across the neck, you can see it.

Good.

Everything is preserved.

Perfect, very happy with that result. Very good.

The operation is a success.

They don't want the case...the bed for the clipping, no? OK.

It's all changed again.

NURSE CALLS JOHN

Thank you, ladies.

John has been waiting nine hours for the operation

to release trapped nerves in his back.

So, decompression bilaterally here

and then extend the spaces down to here.

After being cancelled once before, his operation will now go ahead.

Everything under control?

All right, mate? Very well.

Sorry about the wait.

No, it's not your fault, it's Mr O'Neill's fault, probably.

THEY LAUGH

Cancellations, you know, we don't do these things lightly.

Cancellations in themselves create their own problems.

But our department is under a lot of demand and that comes from

the good service that we offer and the good results that we get.

Valerie...

You're just waking up from the anaesthetic.

Everything is done. The operation is done.

We will keep a close eye on her to make sure she's fine.

-I'm so pleased that we managed to do that.

-Thank you so much.

There's just such a high demand for the NHS.

We've been waiting for this since January, so it's a big relief.

The system is under strain. What do you do?

There's only so much you can do in a week.

You know, you can't beat the laws of physics

and the time-space continuum.

PHONE RINGS

Good afternoon, neurosurgery.

Yes.

What I'll do is, I've sent the letter out to you,

so you'll get the letter instead.

Demand on Kevin's neurosurgery department is especially high.

It's increased by a third in the past year.

He has so many patients, it's never-ending.

What kind of numbers are we talking about?

Easily...

Easily over 500.

So there is quite a long wait.

Many patients choose Imperial

because of the reputation of its surgeons.

We had to cancel a clinic today so he could do a theatre list

and he's doing a clinic tomorrow in his own time

to see the patients, because we don't have the capacity

to move them elsewhere.

Along with routine patients,

Kevin also deals with emergency cases.

Giulio, have you seen Mr Marson?

We're going to see Mr Marson now. I've seen him this morning.

Today, he's concerned about the health of Phil, a crane driver.

Phillip. So, how does this arm feel? Is it quite weak?

-Yeah, it's very weak.

-Yeah.

-And my leg.

-And your leg as well.

So, when was the last time you were able to walk?

-Can you walk now or...

-No.

-No.

Mr Marson came to the brain tumour clinic about a week or two ago

with a history of... Well, you were falling over a bit, weren't you?

And some weakness on the left side, which did actually...

was discovered after attending his local casualty

and they did a scan and found a brain tumour.

It looks like a benign brain tumour,

it's right over the sensory motor cortex.

But the only way to really deal with it is to get this thing out.

So, as he's been getting weak, progressively,

over the last four, five days, we're going to move his surgery

forward and try and do it urgently tomorrow.

So I'm hoping this is just what we think it is

and that's the end of it.

The tumour on the scan looks benign,

but the way it is behaving from a clinical point of view

is making me worry whether it's something more malignant.

Phillip, I've seen him on Monday, has been deteriorating more,

which is very unusual.

It's peculiar about this case, because usually it's not so quick.

These are slow-growing lesions.

Phil's fast-growing tumour has already reached six centimetres.

There's a possibility it could be cancerous.

I'm a tail crane driver. I see a lot of the sights of London.

Don't go up the London Eye too much.

I see it every day, mate.

Yeah, I've got a partner, Chloe, yeah.

Lots of friends and family have rallied round to help

and come and see me, and a big support network, which is good.

What can I do? Can't change what's happened.

Well, hopefully he can.

Phil is on the emergency operating list for tomorrow.

We haven't got any choice. The sooner, the better.

That's the best course of action for him.

-Good evening.

-Hiya.

So, as I said, the operation is going to be done under

general anaesthetic, so you'll be completely asleep.

This lump is here,

it's here, and we're going to expose this side of your head.

What are the risks of this operation?

I mean, we talk about that.

There is a risk of potentially life-threatening complications.

These include a number of awful things.

Risk of coma, risk of neurological impairment,

stroke, heart attack.

Even dying from the operation, I'm afraid, is one of the risks.

I'm telling you, because this is quite unpredictable.

Some people just have them and we don't know why.

But it is my duty to tell you that it is brain surgery,

so any of these are potentially possible.

Yeah, I understand that. Start messing about with it...

-Is this happening tomorrow?

-Tomorrow.

So, I booked you for emergency theatre tomorrow.

And, so, what? Just go down first thing in the morning?

Hopefully, yes. 8.30, 9.00, something like that.

All right, yeah.

And these risks that I've mentioned to this gentleman,

they're actually not far from happening.

Sometimes we do see them, I'm afraid.

This is a very serious operation.

They need to be aware of everything

that can potentially happen, and face it.

Some of these are quite...

Takes over a little bit...when somebody tells you all that.

-It's the realisation, isn't it?

->

Yeah, I could die.

Thanks for that one(!)

It's the morning of Phil's operation.

SIRENS WAIL

11 floors down, a man is admitted to A&E

with a life-threatening bleed on the brain.

Can you squeeze my hand?

PHONE RINGS

So, we've got a gentleman, known alcoholic,

who has a very large left intracerebral haematoma.

He's been intubated, ventilated and he's coming across.

Charing Cross has ten operating theatres.

Each one is booked out to different specialties.

Theatre 8 is for emergencies.

It's where Phil's brain tumour operation

is scheduled to take place.

But the new emergency case is also heading to theatre 8.

I mean, this isn't...

If it's superficial, it shouldn't take too long, isn't it?

So we still might have time to do the other case, potentially.

We're going to decompress, we're not going to chase

all the last bit of clot.

No, no, sure. Absolutely. Yeah, yeah. Fine.

-I mean, this haematoma has priority.

-Exactly, yes.

-OK.

-Yeah.

Phillip, how are you?

-Listen. We were just about to go...

-Yeah.

..and then there is a crashing emergency,

undelayable emergency, that came through the door.

But I don't want to fear now,

because we might have an arrangement for this afternoon.

-We really would like to push for today.

-Yeah.

Sorry for that. As soon as I've got news, I will let you know.

-Yeah, if you'll just keep me informed.

-Absolutely, absolutely.

We need to do this chap today.

He's becoming paralysed, that's our problem.

So, they tell you you're on the emergency list

and then, obviously, the other person is more of an emergency,

so it's fair enough, you know.

They don't just put people in front of you for no reason,

do they? It's not...

It's a selfish thing on my part.

The surgery on Phil's brain tumour must wait.

His life's on hold, and there's a big uncertainty

about his future, so, he's putting a brave face on it,

you know, he's a big, strong guy.

Crane driver, you know, putting a brave face on it,

but underneath that, you can see

the concern and worry in his eyes,

so that's part of the reason we're trying to get on with this.

It's just hard.

Emotions go up and down, you know.

You think, "Oh, what's happening, what's happening?"

People have been ringing me saying, "Oh, what's happening?"

But it is what it is, and what can you do?

Nature of the beast, really, isn't it?

The Government committed that NHS trusts must treat patients

within 18 weeks of GP referral.

At Imperial, 10,000 patients have been waiting for treatment

for over 18 weeks.

We've found, because of administrative problems

and our increased demand, we had more patients

on the waiting list than we realised.

475 have waited for more than a year.

Waiting lists is probably the single top priority in my job,

is to get this problem sorted.

Is the problem going to go away?

Er, so we've got a plan to meet...

to get back to meeting the Government targets by next year.

That priority is shared by the

Divisional Director and the Chief Executive and the Medical Director,

and we meet every week about it.

So, by the end of November, that 475,

what will that number be down to?

-Six have already been treated.

-And we're at the end of November now.

-Yes.

-So I would expect more than 6 of the 475 to have been treated.

But some of these specialities sort of legitimately have too much

going to be able to get this sorted out.

Neurosurgery, it's an increase in referrals.

-Yeah, it's a lot of theatre time, isn't it?

-Theatre time, yeah.

A number of strategies are being introduced to cut waiting times.

At Imperial, like other trusts, these include outsourcing.

So outsourcing is when we take a small number of patients, usually

the routine ones, not the very complicated operations,

and we phone the patient and ask them if they'd be happy

to have their operation done at a private hospital.

And we do that if we don't have the capacity to treat them

quickly enough, within the Government's 18-week target.

They reckon that'll take them 10 weeks

from when we send them out, to see them in out-patients,

arrange a date, do them in out-patients, discharge them.

10 weeks is a lot quicker than we do it.

Really, a private provider?

Yeah. From our point of view,

it's a short-term solution because our waiting lists were longer

than we'd realised and we needed to do something fairly quickly.

Outsourcing team, yeah. So if you have any concerns, give us a call.

A dedicated outsourcing team is up and running.

They are two weeks into the proposed six-month programme.

It should all go smoothly. So best of luck.

I hope everything goes well and you'll hopefully hear from them

very soon with your appointment.

OK, you're very welcome. Thanks for your time.

Thanks. Bye.

So far, 200 patients have agreed to be treated at private hospitals.

Hi, there. I understand that you're waiting

for an appointment under neurosurgery, is that right?

'The private providers have agreed to do this for the same price

'as the NHS pays, so it's financially neutral to the NHS.'

So, ideologically, there's no difference between you being

seen by the NHS or a private provider, paid for by the NHS?

I'm not answering that question. What does "ideologically" mean?

I'm just trying to get patients treated, OK?

So, waiting lists are not an administrative thing.

They're people, actually, who are waiting for operations.

They find it very stressful,

and we need to get them done in a reasonable level of time.

Is that something you are happy to do?

On the whole, people are kind of surprised to hear

about the option, but usually fairly happy to go ahead,

but there are some who are concerned.

No, you don't need to pay, it's all covered.

Where...

Well, she wouldn't want it any sooner, so... She's declined.

At Charing Cross Hospital, all ten theatres are in use.

It is now too late to start the operation on Phil's brain tumour.

Quite frustrating, when you're sitting around all day.

You can't eat, you can't drink, from midnight last night.

Messes with your head a little bit, cos you're hoping to get in

and then you're not and then you are and then you're not.

Kevin and Giulio are not scheduled to operate again

until after the weekend.

Phil's brain tumour continues to grow.

Either we wait, which is frustrating for everybody,

or we re-designate and re-plan

and so we're going to have to find another way.

-Here we go.

-I'm tired. So the juggling continues.

-Yeah.

-Yeah.

It's going on and on, isn't it?

So I think we've got to do it, at least over the weekend.

We could start first thing in the morning,

I could come in, and I know it's a Saturday,

but we can come in and...

-You don't need to come.

-No, no, I will, I will.

-We've got to get these things done.

-It's fine. OK.

We are pretty much at 100% capacity. Beyond, actually.

Ideally, what you need is a bit of leeway to deal with

the reaction of surges in demand and emergency care.

We just haven't got that leeway

and that's why we spend a lot of our time, rather than operating,

running around trying to sort things out. As you can see!

Four floors away from the pressures of theatres,

a clinical trial is underway.

That's very good.

Come over here and sit on the couch.

As well as its five hospitals,

Imperial Trust runs a world-leading clinical research programme.

And now hold both hands up like that, spread the fingers.

Fingers wide.

52-year-old painter and decorator Selwyn

suffers from a brain condition called essential tremor.

And now just hold them by the nose.

Its severity is rated on a scale of one to ten.

-Now, this is an interesting one.

-Selwyn is a nine.

The tremors started about 20-odd years ago.

Something to do with in your head, in your brain.

I'm right handed, so the tremor's in my right hand,

so it's been a bit difficult decorating.

I've basically learnt to use my left hand over the years.

I'm going to get you to draw from that dot, round the spiral,

staying inside the lines.

We're going to treat Selwyn

in order to try and reduce the tremor in his right arm.

The first time I actually saw non-invasive surgery,

interestingly, was on Star Trek, 30 years ago, performed by Dr Sulu!

Selwyn's tremor has worsened with age

and is resistant to conventional treatment.

I went through a load of procedures, tablets and all sorts,

and they said the next course for me

was just a drill drilling into my head.

I didn't fancy that one. But this one, I'm well happy with it.

If it works, it's brilliant.

How it works is that an ultrasound beam, which is not powerful,

as it's used, for example, to listen to babies in mothers' wombs,

and therefore it doesn't damage the baby at all, is made powerful

by the focusing of 1,004 ultrasound beams on a precise target.

The team is preparing for next week's procedure.

They will need a precise image of Selwyn's brain to map exactly

where to focus the ultrasound beams.

So contrast this with what we would have done with conventional,

invasive surgery, drilling a hole in the skull,

putting electrodes 15 centimetres into the brain.

The risks are much reduced

and the good thing is, this is just the beginning.

In the future we look forward to using this for deep-seated

brain tumours, where currently surgery is fraught with risk.

So, it's quite a game-changer.

One of the great things is that it takes this form of surgery away

from a major operating theatre into a scanning unit.

And of course that would allow, in principle,

many more people to be treated, and treated effectively,

without so much disruption or such a great wait for surgery.

You will tell me, OK? That's the deal.

After months of waiting and numerous cancellations,

John and Valerie are recovering on the wards.

Ask me, what do you want to know? How is the cut?

-Yeah, how big is it?

-OK.

It's, in total, like that. OK?

I'm very grateful, you know. I'm here.

I'm alive and kicking, so, yeah, I'm very grateful.

Very grateful for the NHS and what they've done for me.

Take another deep breath in and out, OK?

The thing which is noticeable, right,

is that when you end up here in bed, it's brilliant.

I mean, they're brilliant.

So as soon as they sort you out in terms of, "Right, you're now going

"into the operating room," from that moment onwards, you cannot fault it.

The process before that is a disaster. It's an absolute disaster.

It's just a shame it took so long,

you know, all the messing around I've had, but, hey,

it's done, so that's the main thing.

So I will write to the CO, definitely.

I'll tell her exactly what has happened to me and then

hopefully the NHS will look at that and look at ways of changing.

We'll wait and see.

To deal with patient concerns,

the trust has a dedicated patient liaison team.

Today, they are at Kevin's weekly caseload meeting.

This is one that the patient has made a formal complaint

but what we're trying to do is manage it at a local level

so that we can actually resolve it

and the patient doesn't have to go through

the formal complaint process.

I do know the name.

Thousands of patients are just coming back to me now.

So...

A man who needs spinal surgery

has been waiting several months to see Kevin.

I'd like to see him...urgently.

What are your Christmas plans? Cos I can get him in in December.

Without overbooking.

-Don't have any plans at the moment, I'm just firefighting.

-So you can...

I'll stick him in, try and get him in before that.

Try and get him in before that.

We need to discuss this business of outsourcing and stuff.

We promised patients that they would get treated within 18 weeks.

I think it's a dangerous route, really, to outsource.

My personal opinion.

Cos it really disrupts continuity.

The question is, whether they get the better...

The bottom line is, whether these patients... Talk about out...

It's not like a product.

I don't think it's healthy for a patient to go

and have another operation

by somebody who's never seen them before.

You know, you form a relationship with the patient,

you create an opinion, which may be different from another doctor...

It's just the sheer number of patients we have to get through.

Yeah. It's true.

What worries me is this thing about outsourcing,

it's more of a kind of fudge than a fix. I mean...

To a certain extent, there's a logic to it, and you can see

that it's a fairly quick and easy win for many parties.

But the money, rather than being invested into the system,

is going out of the system.

It is a form of privatisation.

At the moment, it's being passed off as using capacity elsewhere,

outside of the NHS, but why not build capacity in it,

inside the NHS, er...where we can maintain standards and we can

maintain continuity, most importantly?

That's my main concern.

Morning, how are you?

They're sending for our patient, just to let you know.

Perfect.

Let's get this done today.

Kevin and Giulio have come into work on a Saturday.

It means the wait is over for brain tumour patient Phil.

This tumour is on the surface of the brain,

which is why Phil has this weakness.

The difficulty with Phil's case is, it's been very aggressive

in the way it's presented.

Bit unusual for a benign tumour, so it may be it's cancer.

We've done scans, but you can never be 100% sure.

The only way is getting the thing out.

-Right. See you later.

-Right, good luck.

Hopefully today's the first day of the recovery

and getting back to normal.

Go on.

The first step is to remove part of Phil's skull, to access the tumour.

This is a crucial part.

The tumour can often get stuck,

integrated into the skull a little bit.

There's my fingernail.

It's called the neurosurgical finger.

See how it's all stuck? There's remnants.

The tumour's actually invaded the bone, there.

Fresh swab.

There's the tumour.

It is blending with the brain at its edges, which is a bit worrying.

It looks kind of funny.

-Remember we said it could be something funny?

-Yeah.

The tumour will be sent to the pathology lab for analysis.

Do you think it's malignant, Kevin?

Could be. It's looking more like it.

It's a good job we persevered in getting him done, isn't it?

Looks all right. Sometimes he can bleed from the pinpoint.

The skin.

So we managed to take the whole thing out.

He should improve from the way he is now.

I can't really tell you how much he's going to recover,

if it's going to happen or not.

Of course, we're going to keep an eye on him in the meantime. OK.

-Thank you.

-Cheers.

He's waking up.

Phil? Just relax. Just relax. Just relax.

You're just waking up from the anaesthetic.

Just lie back and... let it wash over you.

How's this arm here?

Can you move it? Oh, you can. Got a bit of tone in it.

Can you feel me touch you?

Yeah. Good.

Now the tumour is out, the pressure on Phil's brain is released.

What about your toes? Can you wiggle your toes?

I can feel my toes. I can feel my toes better.

Excellent. Good.

-Well, the tumour's out.

-Is it out?

-Yeah, all the tumour's gone.

When we approached it, it was just a little bit stuck and it

looked like it was invading things.

Overall, if that histology is good, then his prognosis is really good.

It all really pins on what the nature of that tumour is.

I'm hoping he's cured of this, and that's the end of the story.

It's the morning of tremor patient Selwyn's operation.

He's shaved his head in preparation for the procedure.

It's strange. Didn't recognise him yesterday on the train!

How are you feeling about it all?

Bit anxious how he's going to be after the operation.

Hopefully, like you said, tremor free and no side effects.

You just don't know, do you?

Has the patient confirmed his identity? He has.

Has the central-imaging been reviewed? Yes.

Anticipated blood loss? No.

The underlying theme in all of this

is the maximum possible safety for the patient.

You are delivering large amounts of energy,

in a very concentrated fashion, deep in the brain.

Even though we don't open your head,

even though we don't make a cut, or anything,

it's still delivering energy inside your brain, so if it...

So the structures around it,

even a couple of millimetres here and there, are very important.

So the very same thing which would control the tremor

can also make you paralysed.

But ballpark, overall, the risk of any of this happening is 1% risk.

So that's me and, if you're happy, that's you. Sign here.

And that's the other thing. Your handwriting should get better.

A frame is bolted to Selwyn's skull

to keep his head in place when the ultrasound beams are fired.

Being brave, Marianna?

Definitely being brave.

Selwyn is one of only 20 patients

taking part in this ground-breaking trial,

funded by Imperial College Healthcare Charity.

He will remain conscious throughout the procedure.

This is a drawing of his spiral just now,

laying in the scanner before we start operating.

And you can see quite severe tremor.

He could barely keep the pencil to the paper.

We're starting with 150.

150 at ten seconds.

The ultrasound beams

must be directed to the centre of Selwyn's brain.

Extreme precision is essential.

OK. Perfect.

Each time the beams are triggered, Dr Bane

checks there are no side effects.

There are very many

really important pathways

coming close to the area we're operating on.

It's three days since crane driver Phil's brain tumour was removed.

This final examination will reveal if it's cancerous.

Samples of the tumour have been

hardened in formaldehyde

and then put through a variety of chemicals,

the end point of which is,

the tumour being contained within blocks of paraffin wax.

And very thin slices can be cut from that,

and then stained with dyes

which will show the nuclei,

the centre of the cell, in one colour,

and the cytoplasm, the rest of the cell, in another.

The nuclei and the arrangement of the cells

and the shape of the cells

are issues that you examine

when defining how good or not good this tumour might be.

Let's have a look.

We can get rid of that. That's the centre...

And the adjustment, we want halfway.

We should go back to the top and hit it again.

Doctors have been firing ultrasound beams into Selwyn's brain

for two hours.

He's got no adverse effects.

-So do you want to do a big one?

-Yeah.

Let's see how it goes.

The effects on Selwyn are visible and immediate.

That's a pretty magnificent achievement.

It should make a dramatic difference to his quality of life,

using that hand.

Yeah. This is really fantastic.

Just like that?

It's absolutely amazing.

Big smile on his face, yeah.

Well done. That's great.

First right-handed drink for a long time.

The team hope to make non-invasive surgery available

to other patients like Selwyn.

One uses the word "game-changer" very loosely,

but this is truly a game-changer.

This is a much smarter way to use resources.

It could become a day case procedure,

so people could actually have their treatment and walk out and go home.

So, given the full package,

I would say this is almost a no-brainer

for the National Health Service.

Try and lead with your weaker leg.

-Try and hold on with both hands, all right?

-OK, sure.

Take your time.

Kevin has the results on Phil's tumour.

Do you want the pre op and post op, or just the post op?

-Pre and post op, please.

-Yeah.

We're just going to go and see Mr Marson.

This is the tumour beforehand.

I'm really happy for Phil,

because it is actually a benign tumour.

It's not the cancer we thought it might be.

There was a little worry

that it might have been something sinister.

Post op.

You can just see a little fingerprint of where the tumour was,

so it looks really good.

So I'm going to see him now.

I'm excited.

I was going to say, do you look forward to this bit?

Yeah, this is the reward, isn't it? To see the result.

Here he is.

-You're doing very well, aren't you?

-Yeah, I'm doing well, yeah.

This the man who was lying in bed and couldn't walk.

Let's have a look at your arm. Hold your arm up?

-Wow.

-It's all good.

-Can you stand up?

-Yeah.

-Wow.

I can't believe you're walking.

I know, it's amazing.

Been getting better by the hour. It's been very good.

So I think we'll probably be able to get you out soon,

-get you back home.

-OK.

-And we'll have an early follow-up.

All done, all over and done with,

and going home today, by the sounds of it,

so it's all good news.

You can jog down the pub now, can't you?

Yeah, that will be the plan!

The drive to cut waiting lists goes on.

The outsourcing of some Imperial patients to private hospitals

will continue until at least March.

At the end of the day, despite all the problems,

I still greatly believe that the NHS is a fantastic institution.

Something that this country is recognised for around the world.

We still manage to get great results.

See you later.

It's something that needs to be protected.

Seeing people like Phil walk out, when they couldn't walk in,

is what keeps me going.

It's all worthwhile, when you see that.

Overseas officer Terry tracks down foreign patients

to bill them for their treatment.

We use these. ATMs.

I'm from the Overseas Patients' Office.

-You're not entitled to free medical treatment?

-No.

In England, there is this assumption

that it's free of charge,

but that isn't the case.

And he delivers one of the trust's biggest-ever bills

to an overseas patient.

-She's in there, is she?

-Yeah.

-OK, that's wonderful.

I'm not in a position to say,

"I accept that you can't sort the bill,

"so, hey, we won't charge you."

I don't have that power.

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