Episode 2 Hospital

Where is he? You need to shout for help.

Where is he? Which way did he go?

One of London's biggest hospital trusts...

He's having a heart attack, but we'll get him in straightaway and

we'll get him sorted out.

OK, on three. One, two, three.

..treating more than 20,000 people every week.

Flying over the enemy lines.

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

I'm amazed he's alive. He had two blocked arteries.

..where lives are transformed...

Thank you so much.

..but it's under intense pressure.

We have a financial deficit of 41 million.

With growing patient numbers...

We are full. We're always full.

How long has he been here? 13 hours and 46 minutes.

I don't think that's best patient care.

..and higher expectations.

They're can't be nothing in this day and age.

I want to look after him.

First ambulance is on the ramp.

At a time when the NHS has never been under more scrutiny...

We're declaring a major incident at the St Mary's site.

If this was my sister, or a friend, or anyone,

this wouldn't be good enough.

..week by week, we reveal the complex decisions

the staff must make...

Anybody else who hasn't gone knife to skin, they need to be sent home.

..about who to care for next.

Do you reach a point where you say, "Enough is enough"?

Yes. The family may not like that but,

"We are stopping and this is where it ends."

In terms of treatment options, I'm at the end of the line.

They've tried chemo.

They've tried radiotherapy, surgery, and it's still coming back.

51-year-old Glendon has a type of brain tumour

called glioblastoma.

He's tried every treatment his local hospital

in Lancashire can offer.

This is the most aggressive cancer known to man.

You either collapse into a little pile of self-pity,

or you carry on fighting.

And I will carry on fighting until it kills me.

To access a new type of therapy,

Glendon is now under the care of Matt Williams,

a leading oncologist at Charing Cross Hospital.

INTERVIEWER: How did Glendon find you?

I don't know.

I don't know. I suspect Google!

Matt is one of the few doctors in the country

willing to prescribe immunotherapy for brain tumours.

Lots of cancers are able to avoid the immune systems,

so they kind of hide from it.

And what the current generation of immunotherapy does,

is allows the immune system to get active and then attack the tumours.

It's known to work for some tumours.

We do not know whether it works for others,

and yet it is really expensive.

The NHS does not offer immunotherapy to brain tumour patients because

its benefits are unproven, but it can be accessed privately.

So we're going up to the 15th floor,

which is the private wing stuck on top of Charing Cross Hospital.

Doors opening.

In most cases, I think private medicine

means a nicer room, better coffee.

But there has been a change.

There are cases where you'll get access to other drugs

that aren't available on the NHS.

And the number of people who want to access those drugs

is definitely going up.

OK, this is your bed.

Lovely.

I really fancy a refreshing Aperol Spritz!

There must be a little bar around the corner here somewhere, surely?

Glendon is one of Matt's NHS patients.

Since his diagnosis a year ago, he's been exploring all treatments,

including those only available privately.

This is his Novocure.

It sends a current through the brain at a certain frequency

that's supposed to catch the cells before they split,

so they don't set up in other areas of the brain.

They don't have Novocure on the NHS.

Ballpark figure, I believe they're around about ?12,000 a month.

But I phoned them up and begged, basically.

I got it on compassionate grounds.

INTERVIEWER: Glendon, how much have you spent

on trying to cure yourself?

I've only just started.

We've just travelled really and saw a few private...

I'd say about 10,000, but I'm now starting to throw big wodges at it.

What's the war chest? Half a million.

But we haven't really got that sat there. No. Not liquid cash.

Yeah, it's assets.

We'd have to sell more or less everything to get hold of it.

It will be everything else but the house.

I'm not going to leave my family destitute by a long stretch.

Hello. I'm one of the neurosurgical team.

How are you doing, sir? Nice to meet you. We need to get you an MRI scan.

Three months ago, Glendon had surgery to remove the tumour,

but it returned and is growing.

I thought we should talk about Mr Snape.

He's now relapsed again. There are no standard treatment options.

For a whole bunch of reasons,

immunotherapy may well not be effective in

glioblastoma by itself.

There are good reasons to think that adding immunotherapy to a second

course of radiotherapy may be more effective.

And the evidence for? Poor.

The problem is immunotherapy is quite new.

And so far, the results have been very disappointing.

It's ethically hard. There is no open trial for him.

The company won't give him compassionate use.

We're looking at self funding.

So he would have to self fund, he is well aware of this.

Poor chap.

I had another patient in clinic today explicitly say,

"I have some money, if there are extra things I can pay for,

"then I want to know about them."

And in that setting, you can't then not tell people about things,

cos that's clearly the wrong thing to do.

When I started in the NHS,

I never thought I would have to have conversations with patients

and ask them how wealthy they were.

That's the first set of immunology you're going to get and you'll

need three doses of that.

But it's actually going to be more like 6,000, I think,

because he's having a bit less of the drug.

So that'll be kind of 24,000 to start with.

If that doesn't work, we move onto these two drugs,

and that's ?31,840.

That's two immunology drugs that he might need,

and I don't know how many treatments he'll need of that.

You know, you live once.

Life is precious. And I do feel like I'm being asset stripped

for a cancer which is not my fault.

But by doing the immunology, it should,

touch wood, buy me more months.

If you go back 10 or 15 years,

the NHS essentially provided all the treatment that was available.

There is now a gap, particularly in terms of drugs,

where the NHS will not pay because funding is flat,

the demand is rising,

we're all looking at things we can stop doing.

And so that the gap between what is potentially available

and what the NHS will provide, is unfortunately going to get bigger.

Since the NHS was formed, consultants have had the right to do

private work in addition to their NHS responsibilities.

The NHS does encourage private practice because

they get revenue from it.

And all hospitals in the NHS have to look for their revenue.

To enable Imperial College Trust to benefit from private work,

each of its five hospitals has a private ward.

At Hammersmith Hospital, it's the Robert and Lisa Sainsbury Wing.

It's where private patients come.

Occasionally we use it for the NHS,

if we're short of beds on the NHS side.

They're all individual rooms with en suite bathrooms.

I feel like a salesman!

Today, cardiothoracic surgeon Rex Stanbridge

has one private patient on his operating list.

Nice bed.

You've got Sky Movies.

And Sky Sports, your favourite! Star treatment!

87-year-old Mary is having surgery to remove

a suspicious lump on her lung.

Oh, I can see the prison!

Look!

There! That's the highlight of Mum's visit to the hospital!

Yeah, it is. I've been to Scrubs!

It is a very attractive building, I think so anyway.

Right, I'll go and see her for the consent. 11.

Good morning. Good morning.

Right. OK.

As you know, they were following you and they found that you had a lump

in your lung, on the left side,

and that over a period of a few months, six months, I think,

that lump has grown. Yes. I hope you're going to take it out.

Yes. Well, we'll take out the cancer but also it's the upper lobe

of the lung that we may take out as well,

which is our gold standard procedure for lung cancer.

I know as you get a bit older people might argue,

"Why bother?"

SHE LAUGHS

However, I tend to like to think that it's not the age

from the cradle but the age from the grave that we're looking at.

Yeah!

Right, so this is the consent form for you.

Mum has medical insurance and she has this certain amount

of cancer care, so we've done...

all the scans and all the different tests

that she's had to have - we've done all that on the National Health.

Thank you very much. OK. Good luck!

And the only thing that she asked is after the operation that she has her

own room, so that's why she wanted to do that privately.

My husband, he's been dead 28 years so he set it up

and we've been paying ?800 per month.

I think I get a little more peace when you've got your own room.

You don't get people coming in and out and in and out,

and a nice, big window, blue sky.

INTERVIEWER: Do you feel like you've kind of earned it?

Well, I paid for it, let's put it that way!

Mr Stanbridge said he would do it on the same day whether she came in on

the NHS or she came in privately.

It would have been equally as fast from the diagnosis to now.

She pays a lot of money in every month

and doesn't get much out of it,

and she can have the same operation but in a slightly nicer environment.

They get a bit more personal care from the consultant.

I just wanted to check on the bloods on this patient.

Private one? Yeah. Lovely.

INTERVIEWER: If you have a procedure, would it be private?

I haven't got private insurance.

I don't know if I should have to start now,

but I believe it's very expensive.

Next to Hammersmith Hospital is...

It's the trust's centre of excellence

for gynaecological medicine.

Hello. They're ready for you to go to theatre now.

OK.

I'll walk down. We'll take a pillow with us as well.

44-year-old Nicky has ovarian cancer that's relapsed.

I've been given 6-12 months if I don't have any treatment.

In addition to her NHS care, Nicky's crowdfunding to raise money

for a cancer drug.

"My surgical team in Devon have only proposed chemo and I do not believe

"this is my only hope."

Don't be nervous, it's fine. I'm really nervous.

"So I've needed to find out if I can find any other treatment."

We're going to follow the blue corridor.

"I've done much research and the most immediate chance to live a bit

"longer is a large surgery plus ideally

"a new maintenance drug called Olaparib."

You're in good hands, OK?

It has to be paid for privately.

The cost is approximately ?4,000-5,000 a month.

I'm sort of fighting, fighting my corner as much as I can.

Are you all right? Yeah, I'm just really nervous.

At times, it's an uphill battle.

OK, I'm just going to flush your drip here.

No-one talks about the cost of cancer

and I'm determined to try and find a way to stay alive.

The NHS gives patients the right to choose their consultant.

When her cancer returned, Nicky sought a second opinion

from Christina Fotopoulou,

a renowned gynaecological cancer surgeon

who's at the forefront of new surgical techniques.

Nicky's initial diagnosis was a few years ago.

When she had this surgery back then

the ovaries and the tubes were removed.

So when ovarian cancer comes back,

it comes back on the skin inside the abdomen, it's called the peritoneum.

But you can see here,

all this is being covered by little lesions there

that are common to be there at relapse.

However, she has a larger tumour that goes a bit deeper

into the liver.

Good morning.

Christina will perform a radical operation to remove the cancer

that's spread to the lining of Nicky's abdomen and liver.

She's a young woman. We are doing everything in order

to try to prolong her life.

We know from retrospective data that overall survival

can be high if you can get the patient tumour free.

Whether we will be able to get her tumour free,

this is something that we can answer only during the operation.

OK, if you need anything, give us a call. Yeah, all right, thanks.

All right, take care.

Nicky was in remission for a year.

We had no sign of anything for 12 months

and I think probably we got a little bit complacent...

..until we got the second diagnosis.

It feels like your world's just collapsed again.

INTERVIEWER: Do you ever talk about the end?

No, we haven't done yet.

I know we'll have to at some point.

We know it's real, we know what's going to happen.

There's no reluctance to talk about it.

We will talk about it, I think, when the time comes.

Yeah, stick him on the end there, can't we?

Glendon, who wants to top up his NHS treatment

with a self-funded course of immunotherapy

is seeing Matt Williams in his NHS clinic.

This is...

..now post re-resection.

Glendon has already had two surgeries,

chemotherapy and radiotherapy

at hospitals in Preston and Liverpool.

He's obviously got that cavity but he's got this new tumour...

..which might benefit from some of that coming out.

I have another treatment which I am intending to give him

which he's come today to see me about,

but I think an operation first might be a good idea.

My only concern is this is then his third operation.

The main risk I would worry about in him would be

a paralysis on the left side.

What I'm looking for at the moment is obviously to stay alive.

I've got to kill it

and immunology, as far as I'm aware,

is the only chance I have of actually bringing

this nightmare to an end.

I think we are in a difficult place.

There's a significant amount of abnormal tumour

and we feel that if we're going to advance the case, then we should try

and remove as much of that to get as small a target as possible.

How do you feel about the idea...?

I'm fine because I haven't got really an option.

Is there anything else that you want to ask?

The main thing is can we do this so that I'm alive?

SHE LAUGHS Cos I don't want to die.

I don't want to do all this and die at the last hurdle,

that would be infuriating for me cos I've worked so bloody hard

to get to this stage. Sure.

I mean, it really has.

I mean, I've done...

..ten hours research every day since the day I've been diagnosed.

I will spend whatever it takes.

And I know this sounds daft - when I got diagnosed I thought,

"There can't be nothing in this day and age." So that's where I am.

Sorry, rant over. OK. That's all right.

I'll leave you with that audience and I'll see you next week.

Thank you very much.

The point of us offering you treatment to keep you alive

is so you can enjoy your life and spending your time till...

Spending your time till three in the morning

looking up brain tumour treatments...

Thank you so much. ..on the internet,

that's not much quality of life.

Do I know it! You've just made my life so much easier.

OK, but only if you go and spend your time

doing something more interesting.

Traditionally, you used to be able to say to patients,

"I think you should have treatment X

"and you will be having treatment X," and now there's the internet,

so it's much easier to see what is the standard treatment

for your disease in America, Germany,

Norway and our cancer survival rates

are worse than almost everywhere in Europe.

And how we deal with that as a profession,

how we deal with that as a society, is a difficult question.

Katie Urch is the divisional director

overseeing all cancer services for the trust.

INTERVIEWER: How does a drug get approval?

Usually a drug has been developed by a company

and gone through various clinical trial phases.

It is then put forward in this country for NICE approval.

NICE approval means it has been independently assessed

as having some degree of benefit.

NICE is the body responsible for deciding

which new treatments should be available on the NHS.

We are certainly in a golden era of more and more drugs available but

the amount of added life benefit perhaps is quite minimum.

And so the jury is still out on many of them,

of exactly what benefit we're going to see.

Christina is halfway through a two and a half hour operation to remove

cancerous tissue from Nicky's abdomen.

So the disease is stuck on the right urethra on the right pelvic vessels,

and on the right muscle that goes to the leg.

If you dissect it in the way it should be dissected,

then it easily comes off.

I'm stripping it away like you would strip away your gloves

or your tights.

In cancer medicine, for advanced stages,

we talk about prolongation of life, not about a cure.

If we only want to cure people, then we will have to treat

only patients with very early stages of favourable tumours

and let everybody else die.

That's not possible and that's not ethical to do that.

INTERVIEWER: What would have happened if you guys

had stayed back in Devon?

We probably would have started chemotherapy this coming Thursday.

They offered us just chemotherapy,

they didn't think surgery was indicated

and that's why we thought we'd look around

just to make sure that what we were being offered was the right thing.

But each trust has its own rules and they do vary quite dramatically.

The specialists here just finished a research project

that your chances of living longer are higher

if you have surgery before your second set of chemo

rather than just chemo on its own.

Queen Charlotte's and Chelsea offers specialist surgical treatment not

available at most local hospitals.

Around a third of their gynaecological cancer patients

are from outside London.

INTERVIEWER: My understanding is there's drug that could

prolong life expectancy.

As far as I know it's a maintenance drug.

It's something to do with altering the replication of the cancer's gene

and it's supposed to increase the length of time before it comes back.

It doesn't treat the cancer,

it just tries to maintain the situation as it is.

That's the drug that we're hoping to go on in the autumn.

INTERVIEWER: Is this available on the NHS? Yeah, it is after a third

session of chemotherapy so your cancer has got

to come back two times after the first one for you to qualify under,

I think, current NICE guidelines.

It doesn't seem fair. It's available after two sessions of chemotherapy

in some countries in Europe and they've had some success

with it in France and Germany, I think.

Patients will come to you in the clinic and they have read many

things about new drugs. Often they will tell you,

"Why can't I have this?"

So we're finished.

We have to be cost-effective but we also have to balance

very carefully the benefits for the patient.

If we give all this money for a new drug for a few months longer,

we have to take this money from patients in screening programmes,

in early detection of disease that can be cured.

So, it's tricky.

Hey.

Perfect. Really? Perfect.

Everything as expected, no problems, she's tumour free and fine.

So well done. OK? It's all good. Thanks very much.

Some disease on the pelvic sidewall,

some disease on the liver but on the liver, not inside the liver. OK.

Some disease on the diaphragm, like we discussed. Yeah.

That's that. Thank you, Christina. It's all fine. Thank you.

By the sounds of things, it couldn't have gone any better.

There was nothing unexpected there

and she managed to get everything out, which is fantastic.

You hope for that in the beginning but you don't want to hope too much

in case it doesn't happen.

All the best. Take care.

She said you'd be sitting up tomorrow.

INTERVIEWER: Do you ever feel you're being held to ransom?

Held to ransom in that I can't give the drugs that we want to give.

I think we have, in our health service,

an amazing access to drugs and to new therapies,

new surgical techniques.

But there is a balance of which drugs,

which interventions we fund and which we don't.

And every single economy will struggle.

We struggle and come up with a certain answer.

If you're in Europe, you would come up with a different answer.

In America, you'd come up with an answer based on what you can afford,

rather than what you need.

I don't think there is a perfect solution.

I think it's a very difficult balancing across a whole population.

Bye. Good luck. Thank you. See you. See you later.

87-year-old private patient Mary is called to theatre.

It's no good feeling all worried and uptight and stuff like that.

If it goes wrong, well, I've had a good life.

The hospital will recoup the cost of Mary's operation

and stay in hospital from her insurance company.

Nice big breath for me. A nice big breath.

On average, the trust charges a third more

for private work than the NHS tariff for equivalent treatment.

INTERVIEWER: Do you think the public view private work differently?

Yes. They do have misconceptions.

What's the most common?

The most common one is,

"Oh, he's in Harley Street, he must be the best."

This may be true and it may not be true.

Are there cowboys there?

Let's just say that not everything that goes on in Harley Street

is wonderful.

Private work is largely carried in NHS operating theatres

with an NHS surgical team.

Only the anaesthetist and surgeon are being paid separately

by the insurance company.

She's a relatively fit woman, actually.

She's a lifelong smoker. Does that change anything?

No, it doesn't change anything at all. No.

Would the NHS still choose to operate on somebody...?

Yes. Yes. Do you think it should?

Yes. Yes, definitely. Yes.

Flying over the enemy lines.

I'll take a knife to this and then I'll come back

and put the camera in.

Black is soot and it's a sign of smoking,

it's a sign of pollution in the air from all the motor vehicles we use.

She's got a mass on her lung.

A mass has been growing for six months

and is highly suspicious of a cancer,

but we haven't proven it is cancer yet.

This bag just pops the specimen in.

So we're going to do that by taking a segment of the lung.

Pop one wedge into the bag.

Sending it off to the laboratory.

And they'll give us a phone call back

to tell us what they think it is.

If it is cancer, we take out the upper lobe of the lung.

PHONE RINGS

Hello, Stanbridge here.

That's fine. Thank you very much.

And we have a result.

It's a non-small cell carcinoma,

so the biopsy is positive and malignant.

INTERVIEWER: How important do you think private work

is for the future of the NHS?

The NHS is making some money out of it.

A big bag and then we're going to take the specimen out.

And that helps to keep them going,

because they need all the funds they can get.

England is lucky, it's the only country that does have an NHS

quite like it is.

But it's not funded properly.

It's underfunded.

So we could do a lot more with a lot better equipment,

a lot more stuff, if it had more funding.

My headlight batteries have died, so that means I have to leave.

The team are going to close up.

INTERVIEWER: Can I ask a cheeky question?

How different is your invoice for this

compared to if it was on the NHS? Not silly money.

For two or three hours private operating...

..seeing the patient for 15 minutes every day...

..I don't know what you think it should be.

Do you want me to throw a figure out? Throw a figure out.

?1,000. Yup, well, it's not far off.

It's a little more than that. But it's less than two.

Hello. Hello.

It's all over, the operation.

It's good. OK. OK, do you want to sit down?

It's fine. Sure, sure. It's easier, you don't have to stand up.

All right.

She's OK. The result was that the frozen section that we did the wedge

showed that she had cancer, which wasn't a big surprise.

No. So I proceeded to do the full lobectomy.

It's all out. And I'm sure she won't need further treatment for it,

and I'm sure that's a relief.

Thank you. Thank you very much. Thank you.

Thanks. Thank you.

She's OK.

God, she's tough!

I'm sure they were quite nervous that they'd done the right thing

because she's elderly and it's their mum

and they've helped to advise her.

Is she asking anything? Yeah, no, she's speaking, yeah.

She's awake. Yes.

Does she want to know what's happened?

I don't know if she'd be that awake.

You can ask her.

Hello.

Good - everything's good. The operation's done, all right?

Just relax and we'll just look after you for the next day or two.

Good.

Mary will spend up to 24 hours

recovering in the hospital's cardiac intensive care unit.

INTERVIEWER: The people with cancer who have private health care,

do they live longer? I've absolutely no information on that.

In private care, I don't think you can buy life.

Welcome, everyone.

So let's move on to the first item on the agenda,

which is the income report.

In the five years from 2010 to 2015,

the trust's income from private work increased by 40% -

from ?31 million to ?43 million.

So April, the first month of the new year,

was actually a pretty good month for us again.

So it followed the strong trend of the last three or four months.

I think, in terms of highlights,

our cancer business continued to show strong growth.

If you can grow more private patient income,

that will actually help out with the

rest of the national health business.

There's a lot of enthusiasm for working closer with you and finding

the growth. I think there's a bigger understanding of how private works

in the trust - that we need to get those very clear messages going on.

INTERVIEWER: Are there any downsides to doing private work?

I think people think that we make more compromises

than we actually do.

We know that it doesn't compromise our NHS care, but, nonetheless,

it's very easy to write a story that says because there's money in there,

because the NHS needs money,

surely they must be disadvantaging NHS patients in some way,

whereas the truth is that the money

does flow back in to NHS patient care.

And the proposal is to kind of take that income and directly allocate

it down to divisional positions.

Is it possible to say what percentage goes back to NHS?

All of it. It doesn't go anywhere else.

It could go into private facilities.

It doesn't in our case, cos we own all the facilities.

We need all of the things to be flying...

..and I think we need to just keep doing what we're doing.

We have a financial deficit of 41 million,

so if we can make money treating private patients,

then it's better that we address our deficit that way than that we have

to cut back on NHS services, which, to be honest,

is the only other way we can address the deficit.

OK. Great. Keep up the good work.

We've got to get smarter, we've got get more efficient

and we've got to do the best with the money we've got.

I don't think that's a particularly difficult argument.

I think it's reasonably well understood,

it's just not very popular.

Another five big deep breaths, there, for me.

You're doing really well.

Starting to feel a little bit woozy.

Glendon's undergoing three hours of brain surgery on the NHS to remove

as much tumour as possible.

Wow, wow, wow...

Just getting off to sleep now. OK.

Drifting off to sleep.

The operation carries a risk of paralysis on his left-hand side.

OK to start.

Thank you.

That's the skull. He's had a previous opening here.

The opening, the craniotomy,

has been secured with metal screws and plates.

Elevate this.

And we have plainly abnormal tissue under here.

I suspect this will be part of the tumour, this grey,

jelly-like substance here.

Sometimes they're terribly soft and it would be like resecting

creme brulee. But, um...

in this case, as you can see, as we grab the tumour, it's very firm.

It's like almost a hard lychee, or a rock-hard kiwi fruit.

This tumour would be about the size of a tangerine.

It's almost five centimetres across.

When was that? That was... I think that was about four years ago.

Yeah.

Hm! That's the same time.

We went to Cambodia and Vietnam.

We were planning on doing lots more travelling.

We used to walk quite a bit, as well.

Just a picture walking, there.

How did you meet? Through a friend, actually, that I worked with.

Yeah.

She introduced us. She actually did a reading at the wedding,

which was really nice.

Glen hates all these wedding pictures.

He says he looks awful on them.

To be fair, he's probably ill, though,

because that was only six weeks,

probably, before he had his seizure.

Do you feel like he's changed?

Yeah. I mean, he's totally different.

He'd gone manic, at one point, and he was quite aggressive.

Literally, I'd have to walk ten paces behind,

that kind of attitude!

Sometimes I used to get a bit annoyed at him because I thought,

"Well, you wouldn't be like that beforehand."

And even when he's like in surgery now, it's kind of,

"Is he going to come back the same person?"

And, yeah... It's bad enough, like

you say, that he's got this prognosis.

I might lose him at some point, but I might lose him before I lose him.

And to be fair, I've lost some of him already.

That is distressing.

On the angle.

First day.

Three days after surgery,

Mary is recovering in her private room.

I'm grateful that I can have a private room and top-hole surgeons.

I think the kids felt, "Is she going to come out of the operation?"

You know, because I'm old.

I have a lot of confidence...

..thankfully, and I didn't think of dying at all.

I thought, "No, I'll survive."

INTERVIEWER: So how come you're in on a bank holiday?

She's a valued patient and I'm taking a special interest in her,

so I thought I'd come in and see her.

Hello, good morning, Mary.

How are you? Fresh out the shower.

Fresh out the shower. Fresh and lovely.

That's fine.

Is that different than if she was an NHS patient?

Probably.

Good. Did you have a good night? Very good, thank you.

Excellent. Excellent.

I come in because she is a private patient and I come to see her

and I think that's basic practice for private

to come and see your patients every day,

if you possibly can - if it's reasonable.

And the traffic is much lighter on a bank holiday!

I see you've done all the Sudokus and everything.

Oh, yeah. That's pretty good, isn't it?

I enjoy it.

Yeah, it means, you know...

Brainpower. Keeps the brain ticking.

Keeps the brain going. Yes, that's important.

Yeah, it is. Fine.

Well, I'll see you again in two weeks.

A couple of weeks. Yes. That's right.

Good. Well, thanks again.

Very good. Thank you.

Right, thank you very much. So, how's Mary?

I think she's ready for discharge.

Overall, I think she's done spectacularly well.

What do you think of Rex?

I think he's great. Yeah.

I told him I loved him yesterday.

What did he say? He didn't say anything.

He's too shy, I think.

Look at you. Treated like a queen.

The trust's total revenue turnover is about a billion.

The Imperial Private Healthcare

part of the business is about 50 million.

So we're currently about 5%.

See, the sun's shining for me.

We're an NHS Trust.

The priority goes on the NHS patients.

But with the big deficits that the trust faces,

I think our chief financial officer would like me to double the size of

the business and that may well be possible over time.

Glen, the operation is all finished now.

You can start breathing.

Deep breaths, in and out.

That's it. Well done.

We are entering a phase of cancer survivorship where people have been

treated and have emerged out the other end,

that there will be people like this who are having ongoing treatment and

you're still scanning them,

operating on them and involving health costs.

You then become a victim of your own success.

Where's Kate?

Glen? Here, darling. Hi. Hello, hi.

Hello, sweetie.

How are you? I'm fine.

It was just a bog-standard one.

Was it? Give me a kiss.

There you are, sweetie.

Good job on you.

Yeah. You can still move all your left side.

That looks good. Yeah. Yeah.

No deficit at all... by the looks of it.

Hello. Hello.

When I set out to do the operation, I was aiming for 90% removal.

Brilliant. I think we did more than that.

Oh, thank you so much!

You're a genius. Look at this.

No, I'm not a genius.

You've done brilliantly.

You're my hero.

Because it means that I can start living my life again.

And that's what I haven't been able to do for a year.

And if Dr Williams is happy, that will be the cherry on the cake.

He's the immunologist.

Yes. And he says, "Right, yeah,

"we've got enough to crack on with the treatment."

I'm happy. I'm the one who's paying all the money for this. Sure.

Under the trust's self-pay guidelines,

patients topping up their care with drugs not available on the NHS are

only charged the wholesale cost and a fee to administer them.

The NHS, quite rightly, will pay for treatments which are evidence-based.

But there are some patients who want to go beyond that and you could say,

"Well, they shouldn't be having non-evidence-based treatments."

Well, maybe the evidence is there, but it is not of the best quality.

Thank you. Bye.

Fortunately, I'm not sitting the other side of the desk with

a potentially life-threatening tumour

and what would want one do if it was yourself?

So you're ready for a cup of tea?

Coffee. Coffee?

All right. Cappuccino.

That'll have to do.

Be grateful. Say thank you.

If he was very quiet, I'd be worried.

Last time, you pretended I was your sister.

Who are you, anyway?

Yeah, don't start that again!

I'm glad you didn't play that trick this time.

Is there any more water?

My mouth's as dry as a badger's arse.

My mother passed away from ovarian cancer about 18 years ago...

..so I've known about ovarian cancer for a long time.

It was really devastating.

My mother was an amazing woman

and she suffered terribly through her illness.

And I was very fearful when I was first told,

because in my mind I'd seen someone

that I was close to go through the same thing.

Nicky is waiting to be discharged.

In six weeks, she'll start the standard NHS course of chemotherapy

at her local hospital in Devon.

Good morning. Good morning, Christina.

How are you? You look good.

So, we discussed yesterday that I'm happy that you go home today.

How have things been yesterday?

Better? Yeah, I have some good days and some not so good days,

but then I think from Sunday, things got better.

Excellent. I'm happy that you drink some coffee,

that you start eating normally, normal things.

Avoid things that could bloat you.

Any questions or anything?

I don't think so. Maybe just...

Do you have any idea when I could possibly drive and get back up and

running again? Yes. What are you doing again?

I work with horses. Don't do that.

OK. I'll wait a little while longer.

Wait until six weeks, please. All right. You're very good.

I'm very proud of you. OK? Thank you.

Thanks, Christina. See you on the 8th. OK.

Bye-bye. Bye-bye. Thank you.

Hey. Hi.

Hey, chicken. Hello.

I've checked out of the apartment.

Put my ring back on. How long has it been since you were able to wear

your engagement ring?

About a week. About a week, yes.

It's been really hard, cos it feels really strange without it.

It is just your fingers swell up,

because of the amount of fluid that they pump into you.

It feels fantastic to have it back on again.

It was ?7 short of 11 grand.

No way. Yes. Amazing.

I was wondering if it might go over 11,000, last night.

Some friends of mine that used to live in Scotland,

they did an office cake-bake sale.

?271.

I know, it's absolutely amazing.

Well, at the moment we've reached almost just shy of 11,000.

What's the target?

About... 66,000. ?66,000.

Yeah.

Even an old schoolteacher, when I was about 13,

he's donated some money and I've not seen him for over sort of 20,

25 years. I feel quite guilty, in a way,

that I sort of didn't deserve this money, because I'm not very good...

I never really ask for money and I never really ask for help.

So, for me, this was quite a novel thing to do.

I think crowdfunding is becoming

quite a common platform now, I think,

for people to raise money for cancer treatments

that aren't available on the NHS.

Are you ready to rock and roll?

Yeah. I'll get you some shoes.

What happens if you don't make 60,000?

Whatever the money I do raise,

I can still put towards several months of treatment.

So if it's around ?4,000-?5,000 a month, for the Olaparib,

I can still sign up with the drug and then just have as many months of

the treatment as I'm able.

With the amount that I've raised at the moment,

that would guarantee me at least two months

on Olaparib, which is fantastic.

That's already about 20% of the way.

Can you just confirm for me if you received Nicola's authorisation for

medication? Is it a possibility we can have it ASAP?

INTERVIEWER: Can you understand why the NHS don't fund it?

I can understand it, but it's still very frustrating.

Don't get me wrong, I'm eternally grateful for what's happened.

I dread to think how much money has been spent on Nicky's treatment

since the first diagnosis, 18 months ago.

I understand that, yeah.

Somebody does the sums and somebody has to do the sums.

It's an awful job to do but somebody works out how much to spend,

and how long to increase somebody's life by.

Anti-sickness. OK.

Antibiotics. OK.

The research that is coming out now is so promising.

Thank you so much. You've been amazing, thank you.

It has given us a bit of hope.

It could be a matter of months before it comes back again...

..but no-one really knows.

The work I do here is tightly regulated.

I have an annual appraisal

and people keep a fairly close eye on my work.

Outside of places like this and other big NHS hospitals,

if you just go and see someone privately,

there are all manner of snake oil salesmen out there

and I think that worries me.

Hello!

Matt is seeing Glendon in the NHS clinic for the first time since

his brain surgery.

Well, look at this.

Can I give you a hug? I didn't do anything, mate.

You put everything in place for me.

I mean, I just... You know what I was down to.

Take a seat before you fall over.

I'm not falling over, I've been walking all day.

OK, all right, then. Well, before you get tired, then.

So, we need to talk about what we're going to do next.

We had talked about having another round of radiotherapy.

Yep. And we had talked about adding immunotherapy to it in the form

of Pembrolizumab. Yep.

Is that still what you want to do?

Yes. Fine. Unless there's another combination which has come out.

OK, this is the best I can do.

Let's make some informed guesses.

If it works, how long do I keep the schedule going?

They will give you two doses of Pembrolizumab,

one before and one after.

But do I keep carry on taking them for the rest of my life?

No, no, no. Two doses of Pembrolizumab.

Right.

Beyond that, I find it very difficult to justify continuing.

I mean, it's not a money thing, if it works, I will carry on doing it.

I know, I know.

You keep saying that to me.

INTERVIEWER: Have you made a sort of choice

about not giving Glendon exactly what he wants?

Are you trying not to bankrupt him?

Well, of course I'm trying not to bankrupt him.

One of the drugs he's interested in is just under ?30,000 a dose.

I don't think that there is enough data to justify its use.

Immunotherapy can be a bit funny in that...

because it sort of takes the brakes off your immune system...

Yep. And your immune system kicks off, it can give you lung problems,

kidney problems, heart problems, eye problems, skin problems... Yep.

..because essentially it depends which bit it decides.

Yes. I heard the liver was something...

Yes, and liver. Sign and print your name there.

Is it the role of the doctor to say, "Stop treatment"?

We live in a society where people are used to being able to have what

they want, and health care is not like that.

It's difficult because part of our job is to own the uncertainty,

to say, "Here are the options and I will recommend A,

"I will recommend B,"

even when in your heart of hearts you are not entirely certain.

In all honesty, I'm not an idiot.

Somewhere along the line, it's going to be not treatable.

Yes, but my aim

is, where it's appropriate,

is to give you treatment to keep you well for as long as possible.

It's all we can do. That's all I want to hear.

I'm a realist. You're a very optimistic realist.

Thanks. Nice to see you.

How are you feeling about the prospect

of getting the immunotherapy drugs?

It's like going to the bookies really, basically.

You can't turn around and say,

"Oh, yeah, you're on a sure-fire winner here."

What I'm trying to do is kick this cancer further down the line.

The further I can kick it down the line, the more studies go on,

there's more chances of drugs being approved, which are clinically more

effective, so that's why you do it.

Hi, is that the 15th chemo unit?

Hi, I'm calling from pharmacy,

just to say that the immunotherapy

for Glendon is ready to be collected.

I didn't want to go to my grave without covering every angle.

Hello.

Hello. It's for the 15th floor.

INTERVIEWER: You grew up expecting the NHS to always be there for you.

Yeah. Do you feel the NHS is still there for you?

For the everyday stuff, very much so.

So you're staying here, yes? OK.

Hi. Just want to pay for Glendon's treatment.

INTERVIEWER: How does that feel?

It's what needs to be done to get the treatments.

Do you think the hospital, knowing that it's a bit of a gamble,

there's no guarantee...

Do you mean, should they offer him this?

Yes. They've taken a lot of money from you.

Yeah, but it's hope for him,

and if I went home tomorrow with no treatment or forward plans,

I don't think he would cope.

He would give up.

INTERVIEWER: Are you all right? SNIFFLING: Yes.

Just that it is hope, and, you know, it might not work.

In fact, it probably won't work.

Well, I don't know, I don't like to get too optimistic.

But, erm...

You know, if it even

gives Glen something to live for now...

..it's serving a purpose.

All ready, sir?

Here we go. Here we go.

I just want a normal life back.

I want to live to 70.

You know, something like that.

I don't want to die at 50.

Good. Fusing nicely.

You know, you've got to put up with what

you're given, and if I can keep it going longer,

that's what I'm going to bloody do.

INTERVIEWER: Are the NHS in an impossible situation?

Yes.

We are completely screwed.

The NHS is caught between some demographic pressures, so we have

a bigger population and an older population,

but we are also caught in a really nasty wedge in other ways.

Medical technology is developing, more treatments available,

patient expectations are going up,

but increasingly we are no longer able to meet them.

And this country has

skimped on health care for a long time.

Sometimes people talk about a two-tier system,

what does that mean to you?

Well, I mean, we run a two-tier system...

..and most of us would rather not do private health care.

I certainly never came into medicine with any intention of doing

any private work.

The best example of what happens when you have a lot of

private medicine is America.

It gets very poor outcomes.

ANGRY SHOUTING

Is she safe? Is she safe?

St Mary's A is experiencing

a sharp rise in mental health patients...

There are patients in the corridor at the moment

because we don't have enough bays.

..with one of its longest ever waiting-time breaches.

Just to highlight, the first psych patient's

now been in A for 22 hours.

It's not fair on her ultimately, or anybody else here either.

Do you know where you are? No.

Do you know where you are?

And the complex needs of an ageing population...

It's too much for me.

I want to look after him.

..sees more people than ever attending hospital in crisis.

Anyone in society that doesn't know where to turn, they will come to us.

In their eyes, we're seen as

the only people that can help them.

What choices would you make

when faced with complex health care decisions?

Visit our interactive pages to find out how you would respond. Go to...

..and follow the links to the Open University.