Episode 6 Keeping Britain Alive: The NHS in a Day

This programme contains scenes which some viewers may find upsetting.

18th October, 2012.

Across Britain 100 cameras are filming the NHS on a single day.

This change will be a disaster.

On this day more than 1.5 million of us will be treated.

Three days ago you had a stroke.

1,500 of us will die.

2,000 will be born.

The NHS is the largest public healthcare system in the world.

We want that to be in your voice all the time.

Hello, we're going to help you.

-We rely on it...

-Be really brave.

-..complain about it...

-In the bin, that's because of you!

..often we take it for granted.

Lucas! Lucas!

What we expect from the NHS is ever-increasing.

The money to pay for it isn't.

If we could see what this institution does in a single day...

..what would it make us think?

This entire series tells the story of one day.

So, why isn't she waking up?

100 cameras,

capturing the NHS as you've never seen it before.

Baby born at five to three.

RADIO: 'It's seven o'clock on Thursday 18th October.'

-Do they do showers there? I can't remember

-Yes.

-Do they?

-Yes, and you can change clothes there.

-OK.

The plan is ordinary surgery to start with

so a morning of booked patients,

and then I'm duty doctor in the afternoon,

which is the bit that most of us don't like terribly much.

Dr Liz Lee is one of nearly 40,000 GPs in Britain

treating an ever-growing number of patients.

There are so many people with so much more wrong with them now

than there used to be.

When you are young you are very unlikely to do much

going to the doctor, but by the time you're 70 or 80,

you've probably got two or three significant illnesses

and you are going quite a lot.

I mean, we just haven't got enough doctors, because even now everyone

will tell you everywhere you go, you can never get in to see your doctor.

Nicky Barden.

Liz could see as many as 40 patients today.

I've been having a long-standing problem now with my hands,

a lot of stiffness and joint pain, across my knuckles.

It's a bit of a concern for me as I am a musician.

-What sort of musician are you?

-A guitarist.

The thing about general practice is this great breadth of medical

problems, so you have to know a bit about everything.

Can you make a fist?

'And also breadth of life, so you get babies, you do get dying people,

'and everything in between.'

Because you are feeling dizzy, I think, is that right?

52 kilograms, eight and a bit.

Just say, "Ah."

My guess is you'd like to try an antibiotic and see if...

-Yes, if I can do.

-Yes, I think that's very reasonable actually.

To maximise the number of patients Liz can see in a day,

her appointments are strictly limited to 12½ minutes per patient.

12½ minutes, it's not long enough to do an excellent job.

It's long enough if you got a sore throat or a simple thing,

it's really easily long enough, but, actually,

when patients have complex problems, it is nowhere near long enough.

I woke up in the night with a metal taste in my mouth.

It's like headache but it's like the whole of the inside of your head...

The task is pretty awesome really.

Endlessly sifting, sifting, all sorts of funny aches and pains

and things that actually could, in the end, be something that's

life-threatening for the person who presents them to you.

'At the back of my mind I do worry that I will let my patients down

'and some who should be referred on do not get referred on.'

Every so often it happens, within all surgeries, that there is

a patient who comes and sees us several times with symptoms that we

don't pick up and actually turn out in retrospect to have been cancer.

I think that has happened to every GP

who's practised for any length of time.

Janet Bowden.

I'm only running 10 minutes late, which isn't bad, actually,

at this stage in the morning.

Hello, I'm Dr Liz. Come on in.

-RADIO:

-'The government said it is still committed to reducing home energy bills.'

Ah!

SHE GROANS

We're only booking for the afternoon now,

there are no more morning appointments.

SIRENS WAIL

-Safe?

-Yes.

It is a mobile X-ray unit rather than a doctor's surgery.

We only do chest X-rays.

We often get asked for other things

but we have no other facilities, just chest X-rays.

That's it, come and stand here again now.

The TB bus was set up eight years ago by the Department Of Health

to address the problem of increasing TB amongst certain groups of people.

Tuberculosis, a highly infectious disease

that was last rife in Victorian slums,

is on the rise again in Britain. And, just like then,

it's spreading rapidly amongst the most deprived members of society.

Take in a breath again, breathe in. Big breath in.

Breathe in, Paul.

We go to anywhere that homeless people gather, where drinkers...

Drink treatment centres, drug treatment centres.

OK, breathe out.

The idea is that the people we deal with don't tend to go to a GP

if they feel unwell, they put it down to what they are taking.

So we go to them.

The team use a simple chest X-ray

to scan the patient's lungs for signs of the disease.

It's this white circle here, which could be a cavity,

which means that the bug has actually eaten away part of the lung

and it's consumed it. That's why TB used to be called consumption,

because it consumed the lungs.

-And your first name?

-Olwyn.

Pop your jacket on there, Olwyn.

Every time the TB bus is here, I always go and have a test

because you never know when you're going to catch TB.

My father had TB years ago and I know what the consequences are of TB.

This country is rife with it again, I mean, we got rid of it,

or were supposed to, and now it's back with a stronger strain of TB,

that's even worse to get rid of.

-There we are. Are you taking any medication?

-Loads.

If left untreated the disease becomes more infectious

and requires costly medical care.

Catching cases early will save the NHS millions.

Your elbows forward.

OK, breathe in now.

We get a lot of people who turn around and say, "Oh, I don't care.

"If it gets me, it gets me."

This is a breakfast voucher for you.

-You get a free breakfast today or tomorrow.

-Thank you, cheers.

We give a voucher out.

Anyone who has a chest X-ray will get a free breakfast,

so it's a way of encouraging them to come on.

Damn, I forgot to put the socks out.

Drat!

I thought of that last night.

We collect socks because often, for people that are homeless,

They... It doesn't sound very much to you and I,

but to have a clean, dry, pair of socks is quite something.

It's the old carrot.

Well done.

I am late.

I think whatever I do I'm always five minutes late,

it's just in-built into my nature.

But I'm usually a bit late for clinic

so the patients who know me well, they are always late as well

so a clinic that's supposed to start at 8:30 usually starts at about 9:15.

People on the outside sort of think,

"Oh, brain surgeon," and they think about that

and they think it must be some sort of mysterious,

really important job and it is an important job

and it is great to say that you're a brain surgeon

but the reality is that I think that all medicine, you can risk life.

We can cause damage

to patients and we can do really stupid things

that can really hurt patients,

or fantastic things that really can save patients.

-Morning, boss!

-Morning, morning, morning.

Conor Mallucci works at Alder Hey Hospital's neurosurgical unit,

an internationally renowned treatment centre for children

with brain and spine disorders.

-How are you doing?

-Good, good.

-Hey, Ben, how you?

-Hello.

-Are you all right?

How has he been? Perfect.

-Any problems.

-No.

-Yeah?

-Have you had your dinner?

-No.

'GPs probably see 20 or 30 patients with headache a day

'and most of them are just headache. If I see a child with a headache'

I stick him in a scanner and I know what is wrong with him, you know?

Hey, Prasanna.

Today, Conor's patients include Prasanna, a teenage boy with

an incurable brain tumour that's left him with disabilities.

I'm going to look at this scan, double check it.

Do you want to wait here for a sec while we just have a look?

Can we just have a quick look at that?

After more than 50 operations at another hospital,

surgeons there were unable to offer Prasanna any more treatment.

The family came to Alder Hey for a second opinion

and Conor agreed to operate.

It's one of those cases where different doctors will be of different opinions.

Not everybody, when you put a clinical question in the room,

is always going to agree.

The operation today will reduce cysts that have grown on the tumour

to try and alleviate some of Prasanna's more disabling symptoms.

Yes, those cysts are getting bigger.

'At some point with Prasanna you need to think,

"How many more operations can we do on this child?"

We've always got to sit back and say, is it in his best interests?

And I think we are all very happy as a team,

it's the right thing to do and we are going to do an operation that is

hopefully safe and it might, and probably will, help Prasanna.

-Hello, how are you?

-Say good morning.

Are you all right? Nice to see you.

-He has been asleep for the last day so...

-Yes.

-Good, so we are going to do this about lunchtime, OK?

-OK.

Alder Hey's £3 million highly specialised brain scanner,

the only one of its kind for children in Europe,

allows Conor to be more precise.

We are very technology dependent and we are very expensive.

I'm one of the worst offenders

because whenever there's a new bit of kit that I think will improve

patient care I will try it, use it, and show that it works.

It is one of those luxuries,

but it is not a luxury for a child's parents with a brain tumour,

it's a necessity. So, how do you cost that? You don't.

-I saw Sam sitting on a bus.

-I saw Sam sitting on a bus.

Do you mind telling me why you are here to see the doctor?

I'm not here to see the doctor, I'm here to read the paper.

I've just lost my job

and I do equate that with this outbreak of eczema.

Two hours into her morning surgery and Liz is on her eighth patient.

Now you've lost your job, is the stress levels going to go down,

-or are they just going up and up?

-They're going up at the moment

because I have actually gone for a lot of jobs and not got them.

I think my age. You know, a middle-aged woman,

it does sort of count against you looking for work.

-What sort of work?

-Careers adviser.

As the first port of call for most of our medical needs,

trips to see the GP account for 90% of our interaction with the NHS.

One of our jobs is to keep most medical treatments out in

general practice because we are so much cheaper than the hospital services.

-Just remember that it's more important to be happy...

-OK.

..than to worry about your cholesterol.

-That's all right.

-All right?

-Yes.

Some people describe us as gatekeepers.

-He was crying.

-I was crying.

-Were you?

'I can sort of think of the whole NHS as a sort of ecosystem'

and we are a very important sort of outer rim of the ecosystem

and we have to prevent people getting into the central bit.

-OK, so I'll stick on the diet.

-Stick on the diet, yes.

-Very good, thanks. Thanks very much.

-OK, bye.

One of the most expensive wards in any hospital

is the intensive care unit.

61-year-old Stuart has been in intensive care for almost four weeks

after suffering a massive heart attack.

His children, Sarah and Andrew, have been at his bedside

every day since it happened.

He was competing at a motorsport event and he pulled over

on to the grass and it was apparent that he was very in distress.

Thank goodness he got quick attention by the paramedics

that were at the venue.

Yes, he was lucky that it happened there

because he had medical assistance as soon as possible

-and in these cases that is what really is...

-Makes a big difference.

Lucky to be attended there by the paramedics

and then airlifted here to the Queen Elizabeth Hospital.

Stuart has been unconscious since he arrived in hospital.

Every day he spends here costs the NHS £2,000.

-How long have you been here now?

-It's day 25.

-Yes.

-Yes.

Where were you when you heard about your dad?

I was actually on my honeymoon in Mauritius, so, yes, that was...

That was a whole other dimension to the sort of situation we were in,

I guess, but, you know, we just came straight here.

As soon as we could we came straight here. Yes.

When was the last time you spoke to him?

It was when my brother gave us a lift to the airport,

so they were just seeing us off,

so in a really sad way, at least it was a goodbye,

but not the good sort of goodbye that he would anticipate having.

Until Stuart's condition improves, doctors can't be certain

whether he has sustained any long-term damage.

All his family can do is wait.

We daren't plan anything

because for every positive there's

been a couple of little negatives,

so we haven't planned, we haven't really planned at all.

I am waiting to see how brain-damaged he is.

That's what I need to come to terms with now really.

His heart's working properly...

Now we've got to see what's there.

When you wake up in the morning first thing,

is that when you cough most? When you've been lying down at night,

when you sit up, wake up in the morning...

-When I wake up in the morning.

-You do a big cough in the morning then?

-I am not waking because of the coughing.

-OK.

After the smoking cigarettes.

-Do you see blood in it?

-Yes.

-Blood? Every day there is blood?

The last two weeks every day.

The last two weeks there's been blood. OK.

In east London, Jane has found someone with the early signs of TB.

So this gentleman came from Lithuania eight years ago

but has been sleeping under a bridge in Shadwell.

Has been complaining of a cough, he's coughed up some blood,

and he feels very lethargic, which are all symptoms of TB.

Once the X-ray came up

and I could see this patch here of infection,

this sort of white streak here,

obviously that needs to be investigated.

So you drink, do you take any drugs? Do you smoke heroin or...?

No, I am smoking cigarettes.

-But no crack, no heroin?

-No, I am drinking beer and vodka.

Beer and vodka.

OK, so, what we'll do is we will get you to give a sputum sample.

-If you can cough...

-Yes.

-And cough some up into a pot.

We do see quite large pockets of Eastern Europeans

in different parts of London because they tend to gravitate together.

There is also a lot of them sleeping rough now.

They came here for the job

but the jobs have dried up and they are now homeless.

I want the phlegm from the bottom of your chest.

HE COUGHS UP

Let's just see. OK.

Yes, that's OK. And another one in here.

HE COUGHS UP

OK, beautiful. Yes.

Perfect. Thank you.

This one mobile X-ray units attends to 10,000 homeless people

living in London.

Every day is different. I know a lot of people say that

about their jobs but with this one every day really is different.

We have done some pretty rough estates at night, haven't we?

We did have supermarket trolleys thrown at us in Brixton

when we were screening down there one evening.

We had a chap last week who was absolutely plastered.

We actually got him up onto the van and his legs went

and he was all over the place. But this chap got off the van,

stood on the pavement, shook his trouser leg

and the poo dropped down his trouser leg onto the pavement.

He kicked it aside and walked off.

With 50 people screened,

the bus is ready to move on to its next location.

We are going to Emmaus House,

where the nuns feed the homeless.

In Acton.

That is very busy and popular.

Well, he is two months old and he has got two lesions in his spine.

I have explained to the patient, earwax is not a medical emergency.

At the GP surgery, Liz's next patient is a regular.

Last week she came in with chest pains,

asking to be referred to a specialist.

The cardiologist is looking at the letter right now

and so now that bit is out of our hands,

-which I know leaves you sort of sitting, worrying about it.

-Yeah.

If they have got any worries, they will get you straight in

but that bit is being sorted out now.

Just looking back at the specialists you have seen recently, it's...

it's a lot.

Jackie has already had over 100 consultations with

specialists for a variety of conditions, including depression,

which, so far, has been resistant to treatment.

I am thinking, if your neck was the cause of the problems here,

I wonder if a lot of the cause of your chest pain is going to

be muscles as well and it is all part of your sort of depression, really.

I suppose my question is whether you think some of this could be

psychological or whether... I mean, both of you, really.

Whether you think it is that you have got physical troubles as well.

You worry there is a physical thing going on.

Yeah, I think there is something.

There is something more than just blood pressure cos if she

is struggling to breathe, there has got to be a reason for it.

-What is your fear? Heart attack sort of thing?

-Yes, definitely.

There is nothing to say that you are about to have a heart attack.

-You feel more distressed to me today than Jackie does.

-Yeah, I am.

Cos I just keep thinking we are being let down, really,

by a lot of it is because nothing is moving on quick enough

and she has been like this so long now it is getting very worrying.

I am worried about her.

Yeah, I don't know what to say, really.

I mean, people are looking, people are trying.

Do you get that feeling or...?

I just feel that, you know, something should be done quite

quickly because she is not getting any better.

I really want to get something done as soon as we can, obviously,

cos she is suffering with this at the moment and obviously

day-to-day life is making it really uncomfortable

for both of us, really.

Thank you.

I don't know why some people's depression is what we

call resistant depression, nothing fixes it.

I kind of feel like with the depression,

the answer must lie outside medicine

cos we have tried all our medical fixes

and we can't do it but there are people who

just stay sort of unfixed,

and live these very, very, sort of, blighted lives really, in some ways.

You know. So, it is not like a minimal fix.

It is not like, "Just pull yourself together and get over it."

It is actually a blight on her life

and we still can't fix it.

-RADIO:

-It is one o'clock. The latest news now...

INAUDIBLE

Saying you've got a nice rest overnight.

-Just tired you out quite a bit with your physio.

-Yeah.

-So it is good that you're sleepy.

-Yeah.

Don't worry about that.

And you're safe and well. You are really well looked after.

Doctors don't know whether Stuart is aware of his surroundings

and so Sarah and Andrew have been encouraged

to interact with their dad as much as possible.

They play a lot of Rolling Stones and Eric Clapton

and things like that cos Dad's a real little rocker at heart so...

-He likes a bit of ELO as well.

-Yeah.

We start to imagine what it would be like for ourselves

and he must be so bored.

You know, we can only anticipate that he is confused

and he is not really quite sure what is happening so if we can be

here as much as we can so he can hear our voices and play him nice music...

Yeah, nice music when he seems more... He can rest.

He has tried to whistle a few times. So we know that he is enjoying it.

When Stuart had his heart attack, he was over 100 miles from home.

But he can't be moved to his local hospital

until an intensive care bed becomes free.

In the meantime, the family are being housed nearby.

I want to get home to my own creature comforts.

When I left Reading it was the end of the summer.

It feels like it is the start of the winter now.

You know, it has been nearly four weeks so...

We had to get into a little routine.

As a teacher, I am a timetable person and I like a routine

and we get up at the same time, we get here at the same time

and then they go and see their dad.

I guard our belongings that we have camped out with here

and then they come back.

Then it is my turn to go in and sit with him then.

Kevin Edmonds, please, to room 15.

Conor is about to start his second operation of the day to

relieve the pressure in Prasanna's brain.

It's not the surgery itself that's difficult,

it's more that where we are is dangerous.

But we have drained the first cyst nicely, we are inside it.

We're just going to cut away more of the wall so it doesn't come back

and we are going to go looking for the second cyst.

Most tumour operations, we expect the children to be up, talking,

moving, possibly eating and drinking the same night.

With Prasanna, I will be happy if he is awake

and he recognises us and he, you know, communicates with us.

But he has had a heavy toll, Prasanna,

and his mum and dad know that and they just want to stay with him

as long as possible with as good a quality of life as possible.

With his operation complete, Prasanna is taken into recovery.

As part of the efficiency savings facing the whole of the NHS,

Alder Hey has to make cuts of £33 million to its budget by 2016.

Fellow brain surgeon Sasha is doing her bit to cut equipment costs.

Oh, there will be £200,000 worth of stuff altogether, you know.

Because there are things up here that cost £10,000.

You know, it adds up and people just don't realise.

They think if something...

If you don't actually have to pay for something

and it is there for the taking then you just don't think, you know,

and that is the key thing - just to get people to think.

I also go round the hospital turning off lights.

She is pricing up all the equipment so that we know whenever...

I am the most expensive neurosurgeon here, by the way,

because I just use all the kit that I can

and don't worry about the cost

but as a part of our new striving to economise on the NHS,

she is pricing up all the kit so if ever we use something,

we know how much it costs so we will need less wasteful, hopefully. Sasha?

Did you yell?

Now that you are pricing, why don't you put 200,000 on this trolley?

-200,000? I can go to 99,000. £99,999.

-This was 150 grand.

I don't have that big a price sticker.

Are you really pricing everything up?

Yeah, look. Come and see. It's great.

-What is that? £60?

-£600.

-600 quid for one of these?

That's shocking.

The reason why NHS is on its feet is because these cost £430.

That's just ridiculous.

There is no competition so I think manufacturers can charge what

they like. We put in valves for, how much, £600?

At least this is good quality German engineering.

This is £600 for a valve.

But an average shunt, 400, 600, about £2,000 just in equipment.

Let alone the cost. And who knows how much it costs to make? 20 quid?

My next target is actually to get prices for re-sterilisation

of all the trays under here so I can price that up as well

so people know that if they open a tray

even though it can be re-sterilised and it is not disposable,

it still costs £150-odd to re-sterilise a tray

so if you open it up unnecessarily that's another £150. You know.

And you wouldn't do that with your own money.

That's my message, really.

-INTERVIEWER:

-Will you be less wasteful?

-No.

'Rationing those sorts of expenses is not my job, thank God.'

My job is to do the best that I can do for patients with brain tumours,

with the best equipment and give them

the best patient journey in that horrific time.

The beauty of NHS, particularly in surgery,

is that hopefully the decisions are the most pure and ethical because

the only thing you are focusing on is doing the right thing by that child.

-Hello.

-Hello, hello. How are you? Are you all right?

Everything is fine, everything went absolutely fine. OK? Yeah, good?

-He's just out of a scan and we are just waking him up.

-OK.

We will do another scan tomorrow just to check him

and then we'll see how he goes.

OK? All right?

We have many patients who come into our hospital and they say,

"Well, the NHS is free." The NHS has never been free.

We pay our taxes to have an NHS service so it has never been free.

Last year, the NHS spent £42 million treating overseas patients

who are not entitled to free healthcare.

So, right now, what we are going to do...

We have a patient in our day surgery unit and we are going to

interview this patient and try to confirm their status.

Many larger hospitals have started to employ overseas managers

like Carlton to try and get on top of this growing problem.

-Good morning.

-Good morning.

My name is Carlton Stephens, I'm from the overseas visitors team.

'My main concern is is the person entitled to NHS care and,

'if not, are they chargeable?'

-How long have you lived in the UK for?

-12 years.

-12 years.

-Which country are you from?

-Lithuania.

-Lithuania?

-Yes.

-OK.

We have been called racist.

We have been told that we are targeting certain groups.

We have been called every conceivable name you can think of.

But I say to my team,

"As long as you follow the Department of Health

"guidance on the interviewing and assessing of patients

"and their entitlement to NHS care, you cannot go wrong."

Do you have any form of documentation to show that you are an EU citizen?

-Yeah, I left other things outside.

-OK, that's absolutely fine.

Now, from the information that you have presented, I can tell you that

you are entitled to NHS care but for me to confirm that,

what I would like is a copy of either your passport or ID card.

Every year, Carlton and his team invoice over 400 overseas patients,

calculating the exact cost of the health care they have received.

-INTERVIEWER:

-How much is it to have a baby?

To have a baby...

..if it is normal delivery, with complications,

it will cost £1977.00.

-What does that mean? Is that a stroke?

-That's a stroke, yeah.

That's a stroke and it says for the overseas visitors,

the cost is 11,000...

So, the total cost for this is £14,408.12.

There is one that I gave you the other day. Yeah, this one.

It is going to be thousands of pounds.

I would say this could be in the region of up to 100,000.

Chemotherapy is very expensive.

In the last 10 years, the birth rate in Britain has increased by 20%.

We're going to start another drip just to give you some more fluids.

And keep that pan there, just to keep an eye on the colour of your water.

At Birmingham Women's Hospital,

a consultant-led delivery suite caters for the growing

number of women whose births have added complications.

I think I might change your position just to see

if it will help baby cos the heartbeat is

dipping down a little bit and sometimes

if the cord is just wrapped around baby somewhere it can put

a little bit of extra pressure on baby's heart rate.

24-year-old Rebecca and her partner Andy are having their fourth baby.

The midwives are concerned about the baby's heart rate.

Shall I have a little walk then, being as...

Or do you want me to jump on the bed?

Stand up for a little bit and see if that makes a difference.

If not we might have to just lie you on your side and see if that helps.

-Is that all right?

-Yeah.

-Yeah?

-Is the heartbeat OK, yeah?

-It is dipping down a little bit.

-It has got a bit low, isn't it, the heartbeat?

-Yes.

-Can I just feel your pulse?

-Yeah.

When she gets to the contractions, it does drop a bit anyway,

doesn't it?

When she gets to pushing, it can drop sometimes but we are not

at that stage yet so that's why we get a bit concerned and worried.

It's all happening.

I do need to get the doctors to have a little look at baby's

heartbeat though so stay on your side a little bit.

We are probably going to start another drip just to give you

-some more fluids.

-It's not going to be for ever, babe. You know that.

-I know.

-It won't be long.

-I can't wait for him to come.

-I know.

It won't be long. I love you.

Hello.

Rebecca, I just need to talk to you about the heart rate

monitoring on baby, OK?

What we want to know is whether baby is becoming distressed or not

and we can either take a little sample of blood

from the top of baby's head.

It is like doing a pinprick on your baby's head.

The only other option of knowing that the baby is fine is to deliver

-the baby.

-A Caesarean, or...?

-Yeah, well...

-Is this a choice you are offering or is it...?

No, no, I am just watching at the moment.

If baby's heart rate doesn't recover then we might not have a choice.

Do I need to push?

BEEPING

We just need to make sure baby's heartbeat is OK, sweetheart.

-She is still 4cm.

-Yeah, still 4cm.

What's happening is that this baby's heart rate has dropped.

-Is that the true reading there?

-That's the true reading there.

Oh, my God.

-Yeah, I think so.

-It's not worth taking the risk, is it?

Baby's heart rate is not coming up

so I think we need to take you to the operating room, OK?

I am so sorry, darling. You are doing so well.

We are going to take you to theatre straight away, darling.

Once you are asleep, it only takes a minute to deliver the baby.

It takes a bit longer to put you back together again.

-Is this an emergency Caesarean?

-Yes.

-Would I be able to be with her or not?

-If she is asleep, no.

It's going to be all right.

It is going to be over soon, darling, all right?

BEEPING

Do you want some help?

Follow us to theatre.

Do you want to just move your arm up to that?

What is all this traffic anyway? Has there been an accident?

Has she lost enough blood to fill an average mug?

Let's go this way.

-INTERVIEWER:

-Where are we going, Liz?

We are going to do a home visit to a patient of mine

who has got lung cancer

and is sort of receiving terminal care.

I kind of need to get some certain things sorted out in this family.

The reason why it is more difficult than you might expect

is that there are two sick people in this house.

Eric and his son.

And so it is an incredibly unusual and difficult situation.

As you will see.

Hello. Hello, hello. Where shall I sit? Shall I sit over there?

Here if you like, love.

Eric is in the advanced stages of lung cancer.

He is being cared for by his wife Betsy.

Their son Gary has also been diagnosed with terminal cancer.

So, what I am hearing is that it is understandably pretty tense

here from time to time. Is it pretty tense here all the time?

I think the trouble is we are all here all day long, all together.

-But you can't go anywhere. Is that the frustration?

-I can't go nowhere.

He is sat in here all the time.

The boy has asked you if you would like to go anywhere.

I don't want to go anywhere.

But then you don't want to be sat in here all the time, do you?

No, I don't want to go. Where do you want to go?

I'm just wondering if this is part of your illness that actually

everything is... You are fed up with it all. Yes.

Yes. That is it.

That is it, isn't it? First of all...

I get tired of being picked at.

Yeah, it's... What...

If we are looking into the future, if we look ahead now,

-we can't have you...

-Arguing.

-..arguing.

We can't have you like this because it is horrible, isn't it?

-50 bloody years, we have been together.

-BETSY:

-55.

Well, 55, if you want to get technical.

You haven't been arguing for 55 years, have you?

Just leave me up in bed and I'll stay up there out of the way.

-BETSY:

-We don't want you in bed all the time.

What I have got here is something we give

when we deal with people who, like you, to try and find out...

-You class me as very ill then?

-I do, yes.

You can't even go out any more much, can you?

Don't you think you are very ill?

Well, I am walking better today than I was yesterday.

You know what is happening to you at the moment, do you?

Well, as far as I know, I am just waiting to die.

Does it feel a bit hopeless to you then?

Well, got to, hasn't it?

-Anything you look forward to at the moment?

-Not really, no.

-No.

We should talk about where you would like to be

in the next few weeks and months

and whether here is the right place for you or whether somewhere else is.

And it is your choice.

Because this is...

-Do you know, I think this is too much in some way?

-So do I.

-I don't agree with it at all.

-No.

I would rather have a quiet life and what is it?

But I'm never going to get that.

I suppose living should be the most important thing but then...

..I don't see there is much in life for me.

That's the honest truth about it.

We understand that life is miserable.

But that is very difficult for everybody and actually...

..Bet needs a break and if she is going to keep looking after you,

she does need a break and perhaps we can help organise that.

Either you go somewhere for a few days where you can, you know,

have some nurses look after you or else we get some people in to help.

Where I really want to be is here and that is it and all about it.

This is where I should like to end up my days.

So, when you come to the very end, you'd like to be here.

Yes, I would, yes.

I don't know whether it is right for Bet,

by the time you get the undertakers in here and all the rest,

traipsing up and down the stairs, everybody up the house.

It is adding more work to her job, house cleaning

and all the rest of it. I don't know whether that really is the thing.

You can't bring all that into it, can you?

Everybody has to face all these problems. Everyone has to face them.

Would you like to have a little time away and then come back?

That sort of thing. Just to get a break from the... It's a bit intense.

-Yeah.

-We need to start thinking about these things.

Otherwise you guys are going to be fighting.

You know, it's sad, isn't it, to have to be like this?

I think it is terrible that we have got to be fighting.

The same as I have said.

40, 50 years together and to end up like this

when we know we haven't got that much time to mess about.

OK, well, thank you for seeing us.

We will try and do something, try and arrange something. Yeah?

-INTERVIEWER:

-Tricky.

Tricky is understatement.

Such a difficult situation.

They're kind of locked into it and nobody seems to be able to...

Nobody seems to be able to find a way out. We will try and help.

Liz has more than a doctor's understanding of what Eric

and his family are going through.

She herself was diagnosed with cancer a year ago.

-Did you think you were going to die, Liz?

-Um...

I didn't ever...

No, I never got to the stage where I thought, "This is it."

But there were moments in my journey, as we call it,

my cancer journey, when I was waiting for results and things

such as the result of a scan and I thought, "If this is wrong...

"If this is the wrong result, I am going to die."

So, I did have the thing of sitting

waiting for someone to give a result that was rather like,

you know, he puts on his black cap and it's all over.

And I was lucky.

The news was good so I was clear but it's a sort of life-changer.

But it is one that makes you confront the possibility of your

mortality and it is very hard, I think, to have it without

actually at times feeling terrified that you are going to die.

So, um, pretty horrific.

Big breaths. Breathe away on that gas. That's lovely. That's it.

-Big breath in.

-Is Becky all right there?

Yeah, she is obviously a bit upset and a bit frightened but she

understands what is happening and she is happy with the decision, I think.

Nothing is going to happen to her after, though, is it?

-She will be all right.

-No.

-All right. Thank you.

Because the baby's heart rate has dropped dangerously low,

doctors have decided to give Andy's partner Rebecca

an emergency Caesarean.

Well, she was in distress, wasn't she?

The baby's heartbeat continued to drop, did it?

Let's hope things are OK then.

The last pregnancies went perfect, like, you know.

Couldn't wish for better ones.

It's hard work.

It has got to be hard work, ain't it, going through all the labour?

We can't... A male can't describe it, can he?

You have just got to... You know, you feel helpless. What can you do?

You want to be in there holding her hand, ain't it? And you can't.

Nothing more you can do.

-Coming in?

-All right, yes. Thank you.

-Sit in that green chair.

All we ask is that...

The baby's heart rate has stabilised

and Andy is allowed into the theatre for the birth.

Are you all right, baby?

Are you all right, honey?

And it is a cancer of the lining of the stomach.

Well, the patient we are about to see, from the information that

I have, I feel that there may be an issue with their status.

I think that they are living abroad

and they have come back to the UK just to seek treatment

and then go back to whichever country they are from.

In reality, what they should do is go back to their own country,

seek treatment there and then they can return to continue

whatever their business is in the UK.

My name is Carlton Stephens, I'm the overseas manager for King's.

HE CLEARS THROAT

Are you a British citizen or do you...?

-I am not a British citizen.

-OK. Are you a visitor to the UK?

I am not a visitor.

I work with a company which has business in the UK and outside UK.

Do you have any documentation on you at the moment with your name

-and address on?

-No. No. Not on me, no.

-Not on you.

So, what type of visa are you on?

Forgotten.

The patient may not know it but without a settlement visa

he is not entitled to free healthcare.

He says that he has a settlement visa and he told me

approximately around 1999.

So he doesn't have a settlement visa, does he?

Well, that's not good news.

It could be a simple mistake and we have to take it at face value.

We cannot say that he has misled us.

It could just be a simple mistake he forgot.

But I will be informing him that he is a chargeable patient and

he will be charged for all treatment that he is going to receive.

Which is a pity.

Because I do like him.

He is a very approachable man and I think he was honest with us...

..but not fully.

Because this was picked up by my team,

we have now been able to inform this gentleman that he will be charged,

we will be able to recoup the monies, I believe, in this case

and I think the word will get round that that is the case

in this trust and that is my aim -

to make this trust known as a trust that diligently looks for,

finds and bills patients that are not entitled to NHS care.

Very cold water. So, we have delivered your baby's head.

-Do we know what we are having?

-A boy.

Hello, little one. Hello.

BABY CRIES

Aaw.

-Congratulations.

-Thank you.

-Got there in the end.

Like a quarter of all babies born in Britain,

baby Joe is delivered by Caesarean section.

-You have got a visitor. Lift your head.

-OK. He's very well.

And at just three minutes old,

he has already cost the NHS over £2,000.

-Have a good weekend.

-Yeah, and you.

We have just got to sort out the transport, yeah.

Then hopefully we'll get him back later on today and he can go home.

Oh, Mum'll be really pleased. That's great. That's really good.

There's been some unexpected news for Stuart's family.

An intensive care bed has become free at his local hospital.

We are going back to Reading today.

-Oh, wow. Oh, fantastic.

-Yeah.

That's really brilliant.

It is very emotional. It will be very emotional to leave.

Cos it feels more longer than 25 days.

Then hope. Don't mope.

I was just thumbing through a magazine there

and I was looking at new bathrooms and things and I was thinking,

"No, you can't have that, Liz.

"You are now going to have to think in terms of if I can ever get him

"home, he's probably going to need things that help disabled people."

So it's a whole new ball game for me now.

Totally, totally different.

Let me just take that up there.

-How is that?

-That's not too bad.

After 10 hours consulting, Liz still has a backlog of patients to see.

That's lovely. Thank you very much.

Another hour and a bit and then I have to do that...

Hope I don't get a late visit cos a late visit is the last thing

you kind of want, especially if it is a difficult one, in the evening.

Mr Gaetani?

-INTERVIEWER:

-At the end of the day, Liz,

do you go home thinking you have done some good?

Today I think so, yes.

Today I have done some good.

And if you went and asked my patients, the ones who have seen me,

it would be interesting to hear what they say, you know.

And some will say, "No good at all,"

but a lot will say, "Yes, she sorted out the problem I had.

"I came with a problem, I went out feeling better than when I came in."

-Oh, yes.

-There's another one coming up as well.

It went down about a week ago then came up again.

-So, you need antibiotics.

-OK.

-To get rid of those.

-OK.

-Very good.

I've seen 40 people today. I made one referral to hospital.

But the rest I have managed here.

Therefore I have worked as a gatekeeper all day long.

This is the NHS, you know.

It is not expensive private medicine where everything is on offer.

It is a limited resource and we have to husband it

and I hope nobody has suffered as a result.

I'll see you tomorrow. See you tomorrow.

To order your free copy

of the Open University's booklet,

Working To Save Lives,

which accompanies this series,

call 0845 271 0015 or go to

bbc.co.uk/keepingbritainalive

and follow the links to the OU.

Subtitles by Red Bee Media Ltd