The paediatric consultant

Baby Alice is only 13 days old and I had almost forgotten they come this small. She isn’t happy, and she is letting the world know it – a painful, high-pitched howl of a cry, somehow amplified by the quiet concentration of the doctors and nurses, who are working now to save her life.

I am standing maybe 5ft away, next to Alice’s parents. I can’t quite believe how brave they’re being. The mother trembles a little in her seat, lets her tears fall as they please, but she answers every question the doctor asks. Questions about when these symptoms started; had there been any complications during the pregnancy or the birth? In this moment, this is all she can do to help her daughter.

Asking the questions, explaining the procedures and coordinating his team is paediatric emergency consultant Dr Nick Sargant.

As the son of a GP and a midwife, perhaps a medical career for Nick, 38, was inevitable. But in fact his father had gone to some lengths, if not to dissuade his son, at least to make him appreciate the less glamorous sides. During school holidays, he arranged for Nick to do care work, “wiping bottoms” at an old people’s home.

Nick stuck to his path, though, graduating from Guy’s and St Thomas’ at the turn of the millennium. After a brief stint in surgery, he discovered his true vocation in A&E and paediatrics. And, having married a fellow paediatrician somewhere en route, his career found him at the Bristol Royal Hospital for Children.

This is one of around half a dozen hospitals strategically clustered a short walk from the city centre; together with a few other services in the south of the city, they form the University Hospitals Bristol NHS Foundation Trust, or UHBristol, as the staff call it.

I honestly think it’s the best public healthcare system in the world

Paediatric consultant Nick Sargant expects to vote Labour for the first time. Photograph: Robert Ormerod/The Guardian

Next door is the Bristol Royal Infirmary, while around the corner is the Bristol Haematology and Oncology Centre, and the Bristol Heart Institute; farther up the hill is St Michael’s maternity hospital; and across the road are the eye and dental hospitals. It’s a busy part of town for sick people.

These huge brick buildings have featured in some of the most important moments of my life. My grandfather died here; my daughter was born here.

Outside the children’s hospital there is a huge, colourful interactive sculpture, which always brings to mind giant lollipops. Taking the lift, I am welcomed by the cartoon voice of Wallace: “Third floor, going up, hold on to your trousers, Gromit!”

I turn to a nurse sharing the lift. “I bet that loses its shine after a couple of years, huh?”

She offers a wry smile. “Most of us have started taking the stairs.”

But it’s brilliant, isn’t it? All of it, I think as I arrive in the waiting room to meet Nick, and look around at the laminated pictures of friendly aliens and animals. The truth is, I’ve become a bit of a soft touch since I became a dad myself two years ago. It’s for the parents as much as the children, I reason. It’s a message, and I can read it now. It’s saying: “Hey, parents, look, you’ve come to exactly the right place. Your child is in the best possible hands.”

Nick arrives for work shortly before 8am, wearing smart jeans and a shirt. Tomorrow, he’ll be in hospital scrubs, but not today, on account of having cycled to work. Exercise is his other passion. Lots of swimming, lots of cycling – sometimes in painfully close succession.

It helps to be healthy here. We’ll be on the move a lot over the next couple of days. Nick doesn’t really stop, and if he does, it’s only to catch up on emails and the more managerial aspects of his job. But it’s immediately clear he prefers to be out on the shop floor.

He takes me through a swipe door to the central ward, where perhaps a dozen doctors and nurses are gathering for the morning’s clinical handover. The children’s emergency department is equipped to deal with everything from cuts and bruises to life-threatening trauma and illness. Most children who come to the hospital do so through here, and the staff are drawn from a range of specialities to meet every conceivable need.

It’s never exactly quiet, but this is a quieter time of year. There is a seasonal rhythm. Winter is busiest, due to the huge increase in infant bronchiolitis. During such times, Nick says, the short-stay wing can admit and discharge enough patients to fill each bed two or three times a day. He has sympathy with hospital management on this. “It’s difficult to staff a hospital based on the busiest times of the year, when sometimes we’re not as busy. But the honest truth is that we don’t have quite enough paediatric beds at times of peak capacity.”

Nothing like that this morning, though. With everything under control, Nick heads to the cluttered office he shares with three or four other consultants, to catch up on some paperwork. I ask about his journey into medicine, and bigger issues: how does he think the NHS is faring as a whole?

“I honestly think it’s the best public healthcare system in the world.”

So nothing to worry about?

“There’s a danger of being complacent. Of people feeling that we have a God-given right to free healthcare. I don’t think people realise how vulnerable we are as a nation to privatisation.”

Not voting Tory, then?

‘There’s a danger of being complacent. Of people feeling that we have a God-given right to free healthcare,’ says paediatrician Nick Sargent. Photograph: Robert Ormerod/The Guardian

In fact, only yesterday, his financial adviser told him he should vote Conservative. He nods to a photograph above his desk of his 22-month-old son – curly locks, impossibly big brown eyes. He has another baby on the way, and he and his wife are already planning for more. Nick was privately educated and is adamant that his children will be, too. It’ll be a stretch, even on a consultant’s salary, so the political convictions of his financial adviser aren’t something to dismiss lightly.

But no, he won’t vote Tory. It isn’t so much that he thinks they want to privatise the health service, rather that they’re “creating an environment which makes this more acceptable, more permissive”. For the first time in his life, Nick expects to vote Labour. “Sometimes voting the opposite way puts the brakes on madness.”

Then a knock on the office door.

“Nick, we have a 13-day-old coming in now by ambulance.”

Baby Alice is placed, naked except for a nappy, on a special table called a Resuscitaire. It has a gel-type surface and an overhead heater, as well as numerous specialist components to help monitor vital signs. Alice has a raised temperature, a raised heart rate and cries whenever she’s moved. The fever may be the result of an infection which, if left untreated, could be life-threatening. (Globally, a staggering 7% of all child mortality is caused by sepsis in babies under 28 days old.) “Such young babies have very weak immune systems,” Nick explains. “Infections can jump easily from one compartment of the body to another. A simple urinary tract infection might jump to the blood, and then the area around the brain.”

Right now, it is Alice’s irritability that is causing Nick most consternation, because this might well indicate that such a thing is happening – “Some kind of meningitic process,” he tells me later. In the treatment room he calls it a “headache”, and remains reassuringly calm. “This is something we do every day,” he tells Alice’s parents.

The important thing is to act quickly. Nick needs to collect some samples: blood, urine and something called CSF, a clear, colourless fluid found in the brain and spine. It’s this that will tell them if Alice has meningitis. Nick has asked one of the two nurses working beside him to curl Alice up into a little ball, tucking her legs up under her tummy so he can push a needle into her tiny spinal cord.

It is difficult to watch. Nick explains to the parents everything he is doing, and they look on, holding each other.

The samples are proving tricky to get. Nick has to catheterise Alice to get a urine sample, but there is so little urine in her bladder that the team have to administer extra fluids to help things along.

All the while, Nick keeps a watchful eye on the large digital clock. He decides a cutoff time to begin treatment, samples or not. “There is a risk of becoming too task-focused,” he tells me later, “of getting caught up in a single procedure, while losing sight of the bigger picture.”

Around an hour after arriving on the ward, baby Alice begins a treatment, including antibiotics, and within two days she has turned a corner. Nick visits her on one of the paediatric medical wards, where we find her, in a private bay, resting in her dad’s arms and scrunching her toes. He chats to the parents for a while, gives some reassurances, accepts some gratitude, but he won’t stay long. They’re exhausted. And besides, the emergency department is busy today – an ongoing safeguarding issue, pneumonia, countless bumps and bruises. I leave Nick deep in negotiations with a three-year-old boy who was impressively stoic while the cut on his forehead was sutured, but less so at the prospect of going home without that plastic truck. Nick suggests a sticker as a compromise. I trust they’ll come to an agreement.

Ground floor. Going down. Hold on to your trousers, Gromit!

The mental health nurse

There are gaps in services, unmet needs. The provisions simply aren’t there for a lot of the patients we see

Mental health nurse Tom Hulme. Photograph: Robert Ormerod/The Guardian

The man in front of me has taken, by his own count, five overdoses in the past two weeks. He has been eating his own faeces with a view to choking himself.

He weeps a little as he shares that last part, then takes a wheezy breath and his tone shifts to indignant. “I ought to be able to open my own curtains,” he says. He has been leaving them closed because he fears taunts from his neighbours. There are bags of rubbish stacking up in his living room, yet he daren’t leave the house and “risk a hammer in my head”.

Today, he’s ventured out to the adult emergency department at the Bristol Royal Infirmary, where he’s looking for help. Tests have confirmed that his overdose was too small to require medical treatment. “I’m suicidal,” he insists. “I want to walk in front of a car, but I don’t want to put no one else in danger.”

In the small side room with him, trying to work out the best way forward, is clinical nurse specialist Tom Hulme. I met Tom, 47, earlier that day, in the hot, windowless offices of the hospital’s liaison psychiatry team. UHBristol doesn’t run a psychiatric hospital but, given the huge numbers of people admitted for other care, it is inevitable that mental health issues arise. A small team of psychiatrists and senior mental health nurses is on hand to offer support, working with patients all over the hospital.

Tom arrives, cheerful, if a little sleepy. It was a late night. He went to a Hawkwind gig, he explains, and loads a YouTube video for me to watch, before popping back out to make us strong cups of tea and collect print-outs of the day’s referrals. To the accompaniment of loud space rock, I flip through the textbooks and journals stacked on his shelves. A black leather-bound thesis catches my eye: an MSc dissertation in cognitive behavioural psychotherapy.

“That one’s mine,” Tom says, returning with our tea. He sits down beside me and crosses his legs, revealing the unmistakable face of Stewie Griffin on a pair of Family Guy socks – a Father’s Day gift from his kids. I flip through his dissertation. It earned him a distinction – a fact he shares with a certain self-effacing pride. Mostly, he’s just grateful that the trust supported him to do it. He loves his work, and his qualification means he can also offer longer-term therapies for outpatients.

This is all so good to hear, though not, I suggest, the usual rhetoric of a frontline mental health worker. It’s an area I have some knowledge of. In 2005, about 10 years after Tom, I also qualified and worked as a mental health nurse, before moving into research and a career in writing. I witnessed first-hand some crippling spending cuts. Why isn’t Tom utterly despondent? Things are terrible, aren’t they?

A difference, he explains, is that, as an acute trust, UHBristol has been protected from some of the deeper cuts faced by mental health trusts. There has long been inequity between these two sectors of the NHS. An important example is pay: colleagues who are equally well-qualified and doing the same work in hospitals where the service is funded by the local mental health trust are banded lower and paid less. According to a recent report by the Royal College of Nursing, there have been thousands of mental health bed closures in the NHS since the last general election, along with significant scaling back of community services. Might this mean that distressed people are increasingly left with no choice but to self-present in emergency departments?

“I need you to section me,” the man says, weeping again.

Between this assessment, the two that follow, and the teenage girl who will remain in her bed and not be assessed at all because of how often she presents and because the assessments are now deemed counterproductive (“I’ve worked here 10 years, full-time,” a beleaguered nurse tells me, “and I swear that young lady’s here more than I am”), my question begins to answer itself.

Mental health nurse Tom Hulme describes some of his patients’ condition as ‘Shit Life Syndrome’. Photograph: Robert Ormerod/The Guardian

“Have I gotta go out and smash something to get arrested? What do I have to do to get sectioned?”

His question brings Catch-22 to mind, which happens to be one of Tom’s favourite novels. If a person wants to be admitted to a psychiatric hospital, wants to be treated, then they are too “well” to be detained.

But this doesn’t mean they don’t need help. And in any case, this man is using “sectioned” as a shorthand for wanting to stay in hospital – to be anywhere, in fact, other than his flat, with its bags of rubbish and abusive neighbours.

Tom leans forward a little in his chair. He asks questions in a calm, clear voice. And how has your sleep been? And what about your appetite? I can predict them all, from my own time working in mental health. He’s assessing for clinical depression.

Here’s a counterintuitive fact: taking overdoses and saying we want to end it all doesn’t necessarily mean we’re depressed. We might have very good, logical reasons for wanting to end it all. Or we might not want to die at all, but just don’t know any other ways to ask for help.

Tom speaks softly, listens attentively, and eventually the man finds the words: “I just need a few days away. To clear my head.”

The issue, they’ve established, relates to a historical child sex abuse crime, which the man vehemently denies, but which his neighbours believe they have uncovered. This, coupled with some mobility issues, means his life isn’t in the best of places.

Tom has a name for this type of presentation, though he saves it for me as we walk back along the grey rabbit warren of corridors, with a Plan A and a Plan B agreed between him and the patient. He calls it Shit Life Syndrome. He is not being glib or dismissive. He says this with genuine concern, if perhaps a hint of the gallows humour that pervades all hospitals. “It can be frustrating,” he tells me. “There are gaps in services, unmet needs. The provisions simply aren’t there for a lot of the patients we see.”

I wonder if any of this affects his politics. Who will he vote for?

“I’ve no faith in the major parties. I’d say I’m quite apolitical. If I vote at all, I’ll probably go Green.”

Back in the office, he makes a few phone calls.

It’s Plan B. The man will be discharged home. He takes it well enough, all things considered. And Tom is able to put a few extra lines of support in place: a home visit, and a place on the waiting list for a hostel run by the charity sector. (The team rely increasingly on charity services to provide follow-up support.) It becomes something of a conversation point in the office. The concern is that, as statutory services become increasingly stretched, the charity sector is struggling with the burden. It doesn’t feel sustainable.

Then Tom’s off to see his next patient, an outpatient this time; someone he’s been working with for a while now, on a full cognitive behavioural therapy programme. He looks animated again, excited, positive. The patient was referred by her cardiologist after developing panic symptoms. “One of her beliefs,” Tom says, “is that she’ll have a panic attack in public, will faint and everyone will laugh, stare, point, and no one will help.”

So he’s been doing something called “graded exposure”, and they might be about to make a small breakthrough. They’ll set up her prediction against an alternative prediction: that no such thing will happen and that people will help. They’ll test it in the local Tesco Express, where Tom will pretend to faint while the patient observes from the end of the aisle.

“The three times I’ve done this with other patients,” he says, “we’ve always discovered that the latter prediction prevails. So everyone’s a winner. She feels less fearful and panicky in shops, and I get a Mars bar and a bottle of Lucozade after telling the shop’s first aider that it was a diabetic hypoglycaemic attack.”

I can’t tell if he’s joking. But it’s hard not to share in his positivity.

The junior doctor and the medical student

Your biggest fear is making a mistake that will cause harm to a patient. The responsibility builds up

Junior doctor Karan Prakash and fifth-year medical student Simi Seriki. Photograph: Robert Ormerod/The Guardian

In his third year studying medicine at Imperial College London, Karan Prakash, 25, went to visit his grandmother at her home in Paravur, south India. He had been, by his own admission, “scraping by for those first few years”, and now he would have to resit a few exams, too.

The truth was, his heart wasn’t in it. The son of a urologist and a pathologist, he had determined as a child not to follow the same path. “Medicine was all my parents ever talked about,” Karan says as we catch up in the doctors’ mess ahead of his shift. “It was the last thing I wanted to do.”

Yet here we are. How did that happen? He relaxes back into his chair. The room has a student vibe about it. Toy Story 3 is playing on the large TV and a notice for the next “Pay Day Party!!!” is scrawled on a whiteboard. “Looking back,” Karan offers, “I honestly don’t think there was a pressure from my parents, but I sort of wrote myself into a place where I felt it was expected of me.”

He applied to medical schools and, having aced his A-levels, found himself with the pick of the bunch. Privately educated in Newcastle, he felt the pull of London. “I was seduced by the bright lights,” he says with a mischievous smile. And that’s what his first three years were all about: the freedom, the fun times. “Work very much took a back seat.”

Then he went to visit his grandmother. “She was of a generation where women couldn’t be doctors, so instead she married, had five children, and they all became doctors. That’s how she got round it.”

Nobody had told Karan’s grandmother about his resits, and for the first time he felt a pang of guilt. “She was unloading all this praise on me. I was the first grandchild. They love me back home. I’m like the golden child.”

It’s not so difficult to imagine. Karan is good-looking, courteous, clearly very bright. In his spare time, he does Olympic-style weightlifting. What grandmother wouldn’t be proud?

It was a turning point for Karan. He reflected on his past three years; not just the parties, but also the patients he’d seen, a sense of being a part of something important – of contributing. It was time to start putting in some work. Two years later, he graduated with a double distinction. A golden child, after all.

Leaving the doctors’ mess, we walk along a series of bleak-looking corridors, all exposed piping and scuffed paintwork, and emerge into a light, airy space, a brand new wing. There has been some major redevelopment here over the past few years, including a £92m extension to the Bristol Royal Infirmary. There are several new wards, built around a dramatic, glass-roofed atrium. Seeing it for the first time, I genuinely catch my breath. It’s an impressive, and – to my mind, anyway – uplifting space. This work has largely been at the rear of the hospital so, to lend some balance, the front is disgusting. It’s getting a facelift soon, but for now it remains the grim, dirty-looking building that once saw it voted among the ugliest in Bristol.

On the third floor of the new wing is the older persons assessment unit, where Karan will soon complete a four-month clinical rotation – the second of three training positions during his first year as a doctor. “From your first day in med school, you step on to a conveyor belt,” Karan says. “The five years at university are really just the beginning.”

All new doctors graduate into a training scheme. The conveyor belt, as Karan calls it, will now take him on a further nine-year journey to reach the seniority of Nick Sargant; a journey that’s already seen him upping sticks and moving across the country, and will probably see that happen again.

It strikes me as a lot for an 18-year-old to sign up to. What kind of teenager has a 14-year plan? He doesn’t disagree. “I think the American system does it better. They can only do medicine as a postgraduate degree – it’s a more genuine decision.”

For all that, he loves his work and has thrived during his time on this ward, which he describes as “an outstandingly well-run unit”. One of its strengths, he tells me, is a dedicated discharge team, who deal with everything from arranging transport to dealing with safeguarding issues. He reflects on David Cameron’s recent pledge for a “seven-day NHS” by 2020.

“If it’s to happen,” Karan tells me, “there’ll have to be more services in many places. Thinking about the elderly population that I look after, it’s not just about getting patients treated and out of hospital; they’ll also need care at home, or in residential homes.” He hasn’t decided which way he’ll vote.

‘As a doctor, you’re seeing patients from every walk of life. It makes sense that we should be from every walk of life,’ says junior doctor Karan Prakash. Photograph: Robert Ormerod/The Guardian

Today, under the guidance of a specialist registrar, Karan is looking after a wing of seven beds, and is all set to start his first round when he is approached by a fifth-year medical student, Simi Seriki.

Originally from Nigeria, Simi, 23, came to High Wycombe in 2008, where she attended sixth form at a private boarding school. Her father is a consultant in the commercial airline industry; her mother a lawyer.

I’m beginning to see a pattern, and later ask Karan if he has a view on the number of doctors who are privately educated and from well-off families. Do they have an advantage when applying to medical school?

“Definitely,” he says. “But I think that’s changing. Medical schools are giving more sponsorship to students from lower-income families. As a doctor, you’re seeing patients from every walk of life. It makes sense that we should be from every walk of life.”

Simi’s usual mentor is away today, so she wonders if she might work with Karan instead. There’s a saying in medicine: see one, do one, teach one. It refers to a way of learning clinical techniques: you watch someone more senior than yourself, then you have a go, then you teach someone more junior. Often, it’s through the act of teaching that doctors really consolidate their knowledge.

“You’re pretty, aren’t you?”

The patient’s comment might have thrown Simi had she not just 30 seconds before been told the same thing by her previous patient. Between Karan, Simi and the shiny new ward, I briefly entertain the surreal sensation that I’ve stepped into a hospital drama.

Mary, 67, shuffles in her seat. She has advanced rheumatoid arthritis and came in yesterday in considerable pain. Her knee had become swollen and red. It had taken her over an hour and a half to shuffle from her bathroom to her bedroom, from where she was finally able to call for help.

Mary’s leg will be treated with painkillers and physiotherapy. For now, however, the interest is in her hands. Simi practises an examination of the joints, under Karan’s guidance. “You ought to have seen my dad’s hands,” Mary says. “They were all twisted back in a terrible state.”

The truth is, Mary’s hands are in a terrible state, too. Simi crouches down in front of her and carefully takes hold of them. “Hold on,” Karan says. “Before you do that, is there something very important you need to ask?”

“Sorry. Do you have any pain anywhere, Mary?”

She doesn’t. Not in her hands, anyway. When Simi begins to palpate Mary’s joints, she finds her stride, spilling out technical terms as she goes: symmetrical deformity; ulnar deviation at the MCP joint; rheumatoid nodules, widespread over all joints; Z-thumb deformity; fixed flexion deformity on all fingers; swan neck deformity… The list seems endless, and Karan is impressed, needing to prompt Simi only once or twice.

Then onwards. The next patient; the next procedure. At around 5pm, most of the doctors end their shifts, but today Karan is on call. He and another first-year doctor will cover every medical ward in the hospital. As night draws in, the building takes on a different quality: the wards are hushed; the endless corridors feel almost eerie. With a bleep attached to his belt, Karan stays on the move, reviewing patients, prescribing. Some of it is heavy stuff. He is the first to see the test results for an 84-year-old man, confirming liver metastasis.

Is it a lot to carry? “Your biggest fear,” Karan says, “is making a mistake that will cause harm to a patient, but I’m comfortable asking for help. I was told to enjoy it while it lasts because, as the seniority builds up, the responsibility builds up, too.”

He has his sights set on a career in oncoplastic surgery. It’s a highly competitive discipline, but I suspect that in Paravur, India, there is somebody cheering him on.

The porter

We all end up here, mate. You’ve got to make the best of it

Porter Ali Abdi. Photograph: Robert Ormerod/The Guardian

The woman in the bed is dead.

I am not sure how she died, because for the first time since I began visiting the hospital, I have stopped asking questions. I feel utterly ridiculous, standing at her bedside with my notepad, as though I might have something useful to write.

She is dead and that is that. Somewhere, the people who love her will be grieving. Or perhaps they haven’t been told yet? She is shrouded in a sheet. The nurse who was looking after her says, “Bye-bye, my lovely. I’m going to miss you.” She sighs and offers a sad smile.

The dead woman needs to be taken from her bed to the hospital mortuary. Here to take her is the lodge porter, Ali Abdi.

Originally from Somalia, Ali, 50, emigrated to Holland in the mid-80s, where he worked as a train mechanic for 21 years, before coming with his family to the UK.

“You’re late,” Ali grinned when I met him earlier that day. I am precisely two minutes late for the 7am start of his shift. He’s clocked in already – literally, using the archaic machine in the porters’ lodge deep in the belly of the hospital. “Come on, we have a job already.”

After leaving Holland, Ali had hoped to find work as a mechanic in the UK. “That was my dream,” he says as we set off along the corridors, taking some blood to the pathology labs. “But there was no work, it was frustrating. Very frustrating.”

This is the single downbeat comment Ali makes over the next eight hours. His default switch is set to positive and he is fiercely loyal to the NHS, which he joined 10 years ago, working first as a cleaner, before moving to portering.

There are different kinds of porters in the hospital: emergency department porters; house porters, who move goods around the site; and lodge porters such as Ali, who mainly move patients. Does he enjoy it? “Definitely – 100%.”

I wonder if everyone on the shift feels quite so upbeat. When I ask the six other guys on duty if they have any grumbles, Ali quickly cuts in: “The NHS is a family. It’s best to keep it in the family.”

But there is a grumble, one that even Ali shares. It relates to pay: the porters here get less than their colleagues in a neighbouring NHS trust. It’s the exact same issue Tom Hulme on the psychiatry team raised, except that where his team is benefiting, Ali’s is losing out. In 2004, the NHS adopted its current pay system under the banner of Agenda For Change: covering more than one million employees (with the exception of doctors, dentists and some senior managers), it was heralded as the most radical change since the NHS was founded, and intended to harmonise pay scales across the whole organisation. In other words, it was meant to sort all this out.

Who will Ali vote for? He thinks perhaps Labour, though I wouldn’t bet on that vote materialising: “I’m not at all interested in politics. Never have been.” Then he checks his radio and tells me we have a body to collect.

Ali pushes the trolley with a colleague and I walk along beside them. It looks like any other hospital trolley, except it’s covered in green canvas so nobody can see the person underneath. All the staff know, of course, and as we pass anyone in uniform, their conversations drop a notch in volume. We go into a lift, down into the basement of the King Edward VII building, then into a cold brick tunnel that runs under a main road, connecting us with a truly ancient part of the hospital.

This journey requires a little skill. The tunnel isn’t flat. It has a gradual decline before a gradual incline, and the porters need to make use of the first to manage the latter. Ali and his colleague don’t share a word; they’ve done this many, many times before. I find myself running along beside them, building momentum for the climb. As we enter the lift on the other side, Ali explains: “This weighs 150kg. It’s the only way.”

This is the original hospital building, opened in 1737. It is in the process of being decommissioned, and I suppose that, when it is, a shiny new mortuary will be built. This one has the feel of an old brick outhouse – cold concrete floor, exposed brickwork. I don’t want to give the wrong impression: it’s not dirty; I’m not talking cobwebs. This is where my granddad would have been brought, 15 years ago. He’d have been on that little run, too. I’m as sure of this as I am of anything: he’d have had no complaints.

I imagined that someone might be here to meet us, but in fact this is something Ali and his colleague do alone. Ali opens the tall metal door to one of the mortuary refrigerators. There are four along this wall, each containing up to four bodies. He slides out the one empty shelf, and they begin the careful process of placing the dead woman inside. It’s only once they’ve closed the door that they begin to chat openly. Ali shares something surprising: he tells us of the time he went to collect a body from the emergency department and it was someone he knew. Not a close friend, but someone from the Somali community with whom he used to chat from time to time. They got on well. “That stayed with me for ages.”

He shakes off the memory, and he’s back to his usual self. “It makes you think, makes you a better person. We all end up here, mate. You’ve got to make the best of it.”

The executive and the nursing assistant

I don’t think I could say which is the party of the NHS, I really don’t

Deputy chief executive and director of strategic development Deborah Lee. Photograph: Robert Ormerod/The Guardian

Deborah Lee speaks quickly and punctuates her sentences with acronyms. Today she is technically on holiday in Little Petherick, Cornwall, with her husband and two children, but she has returned for an important board meeting. She caught the train last night to avoid any delay from the storms that were forecast. The storms came during her journey: a tree fell and blocked the line.

She meets me in her office at the trust headquarters, wearing a smart black skirt and jacket, and looking alert for someone who has spent the last eight hours chez First Great Western. Has she slept?

“National Rail were great,” she laughs. “They woke me up every 10 minutes to let me know the tree was still on the tracks.”

Deborah, 50, is the deputy chief executive and director of strategic development for UHBristol Trust, with responsibility for somewhere in the region of 8,000 staff.

For the past nine months, she has also held the interim role of divisional director for the division of surgery, head and neck, one of five clinical divisions in the trust. It’s a rung down the senior management ladder, and I wonder why she took that on. I’d have thought her existing two jobs ought to be enough to fill a working week. I once spent a working week writing a paragraph.

“We’d had six divisional directors in the space of four years,” she explains, before adding, with characteristic directness, “some of them didn’t move on for wholly positive reasons. It’s a big job. It isn’t for everyone.” The position had become something of a poisoned chalice and a lot of people were suffering as a result. “There were factions and splits. People didn’t know what to do, what the priorities were. A big chasm was opening between management and clinical.”

It was decided that one of the executive directors should step in “as a kind of diagnostic, to figure out what the heck was going on”. Why her? “We didn’t quite draw straws,” she says. “Having had a week’s holiday and feeling quite bouncy about life, I said I’d give it a go.” Nine months on, Deborah says, they’ve turned the corner, “solving problem after problem”.

Deborah is a force of nature around these parts. Brought up in Bradford and state school-educated, she was the first in her family to go to university. Initially, she trained in nursing. “You know the story: state school, reasonably bright, so study nursing or teaching.” But it wasn’t for her. She qualified, but didn’t practise, instead returning to university where she read economics and later completed an MBA with distinction.

Last year she was named one of Health Service Journal’s Inspirational Women in Healthcare. She doesn’t dismiss it, but wasn’t happy with the judges’ blurb, which concluded, “and she proves it is possible to have a family life alongside a senior role – she has two young children – surely meeting the definition of inspirational”. “How bloody patronising is that?” she asks.

Sitting around the huge boardroom table later, with around 18 of the trust’s executive and nonexecutive directors, gender representation does not appear to be an issue. Less so ethnic representation: everyone at the top table is white. There have been some major initiatives to tackle this, but clearly something isn’t working. Why is that?

“I can’t identify anything about this organisation that would make it more difficult [for BME staff to reach senior management roles],” Deborah says, “but I have to accept that there is, because they’re not alongside me.”

She is honest, and expects the same from those around her. I sit in on a meeting where a colleague of Deborah’s obfuscates a little around some intricacies of a business plan. The conversation that follows brings to mind a worm being skewered on a hook.

Is there trouble at the top? “In that department, possibly.”

Her candour keeps catching me by surprise. Even as we talk, she has her laptop open and is tapping away. I notice that in her meetings, too; she is rarely doing only one thing. She’s on a terrific salary, of course, though she jokes that the hourly rate mightn’t be quite so good. Today, besides meetings, she has four reports due and is right now responding to a patient complaint. “I hate letting people down,” she says. Let’s not forget she’s on holiday.

I mention Cameron’s pledge for a seven-day NHS. Will they achieve it?

“I think we can have seven-day services where they matter the most, but we won’t have it universally.”

Privatisation – that’s bloody awful, isn’t it?

Deborah doesn’t miss a beat. “The principle that I want to stand and fall by is care that is free at the point of delivery. That’s what matters to me. How that healthcare is delivered, I’m much less precious about.”

I make the obvious counter-argument, that a drive for profit might not be aligned with the best care.

“I haven’t seen evidence of that. I’ve seen great innovation come from the private sector. You see good and bad in all sectors.”

OK, so who’s she voting for?

For the first time, there is a slight sidestep. Deborah talks about politicians not playing to their strengths when meddling in the day-to-day, but also believes the service’s political profile can only be a good thing. It means people are talking about it, that they care about investment. “I don’t think I could say which is the party of the NHS, I really don’t.”

But you can say who you’re voting for? “If I could, I’d like to vote for a coalition.” She thinks the healthy tension that comes from two parties in government has been fantastic.

A Ukip-supported coalition? SNP-supported? “That would concern me,” she clarifies. “A Lib Dem-supported coalition. With either Labour or Conservative.”

Deborah seems to surprise herself as much as me when she says that she probably won’t vote. “If I could go into a ballot to pick a prime minister, then I would.”

And then?

“Out of today’s lineup, David Cameron.”

Her PA pops into the office with a stack of papers topped with a Danish pastry, and we head across to the boardroom.

It can feel like the whole thing is run on goodwill

Senior nursing assistant Alison Sweeting. Photograph: Robert Ormerod/The Guardian

But this is my final day here, and I don’t want to end it sitting in an office. Back in the Bristol Royal Infirmary, on the eighth floor, senior nursing assistant Alison Sweeting, 50, is in the sluice room of a gastrointestinal surgery ward, filling a bowl with warm water to give a patient a bed bath.

My first job after school was as a nursing assistant. That was 16 years ago, but spending time with Alison brings it all flooding back: the static and crackle of bed linen, the pulpy cardboard bedpans, the smell of detergent.

The role has changed a lot since I was doing it. I mostly made beds, bathed patients and measured jugs of urine. I am a man who has measured gallons of wee. Alison still does all that, but she also takes blood, administers ECGs, dresses complex wounds and carries out any number of specialist procedures to aid patient recovery after surgery. I had imagined much of this work would be the reserve of the registered nursing staff but, as Alison explains, “Over the years, as the nurses’ responsibility has gone up, so ours has, too.”

With 32 years’ experience in the NHS, Alison has witnessed a lot of these advances first-hand. Less so, advances in pay. “I’d never been on strike before,” she tells me, clearly still wrestling with the decision she took late last year to support two days of industrial action. She shakes her head, “I still don’t feel good about it.” She wasn’t striking for herself, as it happens. Her years of service had placed her at the top of her pay scale, meaning she received the 1% pay rise the unions were seeking. It was her colleagues who’d been denied it. “It was the principle,” she says. “I felt it was needed.”

She’s a mother of two and a lifelong Labour supporter. “They’re fairer,” she tells me. “They’re a working-class party for working people.” She believes the NHS is safer in their hands.

Today, Alison is covering her bay with an agency nurse. There are staffing issues: some recent restructuring has led to several nursing staff moving on, and only a fraction have been replaced. It means more work for Alison and her colleagues, and in the staff room, speaking with half a dozen of them, I get a strong sense that things are feeling unacceptably stretched. Equipment shortages, staff shortages. Morale is low.

We work out that between them they have 104 years’ NHS experience. That’s not to be ignored, is it? Alison sums up the sentiment in the room: “It can feel like the whole thing is run on goodwill.”

It reminds me of something Deborah Lee said earlier in the week. “The bar at which we now look for charitable support is falling. That is a reality.” Five years of cuts are taking their toll, and for the first time in 13 years this trust is set to go into a deficit plan. Deborah was talking about the kind of charity that shakes a tin outside a supermarket, or does a bungee jump, or sets up a direct debit. But there are other kinds of charity, aren’t there? The doctor who stays late, the physiotherapist who takes their paperwork home, or Alison and her colleagues cutting short their break to get back to the people who need them. I wonder how much the NHS is relying on that kind of charity?

Alison wipes down a mattress and I close my notebook. It has felt strange this past month, to be in the hospital all this time and to have done nothing useful.

I unfold a fresh sheet from the trolley, smooth it out. I can at least help to make up a bed. Alison tucks in her side; I tuck in mine.

I think of the dead woman in the mortuary, and the man who is now back at home, afraid. I think of Mary’s poor hands. And I think about baby Alice, a whole month older than when I saw her: she has lived her whole life again.

There is some laughter behind me, and more from across the bay. Alison joins in, too. “I think he needs a bit more training,” a patient offers.

I look down at my terrible, terrible hospital corners.

• Nathan Filer is the author of The Shock Of The Fall, winner of the 2013 Costa Book of the Year award.