Displayed, not particularly prominently, on an otherwise bare wall in the entrance of the Springfield building, the headquarters of the university hospitals of North Midlands NHS trust in Stoke-on-Trent, is a small plaque.

“A patient,” it discreetly says, “is not an interruption to our work, [but] the purpose of it. They are not an outsider in our hospital, they are a part of it. We are not doing them a favour by serving them, they are doing us a favour by giving us an opportunity to do so.”

Britain’s National Health Service is a sprawling, many-layered and infinitely complex thing; an institution famed around the world yet reviled here, at times, as much as it is revered; an organisation so large that the numbers beggar belief.

Famously, the NHS provides care that is free at the point of delivery to everyone resident in the United Kingdom. It treats 1m cases every 36 hours. Its annual budget is £136.7bn. But as that plaque reminds us, the NHS is, at bottom, about people serving other people. Across the country, 1.6 million people work for the NHS. It is, astonishingly, the world’s fifth biggest employer, smaller than the US defence department and the Chinese army, but bigger than the Indian railways and Foxconn.

It employs more than one in 20 of the working population: in England alone, it employs more than 40,000 GPs, 350,000 nurses, 18,000 qualified ambulance staff and hundreds of thousands of other people in more than 350 jobs.

Nearly 80% of its workforce are women, and as many as 11% – including 14% of clinical professionals and 25% of doctors – are from overseas: India, the Philippines, Poland, Nigeria, Portugal, Pakistan, Spain.

At a critical moment in the NHS’s history, as demand for the care it provides soars and questions over its viability mount, how do its employees feel about their jobs, their employer, its future – and what “the opportunity to serve” actually means for them?

The Guardian spoke to staff at three major English hospitals: Royal Stoke University; St George’s, Tooting; and Southampton General. Here is what they said.

The linen assistant: Les Gregory, 57

I’m a small cog in a big wheel. But that cog has to work: a hospital has to have clean linen delivered, where and when it’s needed



Facebook Twitter Pinterest Les Gregory at Royal Stoke university hospital.

For 36 years, Les Gregory worked for Lloyd’s bank. “Began as a 16-year-old office junior, ended in customer services,” he says. “This is different. I work for the NHS. For a caring institution … Not for one that’s about generating profits for its shareholders. That’s the truth of it.”

Amid the stark strip lights and steepling stacks of fresh linen in Royal Stoke University hospital’s estates and laundry division, Gregory says he is “a small cog in a big wheel. But that cog has to work: people don’t think of it, but a hospital has to have clean linen delivered, to standard, when and where it’s needed. It’s vital.”

This is the job: the laundry comes in from the cleaners, orders come in from the wards, the cages are packed accordingly, delivered correctly, and the whole process starts over. Gregory has been doing it since 2012 – first as an agency worker, then employed by the trust. He works around 20-25 hours a week, with overtime, and earns about £6,000 a year.

“It’s not about the wages – though I do need the income,” he says. “I have a good pension from the bank, but not enough to live on. It’s about colleagues, and keeping fit. But mainly it’s about the NHS. I feel extremely proud to work for the NHS. Everyone in it goes the extra mile. The commitment … Extraordinary.

“I can’t really imagine my life without it.”



The A&E clinical director: Ann Marie Morris, 38

I like the pace here, the fast decisions, the never knowing what’ll come in the door

Facebook Twitter Pinterest Dr Ann Marie Morris at Stoke.

Some weeks, Ann Marie Morris works from 8am till 4pm in her office, managing her department, and from 4pm till midnight, seeing patients. Next, because she is also trauma team leader, she will be on call, from midnight till 8am. Then she does another day of admin, knocking off at 5pm.

“I’d thought I wanted to be a surgeon,” Morris says, surveying Stoke’s A&E from a bustling corridor dominated by the smell of disinfectant. “But I liked the pace here, the fast decisions, the never knowing what’ll come in the door. Now I have non-clinical work too, I do rather long shifts.”

Soon to become a mother, Morris confesses cheerfully to being “slightly worried about how I’ll let go … I live and breathe this place. And about whether I can do two jobs – this one, and being a mum – well. I don’t like not doing things well.”

This is a busy A&E department: maybe 140-150 patients at any one time, up to 440 in a 24-hour period. The team has been lucky so far this winter, says Morris, seemingly indefatigable despite being eight months pregnant: “Not too cold, so not many winter injuries and not much flu either. Quite quiet.”

But last year the hospital declared a major incident in January: “We had acute demand, and no flow: lots of flu patients, basically, who we couldn’t move because of the risk of infection. We had 35 in the queue at its peak; St John Ambulance and the Red Cross came out and give everyone blankets and pillows and hot chocolate. We’re better prepared this year. Here at least.”

Morris is rather less confident about the NHS in general. “It’s a fabulous thing,” she says, “and I’m not sure people realise what life would be like if they didn’t have it, but it needs more funding.” She identifies social care as “a really massive problem. It’s not prioritised as it should be, and it’s vital for keeping people out of hospital and keeping them healthy.”

At some stage in the not too distant future, Morris says, “we are just going to have to decide as a country to pay for our care somehow – especially our social care. If that means higher taxes? Well, I know I’d be happy to pay them.”

The matron: Nadine Opiniano, 40

The passion, the dedication – they kind of take you over after a while. But I wouldn’t have it any other way. I’m a nurse

Facebook Twitter Pinterest Nadine Opiniano, a matron in elderly care at Stoke.

Nadine Opiniano’s real reward, she says, “is seeing a patient get well, go home. When a 104-year-old lady walks out of here with her frame, when she only needs one visit a day from a carer – that’s priceless. That’s when you know what you’re really working for. What your job means.”

Opiniano is in charge of six wards with 113 beds and 224 staff and earns about £2,000 a month after tax. Days are supposed to start at 8am and finish at 4pm, except she often comes in at 7am “to meet the night team”, and rarely leaves before 7pm – sometimes 8.30pm or even nine.

“It’s my choice,” she says. “That’s the way I work. The passion, the dedication – they kind of take you over after a while. But I wouldn’t have it any other way. I’m a nurse.”

Modest, determined, Opiniano came to Stoke from Singapore as a staff nurse in 2003. She is originally from the Philippines. “A whole group applied at the same time,” she says. “When we got here, 35 of us, the snow – we didn’t know what had hit us. The nurses’ home was like a Harry Potter schoolhouse.”

Now she is more likely to get depressed by “the frequent attenders, alcoholics for example. People who just keep on making the wrong choices, who we can’t help. And I do think some people here don’t really appreciate what the NHS means. In my country you have to pay for care and if you can’t, you die. I feel proud just to work for an institution like this. I never dreamed I’d be a matron.”

The consultant bariatric surgeon: Chandra Cheruvu, 54

I have trained and worked all over the UK, in Japan, Australia, Brazil – and the NHS is unique. Quite unique

Facebook Twitter Pinterest Chandra Cheruvu at Stoke.

“Surgery,” declares Chandra Cheruvu, whose father was a surgeon in India and whose son, all being well, will be one too, “is my life. My religion, almost.”

And, he adds, “I can tell you: I have trained and worked all over the UK, in Japan, Australia, Brazil – and the NHS is unique. Quite unique. Nowhere else in the world can a patient, from birth to death, simply walk in, and be seen by one of the best-trained people in the field, and not pay.”

Unstoppable and irrepressible, Cheruvu, who has worked for the NHS for 24 years and first came to Stoke as a surgeon in 2003, developed laparoscopic or keyhole surgery here – “People come from all over the world to train” – and launched the hospital’s specialist cancer surgery unit.

Since 2005, his main focus has been Stoke’s obese surgery unit. “The UK is the most obese nation in Europe,” he says, “but despite the fact that they can really, really help, we do the fewest bariatric surgery operations. Yet the costs of the conditions caused by obesity are staggering.”

He believes, he says, in the NHS, “totally. It’s the best thing in the world. But I am concerned. There are some worrying signs … It has to remain a clinically led service. High-volume centres, specialist centres are most probably the way to go, I am sure. But we have to keep putting the needs of patients first.”

The paediatric intensive care consultant: Pavanasam Ramesh, 50

The last thing you want to worry about if you have a very sick child is how you will pay

Facebook Twitter Pinterest Dr Pavanasam Ramesh at Stoke.

You don’t always need more money to do more, says Pavanasam Ramesh gently.

Stoke did not have a children’s cardiology service until last year, but Ramesh trained to do the job in Birmingham and is now the lead for a service that he set up from scratch and has screened more than 580 children, identifying in the process more than 30 who needed to see a specialist.

“Politicians do talk up expectations,” he says. “Everyone – staff, patients, government – has to try to understand this. But you know, we can do more with existing resources.”

This does mean, of course, “that people have to work hard. More than we’re paid for, certainly. But to be honest, I think pretty much everyone in the NHS does that already. It’s just the norm. I’m paid for 48 hours and most weeks I easily do 70. Officially I do 14 weekends a year, unofficially, if I’m needed …”

Ramesh qualified in Tamil Nadu, India, and came to Britain in 1996. The NHS is the best place to practise children’s intensive care, he says, if only because the speciality is so expensive if the family is paying the bill: “It costs £2,000 a day to keep a child in intensive care. And the last thing you want to worry about if you have a very sick child is how you will pay.”

Faced with seemingly irresistible pressures, Ramesh insists, the NHS can sometimes do more with existing resources: “We do not have to pour more money in, all the time. But somehow, we are going to have to manage people’s expectations.”

The nursing care coach: Anne Barks, 59

I believe there’s a special quality in people who want to nurse: a compassion that makes you want to help people, treat people with dignity

Facebook Twitter Pinterest Anne Barks at Stoke.

“Nursing is like an addiction,” says Anne Barks. “I believe there’s a special quality in people who want to nurse: a compassion that makes you want to help people, treat people with dignity. I’m retired really, but I’m still here.”

Barks came back to Stoke part-time last year to help train newly qualified nurses, who are mainly from overseas. The hospital recruited about 150 overseas nurses over the course of the year, in small groups – most from Spain and Portugal, but also from Italy, Greece and Croatia.

Mother hen-like, Barks organised their travel, met them at the airport, and ran a three-week course to teach them about English nursing, cultural differences, the particular illnesses they may encounter here: “We get quite a lot of chest problems here, for example, from the mining.”



The receptionist: Colin Davis, 68

People come up to reception … my job is to send them on their way with the clearest possible instructions and stop them getting any more stressed

Facebook Twitter Pinterest Colin Davis at St George’s hospital in south London.

After early stints as a tailor and in a pub, Colin Davis – bluff, cheery, “a south London mongrel through and through” – spent years on the buses, as a conductor. He hadn’t expected it to serve him later, but it still does.

“I had a lady the other day, wanted to get from here in Tooting to Redhill, by bus,” he says. “I told her: you want the 57 or the 131 to Kingston, then the 405. She was delighted. Absolutely delighted.”

Davis will have been working at sprawling St George’s, Tooting, south London, for 25 years next March – as a general hospital porter, a theatre porter, in security and then in his current job, in reception, since 2006.

“The portering means I know every department, every corridor, every door,” he says. “That’s important now, too. People come in, up to reception, they’re stressed, they’ve got appointments, tests, sick relatives – my job is to reassure them and send them on their way with the clearest possible instructions, stop them getting any more stressed.”

And he loves it. “I just love meeting and helping people,” he says. “Looking back, really, it’s all I’ve ever done, all my working life. I’m three years past retirement and I probably will go next year, but I’ll miss it. I run the heritage tours here, but I might volunteer as a gardener, too. Couldn’t stay away. We do the best we can – all of us.”

The emergency department general manager: Daniel Camp, 32

Some days I’ll spend six or seven hours downstairs, just trying to unblock whatever it is that’s stopping patients moving through the system

Facebook Twitter Pinterest Daniel Camp at St George’s.

“I guess this is the frontline,” says Daniel Camp. “What I like, though, is that it’s a service where the professional boundaries – doctor, nurse, manager – feel less significant. What counts here is teamwork. That’s all.”

Camp’s particular challenge, he says in his cramped upstairs office at St George’s, is managing a large department of 250 people, the budget that goes with it – but also supporting a complex, sometimes fraught, day-to-day operation.

“Some days I’ll spend six or seven hours downstairs, just trying to unblock whatever it is that’s stopping patients moving through the system,” he says. “Lots of the public don’t know where else to go; they come here because the lights are on, basically. So on a busy day we’ll get 400-500 through the door, and maybe a quarter will need to stay.”

A successful A&E department, he says, is “all about the flow. Getting patients smoothly in the front door and out the back door. But the logistics of actually moving them into a bed, or off in an ambulance, can be tough.”

Camp began his carer in physio, moving gradually into management. “The particular pressure here is, the place never shuts,” he says. “My other jobs, you could walk away at 6pm. Here you feel ownership.”

The staff nurse: Karolina Elias, 29

I try to make people on my ward a little bit happier, a little bit calmer, a little bit more comfortable

Facebook Twitter Pinterest Karolina Elias at St George’s.

Compared with the hospital in her home town of Wrocław, Poland, there is “a lot of support, a lot of equipment” at St George’s, says Karolina Elias. “Of course, there are always money questions; I think it is the same everywhere. I don’t really know what the solution will be.”

But right now, “I’m just happy to say I love my job. I try to make people on my ward a little bit happier, a little bit calmer, a little bit more comfortable. My father always told me, you are someone who helps people – it’s what you do. So I’m a nurse; that’s what I do. It’s my choice.”

Naturally reassuring, a born comforter, Elias moved to London three years ago; her boyfriend was already here, working as a bus driver, so the move was not hard. Armed with a master’s in nursing, she spent her first year working in a nursing home but found it “a little bit … boring”.

She is now on a general surgery ward, with 22 beds and five other nurses, working from 7.30am to 8pm, or nights from 7.30pm to 8am. “I like this pattern,” she says. “I had always dreamed of working in a hospital. But as an overseas nurse I wasn’t sure I would be able to. I’m just very, very happy to have this job.”

The consultant vascular surgeon: Rob Hinchliffe, 43

Ultimately, we as a society are going to have to make a very difficult decision about how much we want to pay for our healthcare

Facebook Twitter Pinterest Rob Hinchliffe at St George’s.

Rob Hinchliffe wears many hats: “Clinically, I deal here with the broad problems associated with vascular disease – aortic aneurysms, blocked arteries, that kind of thing,” he says. “I’m an academic, part-employed by the university. And I’m an editor at the British Journal of Surgery.”

He is also a national specialist in iliac arteries – arteries in the pelvis that can fur up and suffer damage after a lot of repetitive stretching. It is a condition that is not generally well provided for in Britain, and particularly affects elite cyclists: “So I get to see quite a lot of them. Team Sky, people like that.” It helps that he’s a bit of an amateur cyclist himself.

A serious, thoughtful man who has seen the NHS from more than one side (his wife is a GP), Hinchliffe feels the organisation “is at a crossroads. The government has to decide whether to put more money in so it remains free at the point of care, or to introduce a rationed, insurance-based system.”

Essentially, he says: “We keep frail people alive for longer, and older patients present more complex cases, and use more resources. In my field, primary care is so much better now that my patients are typically 10 years older, and you don’t tend to see straightforward, single blockages any more – people have multiple issues.”

He objects to insurance-based systems because “ultimately they are not fair”, and believes the most appropriate solution would be “to spend more, which probably means paying more tax. Efficient, cost-effective, evidence-based treatments and procedures – Nice [National Institute for Health and Care Excellence] and so on – are vital, of course.

“But ultimately, we as a society are going to have to make a very difficult decision about how much we want to pay for our healthcare.”

The foetal medicine consultant: Basky Thilaganathan, 51

It’s about defining and funding an effective, safe and acceptable level of free care for the taxes people pay

Facebook Twitter Pinterest Basky Thilaganathan at St George’s.

In November, St George’s became the first hospital in Britain to open a so-called non-invasive prenatal DNA lab – offering pregnant women a simple blood test which, far more cheaply and safely than amniocentesis, can diagnose 99.7% accurately the risk of Down’s syndrome within five days.

“Basically,” says Basky Thilaganathan, “I marched into the chief exec’s office and said women are voting with their feet, sending their blood to the US or China to be tested privately. We either accept invasive needle testing is over and see it as an opportunity, or … well. Thankfully, he saw it as an opportunity.”

Thilaganathan, who is of Sri Lankan origin but was educated in Britain, heads what is the main tertiary referral unit for foetal medicine complications in the south-west Thames sector: 10 hospitals, about 40,000 deliveries a year. “If they encounter a problem in pregnancy,” he says, “they send it here. That’s our bread-and-butter, making sure babies grow well and don’t die in the womb.”

The unit gets about 2,000 referral patients a year, and also sees approximately 6,000 local cases: getting on for 35,000 outpatient appointments a year. “We’re also,” Thilaganathan says, “one of about 10 centres in the world that can provide in-utero surgery. We keep ourselves busy.”

The health service is, he believes, an institution “facing a crisis. Expectations rise, but budgets are finite. For me, it’s about defining and funding an effective, safe and acceptable level of free care for the taxes people pay. If they want more, and are happy to pay for it, well and good. But we need to explain to the public what the standard for free care is – then empower the NHS to deliver it.”

The biomedical scientist: Witness Dzobo, 42

From where I come, this service is wonderful. Some people could be a little more aware of how they use it

Facebook Twitter Pinterest Witness Dzobo at Southampton General hospital.

Witness Dzobo wears his medal proudly: “For service,” it says. “Ebola epidemic west Africa.” He didn’t think twice, he says, before volunteering last year to spend five weeks in Sierra Leone with Save the Children: “I knew what I was going for. And actually, the desire to help drove out the fear.”

Dzobo volunteers a lot. Off duty in Southampton, he is a volunteer interpreter for Shona-speaking patients and their families. “Once, it was for six months,” he says, “The patient couldn’t speak; his parents came over; I had to interpret literally everything for them. Four, six hours a day, outside my day job.”

A broad and smiling Zimbabwean, Dzobo arrived in Britain as a biomedical scientist in 2003 following a well-trodden trail. “Six of us from Zimbabwe came to this trust that year,” he says. He has since completed an MSc – and is studying for a doctorate – in a field he describes as harbouring “the hidden professions” of the NHS.

“Seventy per cent of patients in the NHS receive an intervention from a pathology service, and our labs provide 94% of objective medical data,” he says. “We do the tests on the samples – blood, urine, faeces, tissue – that allow the diagnoses to be made and the treatments to be monitored. We’re the back office.”

Like many of his overseas colleagues, he remains astonished at how some Britons view the NHS. “They complain about the parking! From where I come, this service is wonderful. Some people could be a little more aware of how they use it.”

The porter: Arvin Pagkaliwangan, 44

It’s one of the most important jobs here. Without porters, no one would be able to get to the operating theatre or the wards

Facebook Twitter Pinterest Arvin Pagkaliwangan at Southampton General.

Among the cheerful reds and bright greens of the children’s ward, Arvin Pagkaliwangan, a general porter at Southampton for getting on for 13 years, recalls how thoroughly miserable he felt when he first arrived in Britain.

“I just wanted to go back,” he says. “I was struggling with the language, with the weather. With everything. I’d been an architectural draughtsman in the Philippines … But my wife had a good job here, intensive care nurse. We had to stay.”

Now, earning £1,000 a month after tax for the 37.5-hour week he works taking hospital patients to and from the theatre and transporting samples and specimens, Pagkaliwangan says he doesn’t want to do anything else.

“I not only enjoy it, I’m proud to be doing it,” he says. “This is a way I can express my gratitude to this country. It’s one of the most important jobs here. Without porters, no one would be able to get to the operating theatre or the wards. We’re vital.”

The money “is fine. I’m from a very poor family: what I earn is enough, I appreciate it. But it’s not about the wages, really. If you want to help people, to give moral support when they are stressed … Sometimes patients don’t just need medicines, they need kindness, a little love. So I am happy here.”

The hospital has got a lot busier since he has been there, Pagkaliwangan says. “Massive changes. And patients are getting older, with more problems. The staff are sometimes struggling with this. But the NHS is so special, compared to where I come from. I think if we can all work together, sacrifice a little more, we’ll make it work.”

The consultant diabetologist: Mayank Patel, 44

Type 2 diabetes is scary: 700 new patients a day. Long term, it’s strokes, heart attacks and heart failures, blindness, kidney dialysis, amputation

Facebook Twitter Pinterest Mayank Patel at Southampton General.

Diabetes cropped up in one corner or another of “almost everything I did” as a junior doctor, so Mayank Patel’s specialty ended up more or less choosing itself, he says.

For Patel, who was appointed consultant at Southampton in 2008, most work involves overseeing hospital patients with diabetes: “That’s around 170 every day here – 15-16% of all adults, climbing 1% a year for the past five, six years. Most aren’t in for diabetes, but it can impact their stay. A diabetes patient typically stays in a day or two longer.”

Patel and his team also spend time supporting non-specialist hospital colleagues – who are “not always very confident” around diabetes patients – and GP surgeries.

He says type 2 diabetes, often caused by obesity, is “scary: 700 new patients a day. Long term, it’s strokes, heart attacks and heart failures, blindness, kidney dialysis, amputation – there are more than 135 diabetes amputations a week in the UK now.”

Far, far more has to be done to educate people, “empower them to make the right choices, of diet, exercise” – particularly given the NHS’s funding crisis. “The present model is clearly unsustainable,” Patel says. “People are living longer, and with more complex conditions. We need an open, honest, responsible dialogue around what we are really prepared to pay for.” It boils down to the question, he says, of “wants, and needs … But people who can’t afford to pay shouldn’t have to.”

The research nurse manager: Jennifer Allison, 56

How can you ensure the care you spend money on is the best care unless you do research?

Facebook Twitter Pinterest Jennifer Allison at the Southampton clinical research facility.

In the smart pastel and pale-wood surrounds of the NIHR (National Institute for Health Research) Wellcome trust Southampton clinical research facility, Jennifer Allison, an energised New Yorker who came to Britain more than 20 years ago, describes the inherent tension in what she does.

“A research nurse,” she says, “provides care to patients and healthy volunteers taking part in a research study. You have to assure the patient’s safety and wellbeing – and the accuracy of the research. It’s … a balancing act.”

Allison is the senior research nurse manager at the facility, which has about 300 clinical studies and trials taking place at a time and was the first government-funded centre in England accredited for so-called phase 1 trials (“The highest risk trials, when humans are given something for the first time.”)

It is Allison’s responsibility to ensure the full panoply of nursing standards are met but also that strict, often inflexible, scientific protocols are observed, in studies that range from cancer through “all the -ologies” to respiratory illness and paediatrics.

Coming from the US, where she qualified as a paediatric and neonatal intensive care nurse, the NHS seems “a gift. Just an amazing institution, one that I feel extremely proud and privileged to be a part of. Look, my parents had to pay for their meds into their 90s …”

Her job, she says, “is ultimately about making the best research available to every patient. And research has to be key to the organisation’s future. How can you ensure the care you spend money on is the best care unless you do research?”

The voluntary service manager: Kim Sutton, 60

Volunteers complement the work of the staff, they don’t replace them

Facebook Twitter Pinterest Kim Sutton at Southampton General.

Without Southampton’s astonishing 1,096 volunteers, says Kim Sutton, whose job it is to manage them, the hospital would doubtless continue to function. But the “little extras” they provide would be sorely missed.

“Volunteers complement the work of the staff, they don’t replace them,” says Sutton, a warm if breezily efficient figure who has spent more than 30 years in the voluntary sector. “They release the staff to do their jobs.”

At Southampton, volunteers act as guides around the place’s baffling 7.5 miles of corridors. They spend time simply sitting with patients, talking or just holding hands. They act as meal time assistants, encouraging weaker, sometimes dispirited patients to eat up.

“I had two 96-year-old ladies come to see me recently,” says Sutton, as an illustration. “Their sister was a patient, her daughter was miles away in Milton Keynes, working, and they were a train ride and two buses away. “So she wasn’t getting many visits. Her mood was low. The next time they managed to come back, their sister had had 10 visits in under a week and her mood was transformed. That’s the difference volunteers can make.”

Several of Sutton’s volunteers, who must commit to at least three regular hours a week, are in their 80s and even 90s (the oldest is 97). The youngest are students. They may not keep the hospital functioning, but they make it what it is. So are volunteers the answer for the wider NHS?

“I am worried,” Sutton says. “I’m fiercely proud of working for the NHS, but some things will have to change. My gran, when she started having trouble walking, got a stick; when that happens to me, I’ll expect a new hip. We need to decide, as a country, what we want from the NHS – and we have to be realistic about our expectations.”

Correction: this article was updated on 19 January. A previous version stated that 13% of clinical professionals and 24% of doctors are from overseas. The correct proportions are 14% of clinical professionals and 25% of doctors.



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