Who shall we save today? BBC2's Hospital reveals an NHS in crisis

The cause of his distress – through no fault of her own – is an elderly woman called Janice. She’s seriously ill and currently racing towards St Mary’s in the back of an ambulance. One of her main blood vessels has ruptured and, if she doesn’t have an emergency operation as soon as she gets to St Mary’s, she will bleed to death.

Here’s the crunch: while there are enough surgeons, anaesthetists and nurses to perform operations on both Simon and Janice, there’s only an intensive care bed for one of them. Which means that either she gets her life-saving operation – or he does.

Simon has been told that if Janice survives the journey, his operation will be cancelled for a second time. But if she loses her life en route, he can head straight for the operating theatre. How does that make him feel?

He fights back the tears as he contemplates his answer. Just two words tumble out. “Guilty, actually.”

Cameras have been inside hospitals many times. The story they usually tell is of heroic doctors and their successes and failures in the operating theatre. That’s an important story, and a tried-and-tested TV formula. But this series is trying to do something different.

The production team filmed for six weeks in October and November in the five London hospitals that comprise the Imperial College Healthcare NHS Trust. The focus of their interest is not the ins-and-outs of what goes on in the operating theatres – but the behind-the scenes decisions that enable the operations to happen (or not).

Giulio Anichini (above) works at St Marys Hospital

In any system of healthcare, some people get treatment and some do not. Here we see the people who make those decisions, and we get to see how they solve some horrible dilemmas.

The picture that emerges is of an NHS stretched to its limits – and sometimes beyond. As Dr Simon Ashworth, head of intensive care at St Mary’s, says: “The elastic is a bit nearer to breaking now than it perhaps ever was.”

Watching people make these life-and-death decisions is not a comforting experience. Demand for its services are running so high at St Mary’s that the hospital is several times plunged into “code black”, the highest level of alert.

Though the implications of a “code black” vary from situation to situation, it means that patients are sent home earlier than they normally would be, ambulances are diverted to other hospitals and operations are put on hold.

One of the senior staff featured in the series is Lesley Powls, site director at St Mary’s (below). It’s her job to act as “air traffic controller” at the hospital – making sure that the beds, doctors and patients are all in the right place at any one time.

She likens her role to the children’s building game Jenga. “The tower has never yet come crashing down and my job is to stop that happening. But life here is sometimes a little bit wobbly.”

Professor Tim Orchard is divisional director of medicine and integrated care at the Trust (he’s also a practising consultant gastroenterologist). Given the huge stresses his hospital is dealing with – not to mention the Trust’s expected financial shortfall of £41 million this year – why did he and his colleagues agree to let the cameras in?

He chooses his words carefully. “I hope people will realise that we are having to work pretty hard to make sure patients get the care they need when they need it.”

Shehan Hettiaratchy works at St Marys Hospital

Some of the choices are wretched. Might the Trust want us to see the work of Prof Orchard and his colleagues in order to encourage the public to lobby for increased NHS funding? “I don’t think that’s the motivation. It’s about letting people understand how we work – apart from anything else, it’s so people can understand how they fit in.”

There’s a very sad postscript to the first episode. Simon, the cancer patient, did finally get his operation – just one day later, at the third attempt. But six weeks after surgery he died, after contracting a blood and immune disorder known as HLH.

It’s a reminder that for all the advances in medicine, and all the decent, hardworking people in the NHS, no one can ever guarantee a happy outcome.

The man who makes foreigners pay

Terry Facey (above) is overseas officer for the Imperial College Trust. It’s his job to check whether patients are eligible for free treatment on the NHS — and to present a bill to those who are not.

He says the rules are complicated but, “broadly speaking, the eligibility for free NHS treatment is based on residency. Treatment given in A&E is free, as is the ambulance. But if you’re admitted onto a ward and you’re not resident in the UK, you become liable to charges.”

In the year 2015 – 16 those charges amounted to £4 million; the Trust collected just 40 per cent, or £1.6 million. Facey says very few of those who face charges are so-called “health tourists” — foreign nationals who have come here specifically to receive free NHS treatment.

It’s estimated that health tourism costs the NHS anywhere between £110 million and £280 million a year. “That’s a very small part of what I see. My typical client is a holidaymaker or a family member from one of the poorer countries who’s here for a few months visiting relatives. These people are often elderly, and in the time they’re here they might fall ill or have an accident.”

The bills can be eye-watering. His recent caseload included a 43-year-old Nigerian mother who arrived at the Trust’s maternity hospital, Queen Charlotte’s and Chelsea, after going into premature labour with quadruplets during a flight.

Three babies survived the birth, and were cared for on the neonatal ward. At the time of filming for the series the bill for their care was already £100,000 and looked likely to rise to half a million pounds during the course of their treatment.

Facey also recently took a payment of £54,000 from a patient who’d undergone a neurological operation. She financed her hospital stay by setting up a crowd-funding appeal in her home country.

How do patients react to Facey’s bad news? “There have been a few occasions when it’s been a bit… close. I’ve experienced a few rants. People get angry. But if I feel it’s going to be difficult I’ll ask a senior nurse to come with me as a chaperone. It softens things if there’s a medical person by your side.”

Hospital airs on Wednesday 11 January at 9pm on BBC2