Using fear to build political capital is a tactic as old as politics. All that was new on this occasion was the target – not foreigners, immigrants, scroungers or Muslims, but the medical profession itself. In 2015, the new majority Conservative government, unshackled at last from its Liberal Democrat coalition partners, had the NHS medical wage bill in its sights. Junior doctors, consultants and general practitioners all faced a renegotiation of their contracts and – perhaps assuming ‘junior’ meant weak – Jeremy Hunt had decided to press ahead initially with ours.
The strategy was simple. First, put the fear of God into people by claiming that eleven thousand patients will die annually at weekends because doctors are too lazy or greedy to work them. Next, allay the fears you’ve just stoked so meticulously by promising the solution: the seven-day services the country currently lacks. Finally – and most audaciously of all – insist that a ‘cost-neutral’ renegotiation of the junior doctor contract will deliver said seven-day NHS. The small matter of more staff and more funds being an obvious prerequisite for improved front-line services was conveniently omitted from the government’s narrative. Junior doctors, not the Treasury, were the barrier to safe weekends.
When the dispute began, I had been a journalist for ten years and a hospital doctor for another six, long enough to evolve from nervous ward ingénue into an experienced and valued member of my hospital’s front line. Year on year, I had witnessed the human impact of funding cuts: patients waiting longer and longer for treatment, doctors quietly disappearing from the rotas as recruitment became ever more problematic. Still, my spirits were high. With six years of medicine and numerous postgraduate exams under my belt, I was ready and eager to embark upon my chosen speciality of palliative care. The distressing, sometimes haunting, challenges of helping patients at the end of life to live as fully and richly as possible had touched something deep within me. Not once had I ever predicted junior doctors being targeted by the Number 10 spin machine, or how destructive and demoralising Downing Street’s crosshairs would be.
Through the dual perspectives of doctor and journalist, I would look on, aghast, as the government ran rings round the doctors’ trade union, the British Medical Association (BMA). But what was it really about? Beneath the slews of accusation and recrimination, what actually drove a generation of young doctors to abandon their patients and go out on strike? Even Jeremy Hunt could not in all seriousness have believed we did it merely to preserve our Saturday pay rates. This was a complex, nuanced dispute in which concerns surrounding pay, patient safety, staffing levels and morale were inextricably linked. Even the phrase ‘junior doctor’ glossed over the huge variety of individuals who were doctors in training, ranging from single twentythree- year-olds, fresh out of medical school, to mothers and fathers in their late thirties or forties, experienced doctors on the brink of becoming specialist consultants.
For me, the junior doctor dispute – a pivotal moment in NHS history – was deeply embedded in the wider health of the modern NHS. Strikes were drastic, a last resort. This was the first time that young doctors had abandoned their patients in over forty years, and we would do so on eight different days. Fundamentally, going on strike, for the majority of us, was an act of desperation born out of our lived experience of the NHS front line. Ours is a supremely under-doctored health service. There is simply not the money to employ enough doctors. Statistics from the Organisation for Economic Cooperation and Development (OECD) show we have only 2.8 practising doctors per 1,000 heads of population, fewer than almost any country in Europe, including Poland, Latvia and Lithuania. In Germany, by contrast, that figure is 4.1 doctors, and in Greece it is 6.3 doctors.1
What that translates into for a junior doctor is understaffing that is at best exhausting, at worst soul-destroying. I can’t count the number of times I’ve been left to shoulder two doctors’ jobs when there’s a gap – a missing doctor – in my junior doctor rota. Those ‘rota gap’ shifts are grim, thankless exercises in firefighting, and they are becoming increasingly prevalent. When I first qualified in 2009, they were mercifully rare, but these days they feel like the norm. We dread them and, perhaps more pertinently, so should our patients. Because, no matter how finely honed a doctor’s acute resuscitation skills, we cannot be in two places at once. When understaffing has forced one doctor to carry two doctors’ crash bleeps, the risks of a patient slipping through the cracks have clearly just doubled: too few doctors threatens lives.
A further casualty of doctor overstretch is the one that compelled us into medicine in the first place – and the one we can least afford to lose – our kindness. People say the NHS runs only on the goodwill of its staff: the doctors, nurses and allied healthcare professionals who are willing to go the extra mile not for money, or thanks, or praise, or self-promotion, but for the intrinsic rewards of helping a patient. If that’s right, then working conditions that grind away relentlessly at our capacity for kindness threaten the survival of the NHS itself. More immediately, they are the enemy of the doctor–patient relationship. When doctors are too few on the ground, when you haven’t a chance of managing your workload in the time you are meant to be at work, then every precious second is spent scrabbling merely to keep your patients safe. Talking to patients and their relatives is inevitably left until last. The humanity of a conversation has become a luxury your conditions of work deny. Doctors are turned into hardened machines, patients are left in the dark. You know it’s wrong, you hate what you’ve become, and now perhaps you consider quitting the profession you once loved with all your soul.
We’ve already reached this point. The question that led me, heavy-hearted, full of doubt, to the picket lines in 2016 was not ‘How can I protect my Saturday overtime?’ but, ‘How can I continue to conduct myself with compassion and humanity in an NHS that is falling apart?’ Like so many of my fellow junior doctors, I knew I had nothing more to give. A contract that stretched us even more sparsely across seven days, not five, would, I had no doubt, be the breaking of me.
This is a book about working within the institution in which I was born, gave birth and will probably die, provided it still exists then. An NHS doctor saved the life of my newborn son and, as I write, an NHS oncology team is attempting to prevent cancer from taking the life of my father. Like so many other families in Britain, the members of mine have experienced some of the most joyous, momentous, harrowing and moving moments of our lives within Britain’s National Health Service. And, like so many other NHS doctors, nurses, midwives, porters, physiotherapists, radiographers, pharmacists and dieticians, when it comes to the institution I professionally serve, I am unashamedly partisan. That we are willing, collectively, to pay sufficient tax to ensure no one is denied the healthcare they need because they cannot afford it makes me feel genuinely proud to be British. And providing my patients with cradle-to-grave NHS care based on that clinical need, not ability to pay, is my absolute joy and privilege.
Every day, I bear witness to ordinary NHS staff going about their extraordinary work – dressing the wounds, breaking the bad news, holding the hands, wiping the excrement, restarting the stalled hearts, smoothing the eyelids of the newly dead – with the utmost compassion and care. I love my job. I could not imagine a more rewarding and fulfilling career than medicine. But I am afraid we may have reached the point at which the NHS’s greatest asset – its staff – has become terminally exhausted. The goodwill and kindness without which the NHS will not survive are being inexorably squeezed out by underfunding, understaffing and the ever more unrealistic demands placed upon a floundering workforce. This is the untold story of the challenges of trying to stay kind while practising on an overstretched NHS front line.
CHAPTER 1
WORDS
Four days before the 1997 general election that swept Tony Blair to a historic victory, the then Prime Minister, John Major, was trapped in a chauffeur-driven car in central London gridlock. At 1 p.m. precisely, he was meant to be interviewed on live national television.
It was 12.50 p.m. and, under unseasonably warm April skies, temperatures in the TV studio were rising.
‘I don’t give a fuck how bad the traffic is. Get the fucking Prime Minister here now or we’re not going to have a fucking programme, do you fucking understand?’
The question was directed at me, the most junior researcher on ITV’s Jonathan Dimbleby programme. I stared aghast at my editor, feeling solely responsible for the capital’s congested streets, wishing I could somehow pluck the Prime Minister from his immobilised vehicle and magic him into the studio. I was twenty-three, underconfident, convinced that everything was probably my fault, London traffic included.
The editor stared me down with contempt. ‘Go and wait for him outside. And for fuck’s sake get him here the second he arrives, do you fucking understand?’
At 12.58 p.m., a shiny black car hastily pulled up outside the entrance to the studios. I hustled John Major inside. As we weaved through the corridors to the back of the live studio, he asked me a pertinent question:
‘Do you have a water closet?’
I suppose he’d been stuck in a traffic jam for God knows how long. His bladder was probably bursting. But, at the time, overwhelmed with stress and anxiety, I simply couldn’t compute what this quaint phrase meant. Water closet? I had absolutely no idea what the Prime Minister was asking me. All I knew was that, if I didn’t get him into the studio by 1 p.m., my short-lived career in television was over.
‘W-water closet? I’m sorry, Prime Minister, I – I’m afraid we don’t have one.’
With a thunderous look and a half-suppressed expletive, he allowed me nonetheless to lead him straight onto the set to begin his hour-long live interview. Seconds before one o’clock, the first few bars of our theme tune began. As I exhaled in relief, it suddenly dawned on me that all he’d wanted was an emergency stop at a WC, a urinal. Words. The power of an ill-chosen phrase. I wondered whether his straining bladder would put him off his interview.
On 16 July 2015, the Health Secretary went to war. For a former PR man turned politician, Jeremy Hunt’s weapon of choice would always be words – deployed, on this occasion, with explosive aplomb. Whereas John Major came unstuck with a casual anachronism, the speech Hunt gave at a health think tank, the King’s Fund, that morning appeared precisely calculated to infuriate doctors by casting aspersions on their sense of vocation.
Patients were dying unnecessarily in our hospitals, Hunt claimed, because consultants refused to work weekends, causing an excess of deaths at the weekend. There were six thousand avoidable fatalities a year, to be precise – death on a massive scale.2 Later, he would adjust this figure upwards to eleven thousand weekend deaths a year, but even the more conservative estimate sounded wholly indefensible. ‘When you turn medicine into a Monday-to-Friday profession,’ he told BBC Radio 4’s Today programme that morning, ‘you end up with catastrophic consequences.’3 Seven-day working, he insisted, should be ‘part of the vocation of medicine – which is about being there for your patients’. The implication was clear. Doctors lacked the professionalism and dedication to their patients to give up their Saturdays and Sundays.
The speech had a midnight embargo, ensuring Hunt dominated most of the next day’s front pages. I first learned of his attack at 4 o’clock that morning – the hazard of having a four-year old in the house with bladder issues of her own. Once I’d tucked up my daughter in her bed, I committed the nocturnal sin of glancing at the news on my smartphone. An error. Though Hunt had targeted on this occasion not junior doctors but our consultant colleagues, within moments I was incandescent.
The health secretary’s speech implied that you were 15 per cent more likely to die at the weekend – the so-called ‘weekend effect’ – because consultants were exploiting a contractual loophole that enabled them to ‘opt out’ of weekend working in NHS hospitals. Instead, they would offer themselves back to their hospitals as locum doctors, private contractors whose extortionate weekend rates – up to £200 an hour – were crippling NHS finances. Hunt contrasted these avaricious consultants with their altruistic betters, the ones who every weekend would, ‘go into the hospital to see their patients, driven by professionalism and goodwill, but in many cases with no thanks or recognition’.
Still groggy, initially I was unable to decipher these allegations. For six years as a junior doctor, I’d worked weekends in multiple specialities, across multiple hospitals, typically one a month. Accident and Emergency, General Surgery, Cardiology, Acute General Medicine, Gastroenterology – you name it, I’d done it. But one thing united my one in four weekends. During every one, a consultant had been there by my side to lead a morning ward round on both Saturday and Sunday. For the rest of the day, they were never more than a phone call away. And, when working nights, if required, I could call my consultant at any hour. Should their expertise be needed, they would come straight back to the hospital. Indeed, from what I’d observed, most consultants’ weekends on call began on Friday evening and stretched a full sixty hours, without a break, all the way to Monday morning.
So on this, day one of the NHS strike year, just what was Hunt’s game? The picture he painted of senior medics as opt-out dilettantes was so wildly at odds with my own experience, I stared nonplussed at the screen. Then it clicked. This was the classic politician’s tack of conflating the actual with the hypothetical to construct a superficially watertight case. Consultants did indeed have a weekend opt-out in their contract – but for elective, not emergency care. They could choose to opt out of only non-essential work such as planned operations or extra weekend outpatient clinics. Their weekends ‘on call’ – those spent looking after their existing inpatients and any new admissions – were, in almost all cases, obligatory. Hunt had glossed over this crucial difference to convey a lurid depiction of mass avoidable death for which consultants were to blame. Yet the ones I’d worked with at weekends had been there not as locums, but as NHS employees, already providing seven-day care.
Having stoked our fears with his erroneous depiction of consultant weekend slackers, Hunt simultaneously set out to reassure us. As a result of contractual changes he would impose upon doctors – through brute force if necessary – he would cure the problem he’d just fabricated: ‘by the end of the Parliament, I expect the majority of hospital doctors to be on seven-day contracts’. He issued the doctors’ trade union, the BMA, with a six-week ultimatum: if it could not negotiate a new consultant contract with Hunt in that time, its members would face an imposed one.
It was a beautiful instance of political doctoring. Take some truth, sprinkle in some non-truths, insinuate, cast aspersions and manipulate the data to ensure your argument, however tenuously rooted in fact, guarantees the superficial headlines you seek.
For the rest of the night, I seethed in silent fury. The notion that any of us, junior or senior, exploited weekend opt-outs for financial gain was so deeply offensive it rendered sleep impossible. Doctors can be many things – pompous, opinionated, arrogant, self-righteous – but I’ve yet to meet a single one who joined the NHS because they planned to get rich quick. If it was megabucks that drove us, we’d have chosen the City, not medicine. Way more cash, way less bodily fluid – or so one would hope.
My rage was ignited only in part by the insinuations against my senior colleagues. Almost more infuriating was the brazen spinning – the cynical distortion of the facts to try to turn public opinion against doctors and their union. Could there be a more effective way to win an industrial dispute than to bathe it in avoidable bloodshed? In Hunt’s narrative, the price of the BMA’s refusal to capitulate was nothing less than six thousand lives a year. How could consultants live with the sheer quantity of blood on their hands? How could the public not turn against them? It was disingenuous, deceptive and utterly brilliant – a public-relations masterstroke.
The morning Hunt’s speech went public, I arrived at my hospital’s doctors’ mess, groggy with sleeplessness and still fuming. Even at the best of times, doctors�
� messes invariably live up to their name. At any time their grotty sofas may be strewn with takeaway detritus, abandoned scrubs, grubby hospital blankets, long-lost stethoscopes, perhaps a random rotting trainer. I have encountered doctors’ messes where cockroaches infest the floorboards, sidling out to keep you company on night shifts. Occasionally in the early hours I have seen a rat peep down from the vents in the ceiling. Glamorous the doctors’ mess is not. But, on the morning of 16 July, the filthiness was primarily verbal. Five or six acute medical teams were hunched over their lists of inpatients, ostensibly discussing the day’s issues and concerns before commencing their morning ward rounds. Except on this occasion the talk was all Jeremy. And, when I say ‘talk’, I mean four-letter, no-holds-barred obscenities. This was platinum-level vitriol, Old Testament-style ferocity, from consultants and juniors alike.
What struck me, as we lambasted the Health Secretary, was the unusual sense of unity between seniors and juniors, indivisible under fire. Hunt may have anticipated – even relished – the anger his speech would unleash, but the solidarity would later prove to have caught him unawares. Typically, doctors are notoriously tribal. Medics snipe at surgeons, seniors at juniors, and every medical speciality secretly believes that its is superior to the others. Today, though, we were all just doctors. An angry, aggrieved, cohesive whole. Something in me had shifted, a boundary had been breached, and I sensed I wasn’t alone.
Some two years earlier, at four o’clock one Sunday morning, a weekend night shift got the better of me.
Your Life In My Hands--a Junior Doctor's Story Page 2