That temptation – to conceal, to deny, to shrink into kneejerk defensiveness – is well recognised not only at hospital and individual levels, but also above them, at the level of the government itself. We are all familiar with – some might say sick of – political spin, the legions of governmental press officers whose sole purpose is to package and polish reality into the least unpalatable form in order to persuade voters of an administration’s effectiveness. But, for health workers, this process is uniquely discomforting, given that everyone within the NHS now has a professional obligation to be candid, except, it seems, its highest echelons, the political masters who apparently cannot bear to leave the facts unvarnished and unspun. From the perspective of a lowly member of the NHS front line, candour, like gravity, seems only ever to tug downwards. Politicians float freely, immune from its grasp.
Nowhere is this more apparent than in the thorny matter of ensuring our hospitals are safely staffed. Having identified draconian cuts in staff numbers – the result of a deliberate Trust policy to save money – as one of the fundamental causes of the horrors of Mid Staffs, Sir Robert Francis rightly made safe staffing a key imperative for the NHS. To ensure that patients were never again subjected to such abject failures of care, he explicitly recommended that NICE (the National Institute for Health and Care Excellence, formerly the National Institute for Health and Clinical Excellence) should be commissioned to develop evidence-based guidelines for minimum staff numbers. Francis chose NICE for a reason. Unlike most of the quangos that proliferate in the NHS, NICE has a reputation for strict independence from political control, basing its guidance on objective, evidence-based analyses of clinical and cost-effectiveness.
But staff, as we know, cost money. And though NICE set to work appraising the evidence – concluding that at least one nurse to every eight acute medical patients was necessary to ensure patient safety – after the Conservative Party’s 2015 general election win, something unexpected happened: NICE abruptly announced it was abandoning its safe-staffing programme at the behest of NHS England, which would now oversee the work instead.63
Sir Robert Francis was unimpressed. ‘I am surprised and concerned by this news,’ he told the Health Service Journal, adding,
I specifically recommended the work which NICE has been undertaking for a reason, namely they have an evidence-based and analytical approach which I believed would be very helpful in filling what appeared to be a gap in the discussions on this topic. NICE also has an advantage not enjoyed by NHS England of being independent.63
Fears abounded that NHS England, a politicised body that shares an intimate relationship with the government of the day, would prioritise the political imperative of cutting costs above the patient-safety imperative of introducing sufficiently robust staffing standards to prevent another Mid Staffs. Nursing leaders and patient-safety campaigners condemned the announcement, including, most embarrassingly for Jeremy Hunt, relatives of patients who had died at Mid Staffs. One leading local campaigner, Julie Bailey, who had fought tirelessly for a public inquiry, condemned the move as an ‘absolute disgrace’, warning Hunt that he would lose all credibility with patients and the public by backing it:
We are so disappointed. Jeremy Hunt has championed patients and their safety. This will be a huge step backwards. We’re not prepared to go back to those dark days. We fought too hard for the Francis Report and now we must ensure that his recommendations matter and are implemented to ensure it never happens again.63
An unpalatable truth had been exposed. For all the government’s lofty rhetoric, when it came to the crunch – and Francis’s recommendations came at too high a price for the Treasury – curbing NHS spending, not protecting patients, was the first priority. Jeremy Hunt’s unequivocal response to Francis looked increasingly hollow. On the matter of safe staffing, it seemed, he was willing to settle for obfuscation above candour.
CHAPTER 14
HAEMOSTASIS
The most underrated heroes of the human body are surely its humble scabs. No adults, only children, truly appreciate the visceral joys of a well-formed scab. As a small girl, I could lose myself for hours painstakingly picking at the crusts on my knees, the pleasures of a decent de-scabbing topped only by an occasional nibble to see if dried blood tasted the same as fresh. Both my children, I note with approval, are often similarly engrossed, demonstrating the enduring appeal – in a world of Wi-Fi and tablets – of the good, old-fashioned scab.
Almost as extraordinary as the pleasures of scab-picking are the processes underlying their formation in the first place. Haemostasis – the opposite of haemorrhage – is the body’s way of preventing bleeding by forming clots that contain blood within damaged blood vessels. The lowly scab is the final product of some of the most intricate chemical reactions that occur anywhere within the human body. So bewildering is the infamous ‘clotting cascade’ – the chain of events that causes liquid blood to solidify into a clot or scab – that generations of medical students have given up ever truly understanding it. Only a rare breed of doctor, an erudite subtype of haematologist nicknamed a ‘clotter’, properly grasps the processes by which we staunch our bodies’ bleeding.
In real life, stopping a haemorrhage – achieving haemostasis in a patient – can make you want to whoop with relief. Unchecked blood fills doctors with dread. We know we must act fast or lose the patient. It takes a while to discover as a junior doctor that a little blood goes a very long way. Once, on the cardiology ward, I was called to see a man who had recently returned from a procedure to implant within his chest a cardiac pacemaker, a small metal box that would from this point onwards do the job of triggering his heartbeat. Stealthily, unbeknown to anyone, ever since the cardiologist had inserted the device, blood had been leaking from a tiny nick in one of the vessels close to the heart. By the time I was summoned, the pressure of leaking blood had built up to such a degree that it was now pouring out of his chest wall through the gaps between his stitches. Three or four nurses stood at the bedside, aghast. The patient, ashen-faced, stared in horror at the bloodbath in the centre of his chest while I wrestled with myself to appear confident and calm. Very junior, very out of my depth, the most constructive thing I could do at this point was call for urgent senior help. When the cardiologist arrived – suave, aloof and devilishly handsome – everyone at the bedside was practically swooning. For the patient, admittedly, this was due to blood loss, but the rest of us were romantically swept off our feet. Deftly, the cardiologist snipped open all the stitches, extracting from the gaping wound a large bloody clot – which he briefly held aloft in the manner of a big-game hunter posing with the head of his felled impala – before whisking the patient away to theatre to repair the leaking vessel. ‘Hmph! That wasn’t a big bleed,’ he said nonchalantly, as he disappeared round the corner. Never had haemostasis looked cooler.
The haemorrhage of staff from the NHS threatens its survival just as surely as unstaunched blood around a human heart. If we want the NHS to endure, achieving haemostasis is essential. At my lowest ebb last year, like so many more of my junior doctor friends and colleagues, I decided I had to quit medicine. Withdrawing my application for speciality training was not enough. I reached the point of knowing I had to walk away completely, whether temporarily or permanently I simply could not tell.
The moment my own keeno lifesaver light went out was around ten o’clock one summer evening. A long shift on call was nearly over. There had been a couple of crash calls, one or two sick patients, nothing too arduous at all. But because we were a doctor down on our ward – and had been for many months now – I’d been fighting fire since nine that morning just to keep on top of all the ward jobs. Now, I felt hungry, tired and angry with everyone. The management for ignoring the excessive unpaid hours I was being forced to work daily, the BMA for dithering and failing to define what they were fighting for, the press for accusing me of naked avarice, the Health Secretary for launching a wholly avoidable media war against doctors. I’m sure there
was also a hefty whack of self-pity.
That morning, one of my favourite patients, a softly spoken Scot in his seventies, was desperate for a chat. I promised him I would come and find him later. Callum’s case had touched us all. A virulent skin infection had spread into his bloodstream, causing his kidneys to fail permanently. In a matter of days, he had gone from being fearsomely active, with not a single health problem, to requiring renal dialysis three times a week, each time being hooked up for most of the day to the machine that did the work of his kidneys. Though he was sometimes tearful at being plunged so abruptly from the finest health into immobility, he worked so hard at being stoical. No matter how overstretched I was on the ward, I always eked out a few minutes to chat with him. He loved to discuss the merits of different single malts, insisting I was to go home and try out various obscure new whiskies.
That night, though, my ability to give had run dry. All day, I’d been too busy to sit down with Callum, as I had promised him I would. Every time I scuttled past the open door to his room, dashing to the next patient requiring my attention, he called out, eager to chat.
‘Come on, Doc, we’ve got whiskies to discuss. When are you going to sit down?’
Each time, I sheepishly muttered my apologies, inwardly cursing the workload. Eventually, head down, too embarrassed to meet his eye, I felt the anger that had been brewing inside me all day finding a new and wholly undeserving target. ‘Can’t you see, Callum?’ I wanted to cry at him. ‘Can’t you see that I’m always running past your room? I haven’t even eaten a proper meal today. I can’t stand still, let alone chat for hours about whisky.’ Though I said none of this out loud, my thoughts appalled me all the same. It felt as though the beginnings of callousness – that first twisted step towards the cruelties of Mid Staffs – might be perverting the doctor I had always aspired to be.
Finally, every last job done, an hour or so late for the babysitter, I hovered uncertainly in the empty doctor’s mess, torn between letting down a patient who needed my support and having the chat I had promised him I would. I knew I could just about summon the energy to listen and be kind, but I was paranoid that, if I arrived home that night even later than I was already, my children’s much-loved babysitter might be pushed by my erratic hours that bit closer towards quitting. So I slunk away, avoiding Callum’s room, dragging my heels with shame.
When I began life as an NHS doctor, in the mornings I would freewheel down the hill towards the hospital with a grin on my face. I would lock up my bike and trot towards the doctors’ mess, itching to get started. I brimmed with pride. Not merely at being a doctor but being, even better, an NHS doctor – a public servant whose graft served not to enrich corporate shareholders but simply to help my patients. Now, it seemed that the dehumanising system in which I worked had finally soured the love I felt for medicine, for the NHS and – above all – for my patients. I knew that when my contract ended that summer, I could not continue as an NHS doctor.
As 2016 drew to a close, the BBC questioned whether the NHS would ‘break’ in 2017. Nick Triggle, a senior BBC health correspondent, painted an ominous picture of what might lie in store. ‘Seasoned observers have started talking about a return to the 1990s when images of overcrowded hospitals and stories of patients waiting years for treatment dogged John Major’s Tory government at almost every turn,’ he wrote in the final week of 2016. ‘Could the same happen to Theresa May?’64
His prediction was horribly prescient. In the first week of January 2017, the inhumanity and jeopardy into which a desperately under-resourced health service will at some point inevitably descend erupted into the national press. Reports described one hospital, the Worcestershire Royal, where a woman died of a heart attack after waiting for thirty-five hours on a trolley in a corridor, while a man, also lying on a trolley, suffered torrential bleeding from a burst aneurysm and could not be saved. The husband of a third patient, left in a corridor for a staggering fifty-four hours after suffering a stroke, said, ‘It was horrendous. The nurses did all they could but the place was in meltdown. It was manic. There were at least twenty people on trolleys. It was very difficult to manoeuvre around them. A porter told me they were putting some patients in a decontamination room – basically a big shower room – to cram in more beds. They ran out of pillows and blankets.’65 Other relatives described the hospital as looking like a ‘war zone’, echoing testimony given to Sir Robert Francis by nurses working at Mid Staffs.
The hospital was by no means unique. British Red Cross volunteers and Land Rovers were drafted in to help transport patients between their homes and many other beleaguered NHS hospitals. While this was by no means the first year that the British Red Cross had assisted the NHS, this time the charity’s CEO, Mike Adamson, condemned the situation as a ‘humanitarian crisis’, stating, ‘We’ve seen people sent home without clothes, some suffer falls and are not found for days, while others are not washed because there is no carer there to help them.’66
With overwhelmed hospital Trusts up and down the country being put on ‘black alert’ due to overstretch – too few beds and too few doctors and nurses to cope with the number of patients – the president of the Royal College of Emergency Medicine, Dr Taj Hassan, said, ‘Figures cannot account for untold patient misery. Overcrowded departments, overflowing with patients, can result in avoidable deaths. The emergency care system is on its knees, despite the huge efforts of staff who are struggling to cope with the intense demands being put upon them.’66
Story upon story began to fill the media of misery, indignity and dangerously substandard care – seriously unwell patients being dumped in hospital gyms with no oxygen, alarm bells or even sufficient food for patients; adults being placed on children’s wards; an NHS maternity unit being closed to pregnant women in order to house the flood of patients from A&E; patients’ lifesaving cancer operations being postponed. The defining image of the crisis became that of a baby boy with possible meningitis forced to wait for five hours in an A&E on a makeshift bed of blankets on a pair of plastic NHS chairs.67 Even Simon Stevens, the CEO of NHS England, told MPs at the House of Commons Public Accounts Committee that the Prime Minister, Theresa May, was ‘stretching it’ to pretend she had given the NHS the budget it had asked for. Stevens left no one in any doubt that, if the public’s expectations on health were to be met, more money was required. He effectively challenged the government either to find more money for the NHS and social care or to be honest with the public about the consequences of failing to do so.
In terms of the government’s credibility on the NHS, it felt like crunch time. For the first few days of the crisis, the Health Secretary went to ground. Unseen, unheard and unavailable for comment, he infuriated frontline staff by his absence. In the hiatus before Hunt re-emerged I knew, with utter clarity, how our morale could be restored. What we needed at that moment, more than ever before, was candour. A government that confronted the crisis instead of trying to deny it. One that entered into an honest dialogue with the public about the unsustainability of safe, world-class healthcare in the face of shrinking resources. By openly acknowledging the risks of continuing to try to do too much with too little money, the government would make NHS doctors and nurses feel as though their warnings on behalf of patients were finally being heard.
I had a glimmer of hope Jeremy Hunt might surprise us. My optimism stemmed from the surprising discovery, during the junior doctor dispute, that he was willing to converse face to face with one of his most vocal junior doctor critics.
We were at what was probably the most fraught point in the entire dispute, September 2016, and the BMA had just announced its longest strike yet, five consecutive days of complete withdrawal of junior doctor labour, in only twelve days’ time. Many rank-and-file junior doctors were uneasy about the impact on their patients’ safety of such a long strike called at such short notice. Some of them openly expressed their unwillingness to take part in the action. My concern was the lack of clarity from the BMA about what,
precisely, the aims of the strike were beyond ‘do not impose this contract’. The union, I believed, had backed themselves into a strategic cul-de-sac, having threatened their own version of Hunt’s ‘nuclear option’ without actually spelling out why.
I asked via an intermediary whether Hunt would be willing to meet me in private. Really, I was clutching at straws. I had no power or inside knowledge with which to break the impasse between the government and the BMA – nor, crucially, any mandate with which to attempt to do so – but I hoped that articulating one grassroots doctor’s concerns might at least help convey why we were so angry and determined.
Given the number of times I had called Jeremy Hunt dishonest in print and on television, I was astounded he agreed to meet me. But he did. In a tiny parliamentary office, perched on shabby old sofas, we surveyed each other awkwardly. I felt mildly nauseous. He wore the pained expression the Queen might adopt on being trapped in a small lift with Johnny Rotten. Inexplicably, my opening attempt at ice-breaking small talk involved decapitation. I described how my daughter, aged five, had recently spotted a tall man entering my hospital and shrieked, ‘Mummy! That’s Jeremy Hunt going into your hospital. Go after him and chop off his head.’
After this inauspicious start there was, as expected, much we disagreed on: that the government’s seven-day pledge was unfunded and unstaffed; that the evidence for a weekend effect in hospital deaths was contentious; that there were no data demonstrating how the new contract would improve patient safety, and strong reasons for fearing it would do the opposite. Far more surprising though were our areas of agreement. ‘I have totally failed to communicate with junior doctors and I have torn my hair out trying to think of how I could have done it differently and better,’ he admitted – and I appreciated the honesty. He also stated unequivocally something I had never heard him say in public: that he knew Britain did not have enough doctors. The most striking common ground, however, was what he described as his ‘context to the dispute’ – a commitment to improving patient safety born out of the appalling events of Mid Staffs. He even joked that Sir Robert Francis could be blamed for the junior doctor dispute, since it was Francis who had made him care so deeply about safety that he would do whatever it took to keep patients safe, even if that meant being hated by doctors.
Your Life In My Hands--a Junior Doctor's Story Page 21