Your Life In My Hands--a Junior Doctor's Story

by Rachel Clarke

  For a frontline clinician, there is clearly something concerning about a Health Secretary who seems to regard doctors’ hostility to his plans as the cross he must bear for putting patients first. It suggests profound mistrust of our motives – as though, unlike him, we doctors are somehow too self-interested to prioritise our patients’ safety. I could have chosen to bristle with fury at this subtext, or simply dismissed as bogus his claims to champion patient safety, as if they must be insincere when uttered by a Health Secretary. Yet, on safety, he spoke with disarming, almost messianic zeal. What disconcerted me was not his lack of conviction, but its surfeit. In short, if I suspended my scepticism, I could accept that we shared some common ground. And, if he and I, who disagreed on so much, could meet, talk and agree upon the absolute pre-eminence of patient safety, then a less adversarial future in which frontline staff were not permanently pitted against the Department of Health was, at least theoretically, possible.

  I had to believe in this possibility because the alternative, I was certain, was no NHS. Haemostasis – arresting the haemorrhage of belief, joy, meaning and enthusiasm from the working lives of frontline doctors and nurses, not to mention those staff themselves from the institution to which they were once so committed – entails first and foremost conditions of work that cease, for so many NHS staff, to be unendurable. But it also requires a rekindling of faith. Right now, in spite of everything, the vast majority of the NHS’s 1.4 million employees still passionately believe in the institution in which we work. It inspires us, matters to us, embodies many of the ideals we hold dear. Most corporations could only dream of a connection of this kind between their brand and their employees. How much would a Google or a McDonald’s pay for that kind of devotion from their staff? Abusing, taking advantage of and ultimately squandering this enormous reservoir of goodwill no longer seems merely profligate, but fatal. With the political custodians of the NHS apparently knowing the price of everything and the value of nothing, its lifeblood – its staff – continues to ebb away.

  Faith can be rebuilt, however. Some simple straight talking at a ministerial level about how the NHS is really performing – and, crucially, how much funding the NHS really receives – would do wonders for revitalising a workforce at breaking point. Is this kind of political candour really so outlandish? Would it be political suicide to talk honestly and openly about the fact that, one way or another, a world-class health service requires more money and that, as a nation, we need to decide how much we are willing to pay for it, whether through taxation, insurance or other means? Are the British public that immature? I think not. No one really believes you can fund exemplary healthcare on a shoestring, even if politicians like to pretend otherwise.

  My glimmer of hope was short-lived. In response to the unfolding crisis, the government launched into its most audacious effort yet to spin away NHS frontline reality. Prime Minister Theresa May rubbished the British Red Cross’s claim.68 Jeremy Hunt took to the airwaves to deny the crisis, claiming that only ‘one or two’ hospitals were in trouble, with the ‘vast majority’ actually coping better this winter.69 A leaked memo sent to hospital managers by senior officials from NHS England revealed feverish attempts from above to downplay the scale of the unfolding disaster. It instructed hospitals on the ‘lines’ to take if questioned by the press about the pressures they faced, urging avoidance of language such as ‘black alert’ and issuing a bland form of words to use with the media.70 And, in one of the more surreal moments of the winter, I entered into a bizarre exchange on Twitter with one senior medical establishment figure, Chris Hopson, the CEO of NHS Providers, who also took umbrage at the Red Cross’s use of ‘humanitarian crisis’, listing the Syrian refugee crisis, the Nepal earthquake, the West Africa Ebola outbreak and the drought in Somalia and Central America as examples of real, bona fide crises.

  Is this really how bad things have become, I wondered, that the best we can actually say of our ailing health service is, well, at least it is not as bad as Aleppo?71 An old surgical friend, on call during the week of the ‘non’-humanitarian crisis, told me how he was forced to carry out a surgical procedure on a screaming patient on the floor in A&E, pinned down by another doctor in full view of the other patients and relatives, since all the trollies in the corridors were full. ‘An elderly couple who had been stationed in India for much of their working life came up to me afterwards,’ my friend told me, ‘to say that they couldn’t believe what they had witnessed. They said the patient would have received better care if they’d been in a state hospital in Delhi. And they were right. That week they would have.’

  As a doctor, it was painful to discover that, even with people literally dying on trolleys in hospital corridors – and even after everything Sir Robert Francis had advocated – the government’s first instinct remained, as ever, to downplay and deny a bad-news story that might reflect badly upon them.

  The problem for Hunt and May was, in the days immediately following their denial of the crisis, statistics emerged that flatly contradicted the claim that only one or two hospitals were in trouble. Evidence leaked to the BBC showed that vast numbers of NHS patients – over 18,000 of them in the preceding week alone – had endured trolley waits of over four hours; 485 patients had waited over 12 hours – treble the number seen during the whole month of January in the preceding year.72 Newly released Department of Health statistics then showed that a shocking 40 per cent of England’s 153 acute-hospital Trusts had issued alerts in the week leading up to Hunt’s claim because they were experiencing major problems with too few beds and too many patients.73 Even Sir Robert Francis himself felt the need to reference the government’s lack of candour, describing in the Health Service Journal an ‘increasing disconnect’ between what people on the ground saw going on in the NHS and what was said nationally:

  Let’s make no bones about it, the NHS is facing an existential crisis. The service is running faster and faster to try to keep up and is failing, manifestly failing.

  The danger is that we reach a tipping point; we haven’t reached it yet, but there will come a point where public confidence in the service dissipates.74

  I was not willing to stand by as the government tried once again to silence doctors’ efforts at raising patient-safety concerns. As far as I was concerned, my duty of candour required me not to. So, using my contacts and doctor networks on social media, I gathered testimony from doctors working in Emergency Departments across the country and passed it, with their agreement, to the Guardian newspaper. The tone of some of the comments was desperate. One doctor wrote,

  It’s been like an absolute war zone recently. The government at the moment, not to mention my regulatory bodies, are ignoring the worst hospital conditions in my memory. The London ambulance service is similarly overwhelmed. They couldn’t provide me with a transfer ambulance for an emergency case, an 11-year-old with a sight-threatening infection, in less than 70 minutes. The target is eight minutes. It is a miracle the child didn’t lose an eye.’7

  Another junior stated,

  Our hospital is crumbling and is unsafe on a daily basis. Medical professionals are talking of quitting as they believe someone will soon die on our watch. It is completely out of control … I am so angry that it is being ignored and swept under the carpet. I am angry that we are left to pick up the pieces and apologise for a system we’ve put our hearts and souls into, but now have no control over.75

  The crescendo of concern in the NHS, as well as among MPs of all parties, became impossible for the government to ignore. But, in a surprise move that took me straight back to the beginning of the dispute that had originally turned me into a doctor-activist, Theresa May decided to blame a new group of doctors – not juniors, this time, but general practitioners – for the problems now engulfing NHS Emergency Departments. The reason A&Es were overwhelmed, a Downing Street source briefed the press, was the failure of GP surgeries to offer proper seven-day services, putting pressure on hospitals across the country. Using the same
modus operandi they had previously deployed against juniors, Number 10 invited the public to blame GPs for the NHS’s ills by insinuating that certain GPs did not put patients first: ‘Most GPs do a fantastic job, and have their patients interests firmly at heart,’ said the Downing Street source. ‘However, it is increasingly clear that a large number of surgeries are not providing proper out of hours care – and that patients are suffering as a result because they are then forced to go to A&E to seek care.’76 May ordered all GPs to be open seven days a week, from 8 a.m. to 8 p.m., or lose some of their funding.

  A predictable flurry of negative headlines followed in which irresponsible GPs who, it was claimed, took three-hour lunch breaks or ‘shut up shop’ all afternoon were named and shamed for the A&E crisis whose existence May had denied only days earlier.77 As with the junior doctor dispute, any statistics and evidence that contradicted May’s blame narrative were conveniently ignored, not least the fact that the government’s previous pilot of seven-day GP services had cost a whopping £45 million pounds yet saved the NHS only £3 million in reduced A&E attendances.78 Moreover, according to every health expert and think tank, the key driver of the A&E crisis was not GP failings at the front door but the lack of staff, hospital beds and social care at the back, all precipitated by government cuts. Doctors, academics and MPs from all parties, including Sarah Wollaston, the Conservative MP who sits on the Commons Health Select Committee, united in condemning May’s attempt to divert attention away from the crisis by scapegoating GPs for lack of seven-day care.

  We had come full circle. The potency of the seven-day soundbite for engineering the right kind of headlines had proved once again to be irresistible for Downing Street. No matter that May’s rhetoric was deeply offensive and undermining for GPs already facing intolerable workloads. No matter that it was factually misleading. So long as it took the heat off the government, seven-day spin was back, blaming frontline staff for the shortcomings of a health service set up, by underfunding, to fail. The chorus of outrage from GPs everywhere mirrored the fury of junior doctors a year earlier, when Jeremy Hunt had portrayed us as indirectly causing thousands of avoidable deaths at weekends.

  Nothing, it seemed, had changed. With the same tired blame narratives being reeled out to deflect attention way from the evidence of an NHS is crisis, the future of the health service looked hopeless.

  CHAPTER 15

  HOPE

  Once, I believed my job could require of me no greater act of callousness than that of taking away a patient’s hope. I have observed the faces as other doctors do just that, how they fold and crumple beneath the blow of those words. And I have been that doctor myself, many times. You cannot be cured. You are going to die. He will never wake up. There is nothing more we can do.

  Increasingly, though, I am unsure. It is misplaced hope, I suspect, that is the least kind thing we can give a patient. Yet almost as tenacious as hope itself is the doctor’s desire not to have to strip it away, to be the bearer of despair and hopelessness, even when we know the time for honesty is now.

  Familiar as I am in my working life with both building and destroying the hopes of others, for myself – as perhaps for most of us – hope, like health, was something I largely took for granted. Its absence, however, was crushing. By the summer of 2016, there was so much I had lost faith in. My capacity to continue as the doctor I wished to be, the ability of the NHS to keep safe the patients entrusted to its care, the very survival of a health service so starved of funds and optimism. As my training post came to an end, a sense of hopelessness initially pervaded my newly emptied days.

  On my stepping away from the NHS, life was by no means bad. To begin with, escaping the pressures of the hospital felt like liberation. I started to write. The daily rhythm of the writing and the school run, all my newfound time with Dave and the children, were exotic and unfamiliar. The time out – temporary respite from the burden of doing two doctors’ jobs or living with the fear that someone, inevitably, was going to slip through the net on my watch – was as restorative as any doctor’s prescription. I would stand on the sidelines of a school football match, watching my son and his friends being spattered in mud, feeling as though I could breathe again.

  And then, in the space away from the hospital, something happened that was as uplifting as it was unexpected. I could not, it turned out, leave medicine. I missed my patients too much. Just as I had hung on the tales of medicine my father and grandfather told, I found that, whenever I ran into one of my doctor friends, I lived vicariously through their stories from work, relishing every detail. Sure enough, as the weeks went by, I hankered more and more after the hospital. I began to feel as though what mattered to me most, despite lying dormant and defeated, was still alive and capable of renewal. I remained, at heart, a doctor. I wanted to be back there, amid my friends and colleagues but, most of all, surrounded by patients. Hearing on the grapevine about a job in palliative care, the speciality I had been set on pursuing, I decided to apply.

  Hospices are often understandably feared, seen as sinister citadels of death and dying behind whose doors lurk our most primal taboos. They are, for many, the embodiment of hopelessness. But, to me, the hospice is often filled with more of what matters in life than almost any other part of the hospital. Families who cherish their loved ones, whose shared grief is a testament to their love and longing. Patients who face what we all, at times, pretend not to know is coming, with such dignity and strength it can floor you. Staff who strive their utmost to give those at the end of their time the best possible life they can live. Humanity, compassion, complicated medicine, simple human touch or time – precious time spent listening and bearing witness. Even in an NHS at the end of its tether, the hospice, still, is a space in which you can be every bit as much of a healer you imagined all doctors to be, but which our overstretched, understaffed hospitals and general practices threaten to strip from the heart of the health service. On learning I had been given the job, it seemed so right, so natural, it felt like returning home.

  On my first day back at work as an NHS doctor, the bike ride was a journey back in time. The wind lashed my face but the sky was blue. I freewheeled down the hill into the hospital grounds, as keen and eager as the house officer I had started out as eight years before. No one was more surprised than I was.

  Tucked away on the most peaceful part of the site, the hospice sits within immaculate gardens, devotedly tended by volunteers. Inside, there is a calm rarely encountered in the frenetic activity of an acute hospital Trust in action. Artwork, natural light, discreet nooks and crannies containing semihidden armchairs, a merciful absence of hospital posters ordering people to wash their hands, eat more fruit, take part in the lunchtime Zumba.

  We squeezed into a room slightly too small for purpose, ready to be briefed by the outgoing night team. I took my place among the other doctors, nurses, a child psychiatrist, social workers, occupational therapists, a music therapist, a psychologist and the hospice chaplain. The day’s ward list – each patient, their room number and their reason for admission – read like a litany of medical nightmares. Lung cancer, heart failure, breast cancer, sarcoma, motor neurone disease, glioblastoma, bowel cancer, ovarian cancer, endstage renal failure. But, as we focused in turn upon the needs of each patient, the diseases were scarcely mentioned. What could we do to help Grace feel sufficiently confident to spend a few hours at home with her husband this week? Had the new medications in the syringe driver successfully tackled Bob’s pain? Would it be OK for Jim’s old jazz band to join him and play in the hospice chapel? Was Simon’s daughter less distressed now? Had Anna’s wedding dress arrived and were we all aware the wedding was this Saturday? Life, as much as death, was everywhere and our job was to ensure it was the best life possible, no matter how fleeting.

  One of the most humane aspects of the hospice are the sofas that double up as beds in each room, enabling a loved one, should they wish, to stay night and day beside a patient who is dying. When I started
work, Sarah had already spent forty-eight hours at her husband’s side. They had made a pact, she told me, that, when the time was right, Stuart would like to come here, but only if she were there too. In the confines of their room, dimly lit, curtains half drawn, a collection of cards arranged at the bedside, it seemed that their fifty years of marriage – a lifetime entwined – had more weight and substance than Stuart himself, who by now was so diminished by cancer he seemed more spirit than man.

  ‘It’s as though I’ve already said goodbye,’ Sarah told me. ‘He has one foot here but one foot over there, and, although he knows I’m here, I think in his own mind he has already departed.’

  She stroked her husband’s sunken cheek, knelt down and kissed his brow. In the lightest touch, the greatest intimacy. Even as life ebbed away, love had never seemed stronger. We had managed, through painstaking management of the drugs in his syringe driver, to successfully keep his symptoms at bay. I withdrew, satisfied both husband and wife were as comfortable as possible, humbled by the tenderness I had witnessed.

  Death, of course, can be the farthest thing from peaceful, even in a hospice setting. Theresa, a patient in her forties with ovarian cancer, was tormented by the prospect of no longer being there for her teenage children. Though she worried terribly about the impact of their visiting their mother in a hospice, with her grossly swollen limbs and pain on manoeuvring, the prospect of attempting a visit back home filled her with even greater anxiety. It took coaxing, reassurance and meticulous attention to her symptoms to persuade her that a visit was possible. The whole team – nurses, doctors, occupational therapists – rallied all week to help build her confidence.