‘Hey. Any chance I could come round on my way home from work?’

It was not like Sam, an old friend from medical school, to call me early one morning out of the blue. I had just dropped the children off at school and he had completed a night shift as a surgical registrar in his hospital. For all the feigned nonchalance in his voice, I could tell he needed to talk. An hour or so later, after a long, fraught motorway drive in which he struggled to keep his eyes open, Sam arrived at my house. I took one look at him and started brewing strong coffee.

‘What’s up? Was it a shift from hell?’

It was the tail end of 2016. For months, the papers had been full of NHS horror stories. Maternity, paediatrics and A&E departments folding up and down the country due to lack of doctors. Patients stacked up for hours on trolleys in corridors since there was no space in A&E. Desperately sick babies being transported hundreds of miles to the only intensivecare beds available anywhere in the country, potentially endangering their lives. And then, a week before Christmas, the unprecedented news, leaked to the press, that a letter had been sent to every NHS Trust in England ordering it to suspend virtually all elective surgery for an entire month in an attempt to reduce dangerously high hospital bed occupancy rates. A month’s worth of surgery cancelled at a stroke – the misery for the hundreds of thousands of patients denied their operations did not bear thinking about.

As the surgical registrar on call in his local hospital, Sam was responsible for all the surgical inpatients who became unwell overnight, plus any new patients arriving in A&E needing review by a surgeon. Not to mention the small matter of actually performing the emergency operations when required. Even at the best of times, emergency surgical nights are brutal. But this one was in a league of its own.

‘Do I blow the whistle, Rach? I mean, how bad do things have to be before you can’t stop yourself going to the GMC or the press?’

‘You can’t make any sensible decisions now,’ I counselled. ‘You’re too tired to think straight. You have to get some sleep first.’

‘You know exactly what happens to whistleblowers. You know I’d be destroyed.’

The NHS has a long and grubby history of treating individuals who have tried to blow the whistle on unsafe practice with ruthless brutality, ruining careers and lives.

‘I know. I know what they’d do to you, Sam. But you have to get some rest, please.’

The experience that had so traumatised my friend involved a young child. A&E had been in full-blown, early-hours meltdown. Patients and relatives occupied every available chair. Most had been waiting six hours just to see a doctor, let alone be treated or admitted into hospital. The drunks and the bigots were hurling abuse at the staff. Someone could not be stopped from screeching ‘Away in a Manger’ at a volume that could shatter glass. Many members of the public, seething with rage at the delays, were not holding back at the nurses. Amid all the ugliness and chaos of the Emergency Department, Sam had been asked to see an eight-year-old girl with abdominal pain. When he found her, Ayesha was flushed and whimpering, clutching her mother’s hand. Her pulse was racing, she was hot to touch and the pain in her abdomen was making her cry. She looked, in a word, ‘toxic’ – likely to be suffering a serious infection. Sam’s money was on appendicitis. The very high number of while cells in her blood also seemed to fit with infection.

But something was not quite right. Her abdomen, when Sam had felt it, was completely soft to the touch. Ordinarily, when the abdominal cavity is severely infected, the overlying muscles of the abdominal wall are held completely rigid, clenched in an involuntary spasm. The unusual softness of Ayesha’s belly had held Sam back from taking her to theatre. Nobody wants to be the slash-happy surgeon who unnecessarily cuts open a child. But nor was a CT scan an option to aid the diagnosis since the radiation dose was too high for a young child, unless absolutely necessary. Sam decided to observe Ayesha for a short period, having started intravenous antibiotics, while teeing up the emergency theatre staff for a likely imminent surgery.

All of this was routine stuff for a junior surgeon on call. What happened next was not. A besuited manager suddenly materialised to inform Sam that he was banned from taking the child to theatre since there were no beds into which she could be admitted afterwards. Not only that, he should never have admitted the child for fluids and antibiotics, given the lack of beds.

‘I’m sorry but I don’t think you appreciate the gravity of the situation,’ he explained calmly. ‘If she doesn’t pick up over the next hour with antibiotics, then I’m going to have to take her to theatre because there’s a good chance she will die if I don’t.’

‘No, you don’t understand,’ pressed the bed manager. ‘There are no beds, and I’m telling you that you will not be taking this patient to theatre. If you think they need surgery then it’s up to you to find a hospital somewhere else that will take them.’

‘But if there are no paediatric beds anywhere in the hospital,’ Sam pressed back, ‘then why on earth are you still allowing ambulances to bring sick children to A&E? That’s not safe. Why are you not on divert?’

Hospitals that put out a ‘divert’ – effectively closing their doors to ambulances since they have run out of beds into which to admit patients – face large fines for doing so. Diverts are consequently loathed by the management, costing a Trust that is invariably in financial deficit from the outset even more money that it simply does not possess. In spite of all the other patients requiring his attention, Sam was forced to spend the next two hours frantically phoning every hospital in the vicinity trying to find one that would agree to admit his patient. But to no avail. Nowhere was willing to admit Ayesha because, like his own hospital, they too had no beds.

‘At this point,’ Sam told me, slumped on the sofa with his head in his hands, ‘it was all I could do not to burst into the A&E waiting room and yell to all the parents to get the hell out of the place and go somewhere that might actually be safe.’

Increasingly concerned by the state of his patient, who by now had started to become delirious, he called his sleeping consultant at home.

‘I’m sorry for disturbing you, but I really need your expertise,’ he explained. ‘I don’t know what the right thing is to do.’

Less than half an hour later, Sam’s consultant was present in A&E, assessing Ayesha alongside his registrar. He had never seen a presentation of appendicitis quite like this one, he said, and agreed with Sam that, given how unwell the child now appeared, an exploratory operation was essential. ‘If we leave her much longer and she gets any sicker, she won’t survive the night.’

At this point, the bed manager resurfaced. He repeated – to one of the most senior consultant surgeons in the hospital – that under no circumstances would Ayesha be permitted to go to theatre. ‘There isn’t a bed for her and that means no operation, end of story.’

‘But look,’ said the surgeon. ‘She’s in a bed now. A bed in a side room in A&E. She can come straight back here after theatre, can’t she?’

‘No, she can’t,’ insisted the bed manager. ‘This is an assessment bed, not an admission bed. It’s for assessing paediatric cases in A&E.’

The surgeon paused before answering, working hard, one imagines, to frame a response that did not involve expletives. ‘If there are no paediatric beds in the hospital, then why are we still assessing paediatric patients in A&E? What exactly happens when the conclusion of the assessment is that we need to admit the child?’

The bed manager had no answer. But even a senior doctor’s explicit concerns that the child might die without surgery were not enough to persuade him to relent. Enough was enough.

‘I see,’ said the consultant, curtly. ‘Well. Let me make this crystal clear for you. This child is going to theatre. Now, if you wish to call the chief executive of this hospital, wake him up at home and get him here in his pyjamas to tell me to my face that I am not allowed to save my patient’s life, then – and only then – will I not operate on this child. Otherwise, please get out of my way.’

With that, Sam and his consultant physically wheeled Ayesha themselves down to theatre, where they surgically explored her abdomen. At the scalpel’s first touch, thick yellow liquid burst under pressure from the abdominal cavity. All four quadrants of her belly were swimming with pus from a horrendously inflamed appendix, the worst the consultant had ever seen. ‘It smelled,’ Sam told me, ‘of rotten fish. The anaesthetist had to leave briefly in order to retch.’ Later, the consultant told Sam that, had they not operated when they did, the child almost certainly would have died.

As I listened, aghast, to Sam’s tale, the what-ifs made me hold my head in my hands. What if Sam had not been sufficiently resolute and conscientious to call his boss at 2 a.m.? What if the consultant had been less senior, less confident, more easily cowed by a dogmatic bed manager? What if a little girl had indeed languished in her A&E bed until sepsis overwhelmed her and she died? Perhaps most fundamentally – given that Ayesha had survived only by the skin of her teeth, because two surgeons had stood up to an asinine system in which a man in a suit, not a doctor, dictated whether life-or-death surgeries may occur – what if elsewhere, in other parts of the country, children were slipping through the net? Might other Ayeshas, in short, have already died because hospitals without a single available paediatric bed would rather allow ambulances to keep bringing sick children to their swamped A&Es than be fined for diverting them elsewhere? How would we even know this?

No one could pretend that this is good healthcare. It is not; it is utter madness. Hearing the tale made me want to cry. To a doctor, let alone a mother, the notion that anonymous suits could be stalking hospitals at night, flexing their muscles in this manner with clinicians, was frankly terrifying. It is doctors, not bureaucrats, who know what their patients need, particularly when those patients are in extremis. And if financial pressures are distorting care in this manner – right now, under the radar, in our NHS hospitals – then something has gone horribly wrong with the health service we long to believe is the very best of Britain.

The tragedy for doctors, nurses and managers alike – not to mention the patients we strive so hard to look after – is that we operate within a system that makes fools of us all. When nearly every hospital Trust in the country is running up multi-million-pound debts, as they are, because their income is vastly outstripped by the needs of their patients, Trusts do not stand a chance. Of course, a Trust will fight tooth and nail to avoid the fines that accompany diverts when it is already, financially, on its knees, already facing punitive measures set from on high to address its alleged fiscal irresponsibility. The system – above all the government’s £22 billion of ‘efficiency savings’ that no one in the NHS thinks we can possibly achieve – is set up to pressure Trusts to shave costs wherever possible, let alone incur avoidable ones.

Yet even this misses the most important point – the inescapable, on-the-ground reality – that on this particular night there were no beds. Not in Sam’s hospital, not in any of the local hospitals. There was literally nowhere for Ayesha to go. Even if ambulances had been diverted from Sam’s hospital, how many miles would they have had to drive to find a hospital that could actually admit children safely? What might the potential risks of those long journeys have been for unwell, unstable children? Ultimately, we all know that words – no matter how fine – in the end come up against reality. In the case of the NHS, reality is the actual care that patients receive and that frontline staff both deliver and bear witness to. Reality, on occasion, is nights like Sam’s, when a child nearly dies because there is no capacity in the system to give her the care she needs. And if, as a doctor, my duty of candour – of being honest and open with my patients about mistakes or failings of care – means anything at all, then it behoves me and all of us who work within the NHS to speak out, uncowed, about this reality. How else can we stand up and look our patients in the eye?

‘If you admit you are a doctor in distress, then this will all go away.’

‘This’ was the threat of formal disciplinary action against me, made by a manager in one of my previous hospitals. Candour, I had discovered to my peril, costs. I had had the temerity to break an internal Trust rule I was not aware existed and now I was reaping the consequences. It is difficult to convey how frightening it is, in a profession as rigidly hierarchical as medicine – and as notoriously hostile to perceived troublemakers – to be threatened with disciplinary proceedings. On discovering via email that I might be formally disciplined, I burst into tears on the spot. In medicine, a disciplinary incident dogs you for the rest of your career, its recording a requirement on every subsequent annual appraisal and every future job application. For a junior as junior as I was then, with most of my career still stretching ahead of me, that was a distressing prospect. Which, of course, is precisely why, for a Trust, even a whisper of a threat to take formal action against you is such a powerful means of achieving silence and conformity.

‘What am I going to do?’ I cried to my husband plaintively, temporarily immersed in fear and panic. The answer was provided for me. I received an email summoning me to report to the senior manager to explain my subversive act in person. The prospect of being hauled over the coals by someone fully cognisant of his power to damage my future in medicine was not one that I relished. That night I slept little and fitfully.

Often, doctors who face discipline do so because their desire to protect their patients has forced them into the role of reluctant whistleblower. They know the risks of speaking out, yet the duty they feel to put their patients’ interests first compels them to be candid. Having failed to persuade their hospital management to take seriously their safety concerns, in the end they resort to going above them – perhaps to the doctors’ regulator, the General Medical Council, or to the institution that safeguards NHS standards for patients, the Care Quality Commission. Then, if not beforehand, the full force of their employer descends on them like the wrath of God. Money – supplied courtesy of the taxpayer – is no object as a stellar Trust legal team is lined up against the whistleblower. The NHS is littered with former doctors who, after attempting to raise concerns, have lost their jobs, homes, marriages and health after bitter legal battles with their Trusts. Whistleblowers are meant to have legal protections that enable them to raise concerns about the organisation in which they work in good faith. But, in truth, whistleblowing often destroys doctors, nurses and anyone else who tries to speak out. In standing up for their patients, clinicians can end up sacrificing themselves.

Nowhere was a culture of denial and cover-up more pervasive than in Mid Staffs. When individuals attempted to flag concerns through ‘incident forms’, online reports about issues threatening patient safety, these never appeared to be acted upon. When concerns were reported at Trust board level, these too were invariably ignored. Complaints from patients and their families were swept under the carpet. Sir Robert Francis, in analysing why so few staff members spoke out in Mid Staffs, describes professionals trying their best to raise issues but who, when that failed to have any effect, became disillusioned and in the end gave up. Fear of reprisals also deterred them. Dr Pradip Singh, a consultant at Mid Staffs who tried, if belatedly, to raised concerns about patient safety, was asked why he had not gone further. He explained, in essence, that, though he was brave, he was not brave enough:

Francis identified frontline clinicians’ fear of speaking out as one of the most important factors that permitted the cruelties of Mid Staffs to flourish unchecked for so long. So detrimental did he regard this culture of fear to the overall aim of ensuring patient safety that he went on to investigate more broadly the experiences of NHS staff who attempted to raise concerns. His ‘Freedom to Speak Up’ review found that the barriers deterring individuals from speaking out about their concerns were ongoing and relentless:

My own transgression was by comparison minimal. I was not even a whistleblower. In expressing my concerns to the press about an unfunded seven-day NHS policy several years before the junior doctor dispute began, I had merely committed the sin – albeit a cardinal one, as I would go on discover – of naming the Trust at which I then worked. This, with hindsight, was exceptionally naïve. Unbeknown to me, a draconian Trust media policy required all employees to liaise with the press office before making any reference to the Trust in the media. That my comment referred to a national government policy, neither criticising nor attacking my Trust in any way, was no defence; I was nonetheless in breach of a formal Trust policy.

I sat before the manager with a churning stomach, yet what I hoped was an implacable exterior. I was told again that if I admitted I was a doctor in distress, ‘this’ would all go away. This is a well-documented tactic used by NHS employers against staff who speak out, an attempt to tar them with the stigma of mental instability, neatly delegitimising their concerns from that moment onwards. It needed confronting head on.

‘I can’t do that,’ I stated, ‘because it isn’t true. If you look through my online portfolio, which I’m sure you have done, you will see that my feedback from my colleagues and from patients is superlative. I am not a doctor in distress. I am someone who saw it as her professional duty to speak out against a government policy I believe will be to the detriment of my patients, because it is unfunded.’

It is fair to say this was not well received. Contrition and admission of mental frailty were expected, not unrepentant idealism. An hour later, the meeting concluded with a curt statement that, no, this was not the end of the matter and, yes, I may yet face formal disciplinary proceedings. Eventually, after nearly two months of worry, I was informed that the matter had been closed. The Trust CEO actually took me aside for a quiet coffee during which he apologised for the whole incident. Alongside my feelings of immense relief, I was left with the uncomfortable conclusion that, if this was how an NHS doctor was treated when they had not actually blown the whistle at all, how much more oppressive must the treatment be of someone brave enough to speak out about local Trust practices they believe are putting patients at risk. It is a wonder anyone puts themselves in the firing line in a culture so authoritarian and closed.

Some months after this unpleasant experience, I was chatting with a fellow parent on the sidelines of our sons’ Saturday morning football match. He was a barrister, specialising in medical negligence, and he took a keen interest as I described my head-to-head with my Trust.

‘Something you might not be aware of, Rachel, is that I actually work in Sir Robert Francis’s chambers. I suspect he may well be keen to hear your story.’

I’d had no idea. But the thought of assisting Francis, however trivially, in his efforts to make the NHS safer for patients was an honour. Several weeks later, I received an invitation to attend an evidence-gathering session as part of the ‘Freedom to Speak Up’ review. Francis had previously described junior doctors as the ‘eyes and ears’ of the NHS whose testimony and fearlessness in speaking out had been integral to exposing the horrors of Mid Staffs. He was keen to hear in person from juniors from across the country with experience of whistleblowing. We convened at an informal meeting chaired by Francis himself in a hall in central London. My story was inconsequential compared with what others had endured. Young doctor after doctor described harrowing treatment at the hands of their Trusts, simply for endeavouring to raise genuine concerns about their patients’ safety being jeopardised. Some had been bullied, smeared and denigrated. Frequently, according to the juniors’ testimony, the mental-health card was played by Trusts who attempted to paint the whistleblowers as unreliable or incompetent due to emotional instability.

I remember looking around the room feeling pride and anger in equal measure. Junior doctors reside near the bottom of the NHS food chain. They have nothing like a consultant’s clout. That these juniors were standing up for their patients, sometimes enduring ferocious workplace bullying as a result, was something I found deeply humbling. That Sir Robert Francis had proactively sought out their testimony gave me hope in a more transparent and open future for NHS clinicians and patients alike.

Ironically, the Trust that took issue with my accidental insubordination behaved impeccably towards one junior doctor whistleblower. Conditions in the hospital’s Surgical Emergency Unit (SEU), where I had once experienced such understaffing, did not improve after I left. So overstretched had the juniors become that one of them took matters into his own hands. Barely a year into his career as a doctor, he wrote a letter to the most senior member of the Trust, its chief executive officer, detailing the dangers to patients of the unit’s understaffing. Every SEU house officer had signed it, a collective cri de coeur from the most junior doctors manning the front line. Their concerns had been roundly dismissed by their consultants and immediate managers and so, en masse, they had decided to go straight to the top. And – to his enormous credit – the CEO not only listened, he insisted that the understaffing must be dealt with. Thus, thanks to one gusty house officer, a whole department was changed for the better. It was a model of exactly how a Trust could do it right.

Nor did it not stop there. For a few years, several other doctors and I had run an annual teaching session for final-year students who were about to embark on their lives as new doctors. In it, we invited current house officers to share with the students their real-life stories of how things had gone wrong when they began to practise medicine. The aims were simple but important. To show that mistakes happen to everyone, that they are nothing to feel ashamed of, that every mistake is an opportunity to learn and to make the wards safer for patients, that doctors are as fallible as anyone – and that this is OK, this is human. Sometimes, the stories were harrowing. One or two doctors cried in describing what had happened. The Trust, keen to embrace a culture of transparency and candour, invited us to extend the sessions to an audience of junior doctors as well. It felt progressive – a small step towards a less adversarial future in which learning from mistakes, not apportioning blame, took priority for our patients’ sakes.

Candour is no longer an optional extra for doctors, and rightly so. For too long, patients and their relatives have been kept in the dark about individual and systemic failings that have led to loved ones’ harm. As a direct result of the brutality of Mid Staffs, in 2015 the General Medical Council and Nursing and Midwifery Council introduced a new professional duty of candour upon all individual doctors and nurses working in the UK. A clear attempt to circumvent the cover-ups of old, it required us to be honest with patients and apologise when mistakes were made, something that can only be for the good of our patients.

There remains, however, a tension between the new duty of candour and enduring conditions that discourage speaking out. Bullying and a blame culture are still rife within the NHS, but there is also something more insidious driving individual doctors and nurses away from frank disclosure, namely, the example we are set by our ultimate bosses, the politicians to whom we are in some ways accountable. The government purports to champion candour within the NHS. In the foreword to the government’s formal response to the ‘Freedom to Speak Up’ report, Jeremy Hunt declared:

These are fine words. They inspire hope and optimism. But are they sincere? The report itself went on:

In an organisation as large and as complex as the NHS – operating under pressure, under intense scrutiny and in which life or death decisions are made every day – no matter how strong the professional instinct to do the right thing, no matter how powerful the impulse to care, there are inevitably times when it might feel easier to conceal mistakes, to deny that things have gone wrong and to slide into postures of institutional defensiveness.62

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.