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.
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.