Four days before the 1997 general election that swept Tony Blair to a historic victory, the then Prime Minister, John Major, was trapped in a chauffeur-driven car in central London gridlock. At 1 p.m. precisely, he was meant to be interviewed on live national television. It was 12.50 p.m. and, under unseasonably warm April skies, temperatures in the TV studio were rising.
‘I don’t give a fuck how bad the traffic is. Get the fucking Prime Minister here now or we’re not going to have a fucking programme, do you fucking understand?’
The question was directed at me, the most junior researcher on ITV’s Jonathan Dimbleby programme. I stared aghast at my editor, feeling solely responsible for the capital’s congested streets, wishing I could somehow pluck the Prime Minister from his immobilised vehicle and magic him into the studio. I was twenty-three, underconfident, convinced that everything was probably my fault, London traffic included.
The editor stared me down with contempt. ‘Go and wait for him outside. And for fuck’s sake get him here the second he arrives, do you fucking understand?’
At 12.58 p.m., a shiny black car hastily pulled up outside the entrance to the studios. I hustled John Major inside. As we weaved through the corridors to the back of the live studio, he asked me a pertinent question:
‘Do you have a water closet?’
I suppose he’d been stuck in a traffic jam for God knows how long. His bladder was probably bursting. But, at the time, overwhelmed with stress and anxiety, I simply couldn’t compute what this quaint phrase meant. Water closet? I had absolutely no idea what the Prime Minister was asking me. All I knew was that, if I didn’t get him into the studio by 1 p.m., my short-lived career in television was over.
‘W-water closet? I’m sorry, Prime Minister, I – I’m afraid we don’t have one.’
With a thunderous look and a half-suppressed expletive, he allowed me nonetheless to lead him straight onto the set to begin his hour-long live interview. Seconds before one o’clock, the first few bars of our theme tune began. As I exhaled in relief, it suddenly dawned on me that all he’d wanted was an emergency stop at a WC, a urinal. Words. The power of an ill-chosen phrase. I wondered whether his straining bladder would put him off his interview.
On 16 July 2015, the Health Secretary went to war. For a former PR man turned politician, Jeremy Hunt’s weapon of choice would always be words – deployed, on this occasion, with explosive aplomb. Whereas John Major came unstuck with a casual anachronism, the speech Hunt gave at a health think tank, the King’s Fund, that morning appeared precisely calculated to infuriate doctors by casting aspersions on their sense of vocation.
Patients were dying unnecessarily in our hospitals, Hunt claimed, because consultants refused to work weekends, causing an excess of deaths at the weekend. There were six thousand avoidable fatalities a year, to be precise – death on a massive scale.2 Later, he would adjust this figure upwards to eleven thousand weekend deaths a year, but even the more conservative estimate sounded wholly indefensible. ‘When you turn medicine into a Monday-to-Friday profession,’ he told BBC Radio 4’s Today programme that morning, ‘you end up with catastrophic consequences.’3 Seven-day working, he insisted, should be ‘part of the vocation of medicine – which is about being there for your patients’. The implication was clear. Doctors lacked the professionalism and dedication to their patients to give up their Saturdays and Sundays.
The speech had a midnight embargo, ensuring Hunt dominated most of the next day’s front pages. I first learned of his attack at 4 o’clock that morning – the hazard of having a four-year old in the house with bladder issues of her own. Once I’d tucked up my daughter in her bed, I committed the nocturnal sin of glancing at the news on my smartphone. An error. Though Hunt had targeted on this occasion not junior doctors but our consultant colleagues, within moments I was incandescent.
The health secretary’s speech implied that you were 15 per cent more likely to die at the weekend – the so-called ‘weekend effect’ – because consultants were exploiting a contractual loophole that enabled them to ‘opt out’ of weekend working in NHS hospitals. Instead, they would offer themselves back to their hospitals as locum doctors, private contractors whose extortionate weekend rates – up to £200 an hour – were crippling NHS finances. Hunt contrasted these avaricious consultants with their altruistic betters, the ones who every weekend would, ‘go into the hospital to see their patients, driven by professionalism and goodwill, but in many cases with no thanks or recognition’.
Still groggy, initially I was unable to decipher these allegations. For six years as a junior doctor, I’d worked weekends in multiple specialities, across multiple hospitals, typically one a month. Accident and Emergency, General Surgery, Cardiology, Acute General Medicine, Gastroenterology – you name it, I’d done it. But one thing united my one in four weekends. During every one, a consultant had been there by my side to lead a morning ward round on both Saturday and Sunday. For the rest of the day, they were never more than a phone call away. And, when working nights, if required, I could call my consultant at any hour. Should their expertise be needed, they would come straight back to the hospital. Indeed, from what I’d observed, most consultants’ weekends on call began on Friday evening and stretched a full sixty hours, without a break, all the way to Monday morning.
So on this, day one of the NHS strike year, just what was Hunt’s game? The picture he painted of senior medics as opt-out dilettantes was so wildly at odds with my own experience, I stared nonplussed at the screen. Then it clicked. This was the classic politician’s tack of conflating the actual with the hypothetical to construct a superficially watertight case. Consultants did indeed have a weekend opt-out in their contract – but for elective, not emergency care. They could choose to opt out of only non-essential work such as planned operations or extra weekend outpatient clinics. Their weekends ‘on call’ – those spent looking after their existing inpatients and any new admissions – were, in almost all cases, obligatory. Hunt had glossed over this crucial difference to convey a lurid depiction of mass avoidable death for which consultants were to blame. Yet the ones I’d worked with at weekends had been there not as locums, but as NHS employees, already providing seven-day care.
Having stoked our fears with his erroneous depiction of consultant weekend slackers, Hunt simultaneously set out to reassure us. As a result of contractual changes he would impose upon doctors – through brute force if necessary – he would cure the problem he’d just fabricated: ‘by the end of the Parliament, I expect the majority of hospital doctors to be on seven-day contracts’. He issued the doctors’ trade union, the BMA, with a six-week ultimatum: if it could not negotiate a new consultant contract with Hunt in that time, its members would face an imposed one.
It was a beautiful instance of political doctoring. Take some truth, sprinkle in some non-truths, insinuate, cast aspersions and manipulate the data to ensure your argument, however tenuously rooted in fact, guarantees the superficial headlines you seek.
For the rest of the night, I seethed in silent fury. The notion that any of us, junior or senior, exploited weekend opt-outs for financial gain was so deeply offensive it rendered sleep impossible. Doctors can be many things – pompous, opinionated, arrogant, self-righteous – but I’ve yet to meet a single one who joined the NHS because they planned to get rich quick. If it was megabucks that drove us, we’d have chosen the City, not medicine. Way more cash, way less bodily fluid – or so one would hope.
My rage was ignited only in part by the insinuations against my senior colleagues. Almost more infuriating was the brazen spinning – the cynical distortion of the facts to try to turn public opinion against doctors and their union. Could there be a more effective way to win an industrial dispute than to bathe it in avoidable bloodshed? In Hunt’s narrative, the price of the BMA’s refusal to capitulate was nothing less than six thousand lives a year. How could consultants live with the sheer quantity of blood on their hands? How could the public not turn against them? It was disingenuous, deceptive and utterly brilliant – a public-relations masterstroke.
The morning Hunt’s speech went public, I arrived at my hospital’s doctors’ mess, groggy with sleeplessness and still fuming. Even at the best of times, doctors’ messes invariably live up to their name. At any time their grotty sofas may be strewn with takeaway detritus, abandoned scrubs, grubby hospital blankets, long-lost stethoscopes, perhaps a random rotting trainer. I have encountered doctors’ messes where cockroaches infest the floorboards, sidling out to keep you company on night shifts. Occasionally in the early hours I have seen a rat peep down from the vents in the ceiling. Glamorous the doctors’ mess is not. But, on the morning of 16 July, the filthiness was primarily verbal. Five or six acute medical teams were hunched over their lists of inpatients, ostensibly discussing the day’s issues and concerns before commencing their morning ward rounds. Except on this occasion the talk was all Jeremy. And, when I say ‘talk’, I mean four-letter, no-holds-barred obscenities. This was platinum-level vitriol, Old Testament-style ferocity, from consultants and juniors alike.
What struck me, as we lambasted the Health Secretary, was the unusual sense of unity between seniors and juniors, indivisible under fire. Hunt may have anticipated – even relished – the anger his speech would unleash, but the solidarity would later prove to have caught him unawares. Typically, doctors are notoriously tribal. Medics snipe at surgeons, seniors at juniors, and every medical speciality secretly believes that its is superior to the others. Today, though, we were all just doctors. An angry, aggrieved, cohesive whole. Something in me had shifted, a boundary had been breached, and I sensed I wasn’t alone.
Some two years earlier, at four o’clock one Sunday morning, a weekend night shift got the better of me.
Amid the standard torrent of bleeps from the nurses summoning me from one patient’s bedside to another, I’d answered a call from the cancer ward. Unusually, a patient had arrived by ambulance in the middle of the night, requiring admission for end-of-life care. Such admissions tend to be planned in advance, ensuring dying patients are not subjected to gruelling journeys during antisocial hours. No one was quite sure why this patient had turned up when she did.
‘Of course,’ I chirped brightly, ‘I’ll come right away,’ while inwardly cursing the miserable luck of having to admit a patient for palliation during the early hours of the morning. It’s not that I have no heart whatsoever, but that nocturnal firefighting for fourteen or fifteen hours straight leaves time and energy only for emergencies. When one doctor is on call for several hundred patients scattered up and down the hospital, reaching those with strokes, bleeds, heart attacks and life-threatening sepsis before they come to further harm requires ruthless, robotic efficiency. Tender loving care is all but ripped out of hospitals at night by the shoestring staffing. Now, in the midst of the usual mêlée, a patient had arrived who was actively dying. They’d need hospice-style care – limitless compassion, patience and time – that was simply not in my power to give, enslaved as I was to my incessant pager.
Before entering the patient’s room, I asked the nurses to hold my bleep. ‘Please only interrupt me for crash calls and emergencies,’ I asked, anticipating finding someone in uncontrolled pain, potentially facing the end of her life with neither dignity nor solace.
Instead, the room was perfectly silent. Various family members obscured the patient, crouched like supplicants around the bedside, shoulders heaving with inaudible sobs. A mother, father, sister, brother and, as they drew back, the patient herself, a young woman in her early twenties. I felt more an intruder than a healer, invading collective grief as thick as blood. The family turned to me as one, eyes bright with tears and the expectation that I could give them something, anything. In one glance, I knew I could not. My patient had end-stage cervical cancer. Too young to be approaching death, she looked gaunt, defeated, as exhausted by the effort of remaining alive as it is possible to be while still living. Her eyes met mine. Not once before had I seen anyone so tired, so tenuously connected to life. Bleached and waxen, she was as insubstantial as air. I knew she knew as clearly as I did that she was dying. Words were superfluous; her look said it all.
Anticipating the effort it would take her to speak, I too crouched down low by her bedside, gently taking her hand.
‘My name is Rachel,’ I said. ‘I’m your doctor and I’m here to help you. It’s Sarah, isn’t it? Please tell me, if you can, how you are. And how I can help you.’
Slowly, as if summoning all remaining strength, she shook her head imperceptibly. Then, a barely audible whisper. ‘You can’t.’
I felt redundant, incapable, too inept to make things better.
‘Are you in any pain?’ I asked quietly. Another faint shake of her head. ‘Is there anything making you uncomfortable?’ Another. ‘Is there anything you need me to do?’ Another.
She allowed me to conduct the briefest, most cursory version of an examination I felt I could safely manage. Cancer had stripped her to skin and bone and I knew any movement of her uncushioned frame might cause her unnecessary pain. Her breathing was shallow and rattled. Her heart murmured in between beats as it worked above the odds to keep her blood in motion. Her belly, though grossly swollen with fluid from the cancer, was not unbearably tense. Her skin was intact, her peripheries warm. I found nothing requiring immediate intervention.
As patients approach the end of life, the same symptoms tend to prevail. Pain, of course, often predominates but, in a great many cases, modern medicine has found ever more ingenious ways to control even the most intractable of pains. Breathlessness, too, is common, as lungs fill with fluid, tumour or infection. Managing agitation, anxiety and fear is the third great challenge in palliative care, since the so-called ‘anxiolytics’ – anxiety-lulling drugs – can also, in high doses, leave patients too drowsy to be fully aware of their surroundings.
My patient appeared neither anxious nor in pain. Still, I needed to make sure. I asked her directly, ‘Sarah, are you frightened?’ Another minuscule shake of the head. I wondered whether overwhelming fatigue had obliterated any feelings of fear. Perhaps she had come to see death as a release from the ordeal – the sheer slog – of still living. Though her death was clearly imminent, for now she appeared free from distressing symptoms. I asked her if she was willing for me to talk to her family and, with her murmured assent, we adjourned to a typically tiny NHS relatives’ room.
My patient, at age twenty-four, had lived with her cancer for over a year. Radical, disfiguring surgery had failed to eradicate the tumour, which, it later transpired, had already infiltrated distant parts of her body. Though chemotherapy had given her extra time, it had offered no prospect of cure. Her mother, impassive, led the discussion, while her two siblings cried with heads bowed, and her father faced the wall, looking away from me. A third sibling was abroad in South America, and Sarah’s mother said he would drop everything to come home immediately if there was any danger of Sarah dying.
Doctors try to avoid rash prognostication. If we cannot judge accurately someone’s life expectancy – and all too often we can’t – we are loath to offer what may prove to be misleading speculation. Junior doctors in particular, lacking the years of experience that hone our older colleagues’ instincts for a patient’s survival, are acutely conscious of our limitations. I was very junior, only four years into my training. But it was two or three in the morning, and Sarah’s mother had asked a simple but important question. Should her son catch the first flight home?
I didn’t have to give an honest answer. I could have fudged it, exploited my inexperience to defer a difficult conversation until my more erudite colleagues arrived in the morning. But that felt like the coward’s option. Incapable though I was of giving any consolation, at least I could give them the truth. So, after important caveats about the challenges of making accurate prognoses, I said that, yes, Sarah’s brother should catch the first plane he could, because his sister was very, very unwell. It was possible she could die very soon. Indeed, I would not be surprised if she failed to survive the next few days.
Time hung still for a moment, then the room reverberated with grief. Shrieking, sobbing, a family howled its despair. Sarah’s father punched the wall over and over, moaning and shaking his head. I sat stricken with horror at the emotion I’d unleashed. He turned to face me, almost snarling with anger.
‘You will not dope her up. You won’t take her away from us. I will not allow you to drug her. I swear to God, I will kill you if you drug her.’
The rest of the family turned on him.
‘Dad,’ shouted the sister, ‘the doctor’s not going to drug her up. She just wants to make sure she’s comfortable.’
The father responded by pounding fist against brick more aggressively. His wife screamed at him to stop. As accusations flew back and forth between family members, I felt like a crumb in a maelstrom. I knew it was cancer, not me, that had ripped their world to bits, but that didn’t stop me feeling responsible. Trying to give them time to assimilate the prognosis, I retreated outside to write in the patient’s notes. Perhaps I was trying to hide.
On returning, I found rage had subsided into slumped resignation. Still Sarah’s father wouldn’t look me in the eye, but now he wept quiet tears with the rest of the family. I talked about the delicate balance between minimising distressing symptoms and ensuring a patient remained as alert as possible. How my overriding priority was Sarah’s comfort. That I would strive, I promised, to ensure the end of her life was the best it could be. We discussed the manner in which the next hours and days might unfold. Finally, words ran dry.
On the brink of departing, I found my hand hovering uncertainly above the door handle. I had decimated this exceptionally devoted family and I wanted, I think, to atone for this.
‘I – I hope you don’t mind,’ I said to Sarah’s mother. ‘I’d like to say something to you before I leave.’
She stood up and we confronted each other. As I spoke, slightly nervously, light-headed with the risk of it, her eyes never left mine.
‘When I first arrived in Sarah’s room tonight, I saw two things. First, I saw a patient who was as ill as it is possible for someone to be. You know I didn’t need to be a doctor to see how unwell your daughter was. But I saw something else as well. I saw someone who was surrounded by love. You were all there, and you were giving her what she needed more than anything. You were surrounding her with love. I’ve seen many people die alone. But Sarah is not. She knows she is loved. Because of you.’
It could have been mawkish, crassly inappropriate. But it was, undeniably, true. I have held the hands of too many elderly, forgotten patients, sole witness to their final exhalation in the absence of family and friends. That an entire lifetime can be reduced to this – an end so inconsequential that not one person mourns or even notices – never fails to appal me. Sarah’s mother, to my surprise, stepped forwards and embraced me, tears streaming as she thanked me.
I was spent. I left before I too started crying.
At the nurses’ station, the list of new jobs I’d accrued since depositing my bleep covered most of an A4 sheet of paper. My heart sank. I’d be playing catch-up all night. As if on cue, my crash bleep crackled into life. ‘Adult cardiac arrest team. Adult cardiac arrest team. Ward 6A. Crash call, ward 6A.’ The Nights God had decided to play dirty. ‘Aw, I was going to make you a cup of tea after that,’ said the night sister kindly as I ran, cursing inwardly, down the corridor.
Around this time, the Medical Director of NHS England, a heart surgeon called Professor Sir Bruce Keogh, was starting to make waves in the media with his talk of an important new mission, a ‘seven-day’ NHS. Only that weekend, the papers were full of his quotes, each glaringly omitting to mention how anyone would actually pay for his visionary new seven-day service.
Several hours, the crash call and a small mountain of jobs after my encounter with Sarah, I paused for a few minutes to slurp caffeine in Diet Coke form, my drug of choice on night shifts. I glanced at one of the headlines about Keogh and something in me snapped. Only an NHS apparatchik singularly disconnected from the overstretched NHS front line could possibly push for seven-day services in the absence of seven-day funding. In five minutes, through a haze of rage, I found I’d hammered out a draft of a letter to a national newspaper. Over the coming weeks and months, I weighed carefully whether or not to submit the letter for publication. On balance, I decided that highlighting my concerns about the potential costs to patients of an unfunded expansion of services was not only defensible but necessary, since my first duty as a doctor was always to act in the best interests of my patients. The letter read:
Dear Sir,
It is 4 a.m. and I am a junior doctor writing from a weekend night shift at a respected teaching hospital. I have run arrest calls, treated life-threatening bleeding and sepsis, held the hand of a young woman dying of cancer, tried to comfort her family, scuttled down miles of dim corridors occasionally wanting to sob with exhaustion, forgotten to eat, forgotten to drink, drawn on every fibre of strength I possess to keep dispensing compassion, kindness and, above all, good medicine to my patients this never-ending night.
And right now, huddled over a Diet Coke and a laptop, I am struck by the utter absurdity of the fantasy politics played by Professor Sir Bruce Keogh, government and opposition alike that a seven-day NHS is possible without an appropriate increase in funding.
Do they really not know how desperately thinly we are stretched? I don’t think so. The maths is simple. Pretending that the NHS can provide a seven-day weekday service without funding it isn’t just disingenuous, it is downright dangerous for patients.
Yours sincerely,
Dr Rachel Clarke
I wouldn’t know it for many months, but this letter, when published – to the considerable ire of the hospital I worked in – framed the essence of many junior doctors’ opposition to Jeremy Hunt’s seven-day crusade. It certainly wasn’t hostility to better weekend services per se. Although the evidence on the ‘weekend effect’ was debatable – some studies demonstrating an increase in deaths at the weekend, others showing no increase in weekend mortality – the fact remained for me that I would dearly love weekends to be better resourced in my hospital. Junior doctors know better than anyone that, while some parts of the hospital, such as Accident and Emergency, are equally staffed every day of the week, most hospital inpatients are looked after by a skeleton crew of doctors whose main objective is to attempt to keep their patients safe until Monday morning, when full routine services resume. Patients can sit in a two-day limbo, denied non-urgent scans and other investigations through lack of weekend capacity.
But where we differed from the politicians was in the knowledge that beefed-up weekend services could not be manufactured from spin alone. They needed resourcing, they needed staffing. From the front line, it was perfectly clear that the primary barrier to better weekends was not contractual change in our terms of employment but the finite number of NHS doctors, nurses and other allied health professionals. Without additional medics, there were only two ways to roster more of us at weekends: either take us away from our patients Monday to Friday, or force us to work longer overall hours. I failed to see how either option could possibly have patient safety at its core.
At ten o’clock that morning, punch-drunk with fatigue, I finally set off home. Driving post-nights can be fraught. Several junior doctors in the UK have died in recent years after falling asleep at the wheel. Indeed, the journey home after my first ever Easter weekend on call was very nearly the death of me. In the split second during which my eyelids drooped, I crashed my car headlong into a stationary vehicle, somehow emerging unscathed from the wreckage. On the morning after meeting Sarah, however, I pulled over for a different reason. Not because my eyes were closing but because, without warning, I’d found myself blinded by tears. I hadn’t cried all night but now, in a dual carriageway lay-by, still dressed in trainers and my stinking scrubs, I thought I’d never stop.
She was more than a decade younger than I was, with a cancer that had consumed her before her parents’ eyes. Attempting to help them that night, while keeping all my other patients safe, had required enormous stamina, yet failing to do so had not been an option: it would have felt inhuman. And this was nothing special. This was routine, everyday stuff. This – in one night – was the NHS front line. Threadbare, scrappy, perilously understaffed, decent, bloody-minded, barely held together by the indefatigable legions of nurses, doctors and allied health professionals not asking for thanks or expecting recognition, but simply getting on with it, heads down. A thousand such scenarios played out across our hospitals day in, day out, up and down the country.
Against this backdrop, on 16 July 2015, Jeremy Hunt chose to take an axe to doctors’ efforts at caring. He portrayed us, quite deliberately, as lazy and grasping. It was as calculated as it was aggressive.
Smarting, astonished, furious, the front line was about to fight back.