MARY WAS 78. SHE lived with her only daughter not far from the rugby stadium in town, very close to the port. Together they managed a small hotel frequented by visiting teams and their families as well as ordinary tourists to this small Pacific island. There were eight rooms upstairs all with verandahs and terrific views looking out to the northwest over the bay. The ones at the front looked directly onto the port where the newly arrived yachts came in to moor or seek shelter, then across to the wharf that was often obscured by mammoth cruise liners that came and went either side of the cyclone season.
Mary had been a fit woman. She worked hard and apart from smoking briefly when she was in her twenties, she had led a healthy life. Her daily routine seemed to have been a mix of work and pleasure—cleaning in the morning, socialising with her friends in the afternoon, and doing bookwork in the evening. She had only one child, unusual in these parts, due to the premature death of her husband in an accident at sea when her daughter was three.
Ten years before I met her, Mary had travelled to New Zealand to have her gallbladder removed following several bouts of cholecystitis. In the subsequent years she had slowed up quite a bit, becoming overweight and, with that, increasingly sedentary and more tired. Work that she had managed to do without much effort in the past became more burdensome and, in the end, she spent more and more time at the front desk and less time on her feet moving about. Mary had lived a good life but her world had shrunk to the point that she was now quite limited in what she could do.
We met in the medical ward of the small hospital. I had been asked to see her by a young doctor worried about how she was doing. Mary had been admitted the previous evening with a fever and a five-day history of right-sided upper abdominal pain, profuse diarrhoea, dehydration and acute renal failure.
When I saw her that morning, her daughter Kara was with her. Together, we reviewed the events of the past few days, including their visit to a local GP to seek help and an explanation for the pain. He had thought Mary was constipated and prescribed her laxatives. Thinking they would help, Mary had taken them by the handful, ending up with days of diarrhoea and profound dehydration prior to her hospital admission.
When I examined her in more detail, she was confused, feverish and sore. The pain and tenderness was mostly on her right side, at the top of her abdomen where the liver lives. Although she was breathing well, Mary was still under-resuscitated. Her tongue was dry, she was thirsty, and she wasn’t making much urine. Her heart was racing, her blood pressure was low, and her hands and feet were cold.
The blood tests that had been done the previous evening suggested she might have an infection affecting her liver and bile ducts because she had a raised white blood cell count and a nonspecific derangement of her liver enzymes with a mildly elevated bilirubin. As a result of all of those things Mary’s creatinine was elevated, signalling that her kidneys were failing.
Despite the efforts of the medical team overnight, Mary was still incredibly sick, most likely from infection compounded by the effects of dehydration and shock. Without more aggressive treatment she would surely die but just how aggressive that treatment should be was the question we needed to discuss because, at her age and stage, I didn’t think she would survive a round of full-bore intensive care.
Of course, there was a time when no such discussion would take place, no explanation would be given, and decisions would be made by a medical team who knew what was best—‘don’t you worry your pretty little head about it, dear’. These decisions weren’t necessarily wrong, but they seldom took into account the thoughts, concerns and desires of the patients and their families. Nor did the people making them see the benefits of taking families with them as these important questions were decided.
Thankfully, the tide has turned on that kind of thinking and in the twenty-first century, clinicians are expected to share their thoughts with patients and their families and doctors are expected to spend time with them, to judge together what the best course of action might be for any one patient. This approach is liberating for all parties because, unlike the certainty of death and taxes, medicine has few blacks and whites, just endless shades of grey, multiple possibilities and some probabilities following any course of action.
Diagnosis and treatment are as much an art as they are a science, and the final result may not in fact be final because of ongoing changes in how patients respond to their treatment over time. This is the context in which we operate—this is the art of medicine where we know what we know and we apply what we know, see what we get and make adjustments as necessary to get the best for each and every patient. There is an honesty in this approach that does not need to be confusing or unintelligible; it just needs to be recognised and talked about.
This more open and collaborative approach between patients and their doctors is a world away from the arrogance of certainty that was such a big part of medical practice when I first started. Now that I am in the mid-afternoon of my career, it seems that medicine might become what I always wanted it to be: a true partnership between those intimately involved.
These thoughts and many more were swirling in my head when I finished my examination and prepared to speak with Kara. For my part, the easiest thing of all would have been for me to go all out for Mary’s survival by pulling the trigger on every technology and intervention to treat the underlying condition and fix those bad numbers reported back from the lab. Those interventions would likely include the full-court press you have become familiar with: putting Mary off to sleep, taking over her breathing, inserting a big central line into the jugular vein in her neck or a femoral vein in her groin to give powerful drugs that support her blood pressure, putting her onto a dialysis machine just in case her kidneys didn’t recover, and marinating her in antibiotics. Once most of that was done, she would need a series of investigations to determine the exact cause of her problem. A CT scan of her belly at the very least, using intravenous contrast material to outline the various structures to help interpret the pictures, then a plan to intervene as necessary by way of a drainage procedure or even an operation if that was thought to be necessary. In Mary’s case, all of that would have been the medical equivalent of the invasion of Iraq—and we all know how well that went. Yes, that was the easy option too: total control but with Rumsfeld-like consequences.
A full-blown course of intensive care is gruelling beyond description. Young people who do well in the short term can take months to recover their physical and emotional strength after a critical illness that requires ventilation and organ support. If we did that to Mary, at worst we would surely kill her or at best she would never get back to anywhere near where she was before she fell ill.
When dealing with frail patients, the elderly, and those with advanced chronic disease, often less is more. In my view, even doing the CT scan carried an unacceptable risk because the intravenous contrast necessary to delineate the images clearly would worsen her renal function and likely push Mary’s kidneys beyond the point of recovery. Even if we found the source of her infection—a stricture in her bile duct as a result of her previous gallbladder surgery or an infected collection of fluid in her abdomen—I wasn’t sure Mary would survive the interventions necessary to fix them. My sense was to do simple things well and see if she improved. That formed the basis of my discussion with Kara and Mary.
We sat and spoke together for an hour. I explained what I thought was going on and the risks of the different options but it was Kara who did most of the talking while I listened. She told me much more about her mother’s life, the ups and downs of hotel life, her love for Kara’s three children, her time studying at university in New Zealand. Finally, she spoke in more detail about how Mary spent her days and what she now valued about her life. In a roundabout way, this was how Kara dealt with the information that I was giving her to help decide what she thought Mary would want. In the end we agreed: no heroics, no escalation of care to ventilation if her breathing deteriorated, no dialysis if her kidneys stopped functioning completely, and no CPR if she had a cardiac arrest.
Instead we would tread carefully along the thin line between treatment and torture, keeping Mary’s comfort as our number one goal, while doing the simple things well in the hope that she would get better.
Soon after, we moved Mary up to the small ICU on the first floor so we could monitor her progress more closely and do the things we planned. We attached her to some basic monitoring and continued to resuscitate her with fluids. We started a couple of intravenous medications to improve her cardiac function and blood pressure, all of which were given through an existing IV line in her forearm—no big neck lines for her. We broadened her antibiotic cover, then we waited and we watched.
There are millions of patients like Mary living happy, high-quality lives within ever-decreasing circles as their worlds shrink around them as they age and become more infirm. Managing their illnesses to maintain that quality of life is one of the greatest challenges facing modern medicine. It is also one of the most rewarding. Although some of the means to do that better will come from new knowledge and emerging technologies, medicine’s greatest achievement will be successfully customising these treatments to the changing needs of those individual patients. This is the pointy end of the art of medicine, a nirvana of medical practice where the right approach for one patient might transform their ability to live their lives as they want to. This is a serious challenge to current medical practice because it requires much more than technical skills and knowledge. What’s needed is a genuine interest in the lives of each of our patients, and the patience and wisdom to shape that knowledge to get the results that matter most to them. Currently this is the purview of geriatric medicine and palliative care but this approach clearly needs to extend down across the practice of medicine more generally.
Over the next few hours, Mary improved a little. As I went back and forth across the room from one patient to the next, I’d stop and do a quick end-of-the-bed-o-gram, taking in the things that I needed to see. Her pulse rate was steadily coming down, her blood pressure happily moving in the other direction, and she had a better colour. Her urine bag had started to fill, and when I touched her feet, they seemed to be warmer. All of these were signs of an improved circulation in response to the fluids, drugs and antibiotics. Kara could see that too and we joked that even Mary’s spiky grey hair seemed to have a bit more body.
She continued to make slow but steady progress. By the second evening, she was talking sense and starting to drink a little. Her white-cell count, a marker of infection, had dropped back towards normal. Her renal function continued to drift off but at a slower rate than before. Some things just take time to get better and, sure enough, the following morning her blood creatinine level, a marker of renal function, had plateaued and then began to fall. She was heading in the right direction and my job became clearer—to slowly back off and let her sort herself out.
I can’t tell you how pleased I was. Kara and Mary had shared so much about their lives, and it looked like they would get most of that back. I was thrilled that we got it right—we made the right call when it could so easily have been a very different story.
Although Mary was very limited in what she could physically do, she was at that stage in her life when she spent more time looking back than looking forward. She was enjoying making sense of all that had happened and what she had done. In almost every way, she was no different from you or me: to our family and friends, we are simply irreplaceable. To be able to help her stay a little longer and continue to do that without her suffering, with less rather than more, gave me an immense sense of satisfaction.
It’s not unusual for people I have completely forgotten to approach me and thank me for saving someone’s life, often many years ago. Exactly that happened in an airport queue recently. Although flattered, I am always a little embarrassed when this happens. Interestingly, I often get the same thanks for looking after people who die. In each case, I like to feel that the system has done its best for each of those patients and their families and, although some are left grieving, we have dealt with each of them with compassion and clarity.
For those patients who survive and do well, we play a pivotal role in making interventions that might lead to an improvement, and in time that improvement might lead to a recovery. While we might have a box of fancy tricks and a room full of technology, the things that we do just make other things possible. Ultimately whether patients survive and recover is determined far more by them and their pre-existing state of health and well-being.
Acute care doctors like me mostly work in hospitals. We are a mixed bag of people from different specialty groups—surgeons, anaesthetists, physicians, emergency doctors, obstetricians, paediatricians, and intensivists like me. All of us work in teams to provide a 24/7 service to the public. We work on call rosters—days, nights, Christmas holidays, Yom Kippur and Rosh Hashanah, and sometimes even on our own birthday. Experiences like meeting Mary and Kara, and being able to make such a difference to their lives, are amazing but I would be lying to you if I pretended that my job was always full of such joy.
For six years in the 1980s I worked and trained at a London teaching hospital. Back then, it was the Jews and Muslims who always worked Christmas—on top of the 134 hours we did every second week. The week in between was a doddle by comparison; then we only worked 72 hours.
At the same time, I was studying for my first set of postgraduate medical exams and trying to hold down a relationship with a similarly hard-working lawyer who also worked long hours for a law firm that sued doctors!
One Monday night, after a typically miserable weekend on call, I arrived home to a dinner of roast chicken—well, almost, because it wasn’t quite cooked. It sat there alone on a big plate, in the centre of the table in the dining room of the fine old Edwardian house we had bought a few years before. There we were, the two of us, and the bird, sitting there in a silence that was deafening. Words were not necessary. Worn out, half-cooked, looking as despondent as me, the bird on that plate said it all.
Despite overwhelming tiredness, I was not so out of tune with the real world not to be able to read the signs. I had gone AWOL, becoming lost at work, drowning at sea. On the odd occasion when I was home, I really wasn’t. My mind was always ticking over, wondering how the alveolar gas equation went or trying to remember how to draw the intricate workings of the Manley ventilator. The half-cooked bird and the silence helped me see all that, but a bit too late for my first go at a postgraduate exam.
It was a cool winter’s morning when I stepped out onto the front steps of our house on London Fields on my way to Bloomsbury for the oral exam. As I opened the door, a funeral procession slowly passed. One of those dour and grim processions with pale men in frock coats and big hats, one black car after another; as I watched, my heart sank and my head followed. I should have turned around and gone back to bed, because when it was my turn to answer the examiners’ questions about things I knew well, I was close to mute. I sat there in an almost trance-like state, my mouth so dry I could hardly talk. All I could think about was getting out of there. I had never failed an exam before and never have since, despite sitting many more over the years. That and the uncooked bird were a wake-up call to me. I was a good doctor but I was going over the edge. I had lost my way, and with it all sense of myself and what really mattered. That had to change and I remembered something my father used to misquote: ‘If I am not for myself, who will be for me?’
I was not alone it seemed because many of my junior colleagues at the hospital were in a similar situation. Some coped better, a few worse—one of them, Terry, a lovely guy, ended up killing himself with a drug overdose. Our consultants had survived all of that and, having completed their training, had secured jobs for life. All of them seemed to be reaping the rewards of their hard work, many double-dipping in public and private practice. They drove flash cars and spent their evenings at the opera. Despite all that, they remained kind and were especially good to me when I so obviously needed their help. We are all a product of our upbringing, and we are shaped by our experiences and memories. So when I was overcome and my life was a mess, I stepped back to remember where I was from and who I was, and I vowed that I would never again get into that state.
Both my brother and I visited the mohel on our eighth day, and we grew up in a Jewish household. Among friends, I still jokingly describe myself as a Polish Jewish aristocrat. My father had lived under the constant gaze of his grandfather, the Chief Rabbi of Poland, and during his early years he lived an observant life. My mother, an only child, also had an orthodox beginning.
In New Zealand, ours was a Jewish house. Yes, on the right-hand doorpost at the entrance was the mezuzah, a piece of parchment inscribed with the verses of the prayer Shema Yisrael, which was contained in a small, plain, metal case. We celebrated the Jewish holidays with the same gusto as we did those of the goyim. We ate chopped liver and drank borscht. My mother made gefilte fish and in our fridge was a constant supply of herrings, pickled gherkins and smoked eel. I dined on sauerkraut with caraway seeds, Polish potatoes, Wiener schnitzel with horseradish, and I took sandwiches with strange fillings to school. At night, when I was overly boisterous, my mother gave me ice cream—with brandy. The house was full of mad Europeans who played poker and drank too much. My mother and Aunt Nina smoked constantly and always, there was cake.
We were Jewish to the core but were we religious? Hell no! ‘Where was G-d when we needed him?’ my parents would ask. ‘G-d is a creation of man, not the other way around,’ my father would repeat. My father repeated lots of things—especially jokes he was particularly fond of. One of his favourites was reliably retold every year, 194 km north of Wellington, as we drove to our summer holiday destination. Anticipating this, my brother and I would look at each other in silence and nod knowingly. On cue, Dad would laugh to himself and say, ‘Boys! This is the only place in the world where you can get milk from Bulls!’ Once, twice, a third time, every time it was hilarious. We would laugh and laugh—not at the joke but at Dad. He was simply terrific. Another favourite joke, shamelessly stolen off him and used by Jim Jarmusch in the film Down by Law, referred to ice cream. ‘I scream, you scream, we all scream for ice cream.’ So did we!
Jewish we were, but kosher we were not. Each year I would accompany my father to the fish and chip shop opposite parliament in Wellington to buy the first of the season’s Bluff oysters. In the intervening months, we would eat pork. My mother especially liked the crackling. Years later, as she was dying, she said she would miss that more than anything—apart from her family, of course!
Funny and a little weird as he was, Dad was a smart man. He joked about life and death, but underneath all of that he was deeply serious and had figured out what really mattered in life. Someone he spoke of and admired was the Babylonian sage and scholar, Rabbi Hillel. When I was in a state, it was Hillel’s famous aphorism that I remembered:
If I am not for myself, who is for me?
And when I am for myself, what am I?
And if not now, when?’
Judaism is full of these aphorisms and allegories. Scholars pore over them, arguing about their multiple meanings and the lessons that lie within. On the face of it, this is a simple one where Hillel tells us what really matters—know yourself and you will know the world; love yourself and you will be able to love others. Having found yourself, live for the benefit of others and start that now. Damn good advice, I think.
A lot of time has gone by and in the meantime the life of a jobbing junior doctor has changed enormously. No longer do they do those terrible hours, but they still work hard and the pressures on them are significant. Much cleverer than I ever was, they now compete with each other at school for top marks. They then compete again at university in the pre-med year. Now only the very best academically seem to be interviewed—so tough luck to those bus drivers out there aspiring to be doctors, you’re fat out of luck.
In many countries medical students are selected directly from school, separated out from their peers and injected with increasingly addictive doses of medicine in all its fascination. At a time when their brains should be expanding out into the world, perhaps we are doing them a disservice by limiting their experiences. They are taken underground into a labyrinth of facts and figures about diseases and treatments, leaving little space and time to discover themselves and those around them.
Exhaustion and the chaos of work were some of the things that took me down so many years ago, especially responding to unexpected emergencies at all hours of the day and night. So in 1991, when I started my first specialist job 20,000 kilometres away from London, I hoped that things might be different, but they weren’t. Nothing much had changed apart from me. Once again, I would regularly and frequently be called to see patients extremely late in the course of their deterioration. Some of those patients died and more were admitted to the ICU at enormous cost to themselves, their families and to the state.
At first glance, those calls seemed to come at random times of the day and night but when we looked at the data, we began to see a pattern. Most of them came at the changeover of a shift when new nurses and doctors would come on duty and see things through different eyes. When we looked at this in more detail and spent time talking to the staff, the nature of what was referred seemed to be more related to the experience, intuition and, importantly, the confidence of the nursing and medical staff on call. We also found that many staff, especially the more junior doctors and nurses, felt intimidated and scared of their seniors. This meant that they did not refer on, ask for help, or act on their intuition despite their patients so obviously not doing well.
A few years later, articles began to appear in prestigious medical journals describing the very things we were experiencing in our corner of the world. These articles detailed cases of patients clearly deteriorating over days and ultimately being unexpectedly admitted to an ICU or, worse, dying. The paper proposed a system to identify and manage those patients much earlier. Way back then a group of us tried to introduce one of those simple systems—an early warning score—into our hospital. We were too naïve and totally underestimated the barriers to implementing change despite the obvious good sense in what we were doing. It took another ten years before we gathered enough support to do this successfully and several more before it became essential everyday practice.
In the late 1990s, we intensivists also began to talk more about the changing nature of the patients we were being asked to see. Before then, our patients were generally younger people, many with infections: pneumonia in winter, infants and children with meningitis, complications of abdominal surgery and drunk people injured in car crashes or fights.
Late at night the emergency department exuded the sweet smell of alcohol and blood and under the curtains of the cubicles could be seen the blue trouser legs and black shoes of the local police. I remember one young guy who had been badly beaten outside a tavern not far from the hospital. He was brought in unconscious with obvious head injuries, fractured ribs and a collapsed lung, most likely from being kicked while he was down. He also had the worst haircut I had ever seen. The next morning, the police came to see if they could interview him but to no avail—he was still too drunk and concussed to make any sense. As they left I suggested they might wish to arrest his barber as well as those who beat him and they agreed! That’s what it was like—the doctors and the police were on the same side most of the time, both in a war zone, and to stay sane we just had to see the funny side of it all.
About that time, the nature of our work started to change. Our middle of the night and early morning calls weren’t to the ED to see drunks, they were to the wards, at the same ungodly hours, to see people who seemed to be suffering from the same set of diseases. Eventually we called this recurring phenomena the South Auckland Full House—a six-card hand of obesity, diabetes, renal impairment, hypertension, ischaemic heart disease and gout—a plague that is now overwhelming poor and rich nations alike.
Almost all of the patients who held the full-house hand had folders of notes recording visits to countless numbers of clinics to see doctors and nurses who looked after their different diseases and different parts of their bodies. These folders were full of reports and results, letters written by one doctor and addressed to another, always beginning with a standard format introducing the patient and outlining their previous medical problems, medications and allergies and much more. Then, and now, large swathes of each individual letter were a cut-and-paste from the previous correspondence to the next, so G-d help you if the information was wrong. The inpatient admissions were there too, detailing and documenting what seemed to be an inexorable slide toward end-stage disease. Reading this material was very helpful to understand what the medical services thought about the patient and his problems, but nowhere was there any information about the person, what they thought or, crucially, what they wanted when the wheels inevitably began to fall off.
Put yourself in my shoes. It’s four in the morning and I’ve been asked to urgently review a patient on one of the wards. Pele is 69. He was admitted to hospital three days earlier with complications arising from his diabetes. He is now deteriorating fast. When I arrive, twelve or more members of his family—all looking extremely anxious—are gathered around him. They look at me as if I am the cavalry.
When I first started in medicine, uncertain of my own knowledge and abilities, I found situations like this incredibly confronting. Instead of acknowledging that, I felt an enormous pressure to do the opposite and bluff my way through. So, nervously, I would examine my patients, write my notes and then, feeling the gaze and expectation of the family bearing down on me, I would gabble away about all the positive things we could do to beat the disease and restore life as it once was. I felt that pressure to act so acutely, to intervene, to prescribe, to refer on for surgery, because that’s what I thought I was trained to do and because that’s what I thought patients and their families always wanted from us—to go all out, to prolong life in the hope that their illness and suffering would succumb to the miracle that is modern medicine.
Of course the truth is quite different from that and I now have a much better understanding of why I felt and behaved that way. Back then I was still a young man and knew little about death and dying, I completely lacked the kind of experience and confidence to help advise others staring down the barrel of their own mortality.
With the family watching my every move, I quickly introduced myself and took a look at Pele. My first impression, the end-of-the-bed-o-gram, was not good—he was pale, his breathing was irregular, he was gasping a little and his skin was yellow. When I took his hand and felt for a pulse his skin was cold. His pulse was fast and irregular and his blood pressure was low. When I called his name he hardly stirred.
I spoke with the family to gather more information about Pele, then I asked the staff what they knew about him and, finally, I read the patient notes. The three nurses rostered on that night knew very little about him. The on-call doctor had never met him before. His medical records detailed a steady deterioration in function over the past three years, with multiple admissions to hospital for complications from his multiple illnesses. I scanned through his notes but nowhere could I find any record of a conversation with Pele and his family acknowledging that he was slowly and steadily fading away.
From my earlier position of hesitation and fear, I am now much more comfortable having these discussions. They are honest and they are meaningful and we talk about things that matter.
In the past, conversations like this—if they happened at all—were left to the junior doctors on call in the darkest hours before dawn, when people were already over the edge and falling. I knew then that it didn’t have to be that way.
Informed by what I saw and learned from his notes, I sat down with the family to find out more about this man Pele, who was so clearly dying in this room in front of our eyes. There were stories and there were tears and, in the end, there was relief in the faces of this family, who knew him better than anybody and had seen his progressive deterioration over many months. Of course we will care for him, I told them, but our attention and efforts will focus on his comfort, not on trying to save his life—he had been beyond that for months.
In my years as a specialist, I have had hundreds of conversations like this, all of them with families wanting the best for the person they love. Outside of the intensive care unit, when I see new patients like Pele, I work hard to establish an immediate rapport with them. In my experience that is best done by being polite, respectful and honest; by listening to the patient and their family; by showing a genuine interest in the person and not just their illness; by acknowledging what you don’t know and, importantly, by doing what you say you will do. Open-ended questions can be enormously helpful in finding out what they know, what they fear and what they hope for. ‘What do you understand is going on with your mum?’, ‘What do you think she would want for herself?’ are simple examples. Conducted well, these discussions will usually deliver answers to the difficult questions and a way forward will emerge. This means that what could have been a contentious and tricky situation is resolved to the tangible relief and benefit of all involved.
Inside the intensive care unit, I will never walk past a family visiting one of our patients without stopping to say hello and to chat. That, combined with our open visiting policy for family and friends, means they see us at work, with each other, with other patients and their families. As we chat among ourselves, they also get a sense of who we are as people outside of being a doctor or a nurse. So when it comes to more formal discussions about difficult decisions, we already have a relationship together, which eases the process for all of us.
Those more formal meetings serve multiple purposes for all parties. They allow us to ensure that the families have all the information they need to understand what has happened to their loved one. They provide families with the opportunity to ask questions, and for them to play a meaningful role in the decision making that will ultimately follow. These meetings are also a chance for the medical staff to be clear about our role in taking responsibility for those decisions. By way of example I have not and will never ask a family to make the call to remove someone they love from a ventilator—that decision is a medical one. At the same time I would never remove a patient from the ventilator if the family objected.
My approach is to engage families and to always take them with me as we work through those difficult decisions, ensuring that they understand all that they need to understand, and, in the end, accept our plan.
Compassion and patience helps people on this journey to come to understand that the one they love is beyond our help and to agree with our plan to return them to a more natural state or put them in the hands of G-d. This takes time because individual family members come to accept the seemingly unacceptable in their own time. Occasionally, I hear about a stand-off between a group of doctors and a family unable to agree on a proposed management plan, but in all my years in practice that has never happened to me.
Years have passed and so much has changed in how we think about, plan and deliver health services. Patients and their families are now much more at the centre of what we do and more involved than ever in contributing to their own health plans. Services are increasingly being devolved to where patients live, in their communities, and close to where they work. Our junior doctors are increasingly unburdened by fewer hours at work. Our hospitals have adopted early warning scores and we are detecting and intervening earlier to improve the outcomes for acutely unwell patients with unstable physiology. All these things are good and contribute to improving the value of our investment in health, the most costly sector of government spending, but we are still a long way from where we ought to be—a nation of people who are independent, self-reliant, healthy and well.