NHS
The sad state of our NHS
A relative of mine is currently struggling with the intransigencies of a creaking NHS. I’m doing my best to find a way through that gets the patient the much-needed attention without further demoralising a team of professionals fighting fire because of impossible targets and too few resources. After all, I, more than many, appreciate both sides: I was a small cog in the healthcare machine myself for donkeys’ years, and I’ve been on the receiving end many times too. So perhaps a book by someone who buckled under the burden of working in such an environment was bound to resonate for me.
Adam Kay‘s This is Going to Hurt is absolutely brilliant. One of a family of doctors, his ‘default decision’ as a teenager was to follow in their footsteps, but nothing prepared him for the reality of life post-qualification, the life of a junior doctor.
Recording thoughts and experiences is a recommended part of ‘reflective practice’, and This is Going to Hurt is based on Adam’s diary scribbled in secret after endless days, sleepless nights and missed weekends. It’s a no-holds barred account of his time on the front line. 97-hour weeks. Life and death decisions. Ingratitude and complaint. Raw experience. Terror. Failure. Success. Innumerable objects in assorted orifices. A tsunami of bodily fluids drenching his person and his imagination. All recounted with honest brutality and a fabulous line in whacky humour.
Kay spent six years training and a further six years practising medicine, specialising in obstetrics and gynaecology. But eventually the price he was paying was simply too high. When something terrible happened on his watch, he finally crumbled. The patient suffered a torrential haemorrhage during a caesarean section – she had an undiagnosed placenta praevia. Dr Kay hadn’t been negligent and there was no suggestion otherwise; any other competent doctor in such circumstances would have done exactly what he did. But he expected more of himself. He was the most senior doctor involved and everyone was relying on him to sort out the horror. He felt overwhelmed by the tragedy.
I knew that if I’d been better – super-diligent, super-observant, super-something – I might have gone into that room an hour earlier. I might have noticed some subtle change on the CTG. I might have saved the baby’s life, saved the mother from permanent compromise. That ‘might-have’ was inescapable.
Much like the NHS itself, the book is filled with hope and despair, miracles and disasters, catastrophes and absurdities, intense sadness and riotous gallows humour. I defy anyone to read it without laughing out loud, or more importantly, without a sinking heart. It’s a damning indictment of a system that expects its practitioners to work impossible hours, assume phenomenal responsibility, compromise their health and relationships, for less pay than ‘the hospital parking meter earns’.
No wonder it won Book of the Year in the 2018 National Book Awards.
It’s difficult to avoid technical terms in such a book, so the author offers helpful footnotes –
I’ll help you out with the medical terminology and provide a bit of context about what each job involved. Unlike being a junior doctor, I won’t just drop you in the deep end and expect you to know exactly what you’re doing.
The footnotes themselves are often hilarious.
Diathermy is essentially a soldering iron – it heats up the area you touch it on and stops small blood vessels from bleeding by sealing them off. It is important not to clean the skin with alcohol-based antiseptic before the operation, otherwise diathermy sparks can set the patient on fire.
Swabs (used in surgery) are designed with a radio-opaque thread running through them as a marker, which shows up on X-rays as a line. A bit unimaginative – I’d have gone for a radio-opaque ‘WHOOPS!’
But I think my favourite one is:
I once put another of these standard dementia questions to a man in his nineties – ‘Spell WORLD backwards’. He paused and said, ‘As in “the planet” or “the past participle of ‘to whirl'”?’
Having spent years delivering babies myself as well as caring for the very sick and small ones, many of Kay’s obstetric stories rang bells for me personally. And I was moved by the care and empathy that this young doctor felt, that had him sneaking back to check patients were OK, or weeping for an hour when things went wrong. What a shame that this sensitivity cost him too dearly to remain on the giving end. We needs practitioners who really care.
Medicine’s loss is the entertainment industry’s gain. Adam Kay has gone on to become an award-winning comedian and writer for TV and film. Indeed he’s actually performing in the Edinburgh Fringe this year! But his book conveys in the best way I’ve ever seen the pain and the joy of working alongside disease, despair and death. And finding the humour and words and humility to share the emotional costs. It’s already been a No 1 best-seller, attracted over 6,500 reviews on Amazon. I devoutly hope it’s on the essential reading list for the new Secretary of State/Cabinet Secretary for Health and Social Care/Welfare. Changes have been made since Adam Kay was practising, but not enough. Not nearly enough.
NHS successes and failures
Last week I had yet another full examination by a consultant as part of my follow-up cancer care. Meticulous head to toe inspection. I’m overwhelmed by the efficiency, skill and compassion I’ve experienced at first hand in the years since I had the primary tumour removed. It could not be bettered.
And who could fail to be awed by the detailed reporting by the BBC this week of the Pakistani conjoined twins, Safa and Marwa Ullah. Two years old and recently separated.
Vast teams of top ranking practitioners working to give those two little girls as good a future as possible. The sight of the grateful mother, a widow with seven other children, kissing the hands of the surgeons said it all.
But I’ve also seen things go pear-shaped – for relatives and friends as well as those I’ve read about. 
And according to the media, a new publication, the NHS Resolution report, provides a worrying picture of the rise in claims for compensation. In England alone, in 2018-19,10,678 new claims were made for clinical negligence. The costs in payouts increased by £137 million to almost £2.4 billion! (NB. this includes legal costs not just the money paid to the claimants.) Mind blowing statistics, aren’t they? Furthermore some 10% of those claims related to perceived deficiencies in maternity care but, because these are extra costly, they represent a disproportionately high percentage of the total costs.
As the CEO of the Medical Defence Union said, this amount of money could have funded over 15 million MRI scans or 112,000 liver transplants. What a sobering reality check.
I feel a mixture of emotions: regret for those people whose care has fallen short certainly but also anxiety for those whose practice is called into question as well as for the NHS as a whole. Every example of negligence exacts a toll from the patients and families concerned. But the spiralling costs of compensating dissatisfied clients affects us all. Our world renowned health care system is buckling under the strain. Something has to give.
One of my ongoing files for a possible future novel is labelled RESOURCE ISSUES. My life-long aversion/allergy to numbers has kept it low down in the pile, but it might yet become a front runner if this state of affairs continues to escalate.
The miracles of modern medicine
Two days ago I experienced a miracle at first hand. Please indulge me this week if this post is entirely personal.
For the past six months my heart has been chaotic. In physical rather than medical terms I’ve been dizzy, sick, fainting, tired beyond belief, dependent on powerful medication to give even a pretence at normal functioning.
Two days ago I was lying in a special lab/theatre watching a rather shy, self-effacing man (known in the medical world as a consultant electrophysiologist) thread a catheter directly into that said heart, fire things at it, burn bits of it, provoke it in mysterious ways, and then calmly tell me he had successfully treated the malfunctions. Yep, there and then.
Here’s the written evidence in his own hand:
Six hours later I WALKED out of the hospital at night unaided (yes, of course, with medical approval!). Three days of recuperation and I should be back to my original self – but hopefully wiser, more appreciative, more tolerant … well, miracles do happen! The only slight caveat is the heart might just have been stunned into silence and not actually cured, but that we should know within two weeks.
Words can’t express my personal gratitude for this transformation, but let’s hear it for our brilliant NHS and all who play a part within it. I met with nothing but kindness, professionalism, friendliness and support at all levels in a clean and well-ordered hospital. God bless them all.
Off now for the prescribed ‘rest’ surrounded by the evidence of huge support from family and friends. Thank you all more than I can say. I am officially off the worry list.
PS. For those who have a highly developed curiosity gene or are interested in all things medical, you can watch a video of what an ablation involves here.
The Kindness of Strangers
This past weekend, on 1 November 2014, a beautiful and highly intelligent young American woman of 29 calmly and deliberately took her own life in Oregon, with the tacit agreement of those who loved her devotedly. She and her new husband moved there from California so that she could legally take this step.
Though I never knew her, I feel sad that Brittany Maynard has missed out on so much that is wonderful in life. Nevertheless I understand her actions: she was terminally ill with a brain tumour and she did not want to deteriorate slowly and unpleasantly. Who can blame her? As she said herself: ‘I do not want to die. But I am dying. And I want to die on my own terms.’
As it happens, I’ve been identifying more closely with this vexed issue of assisted death than usual this week, because while Brittany was calmly contemplating taking a fatal dose of prescription medicine, doctors were actually working hard to save my life.
After seven decades of valiant but largely taken-for-granted service, my old heart decided to make its presence felt and create a bit of havoc in my life.
It has set a few records in speed and variety of rhythm over the past week, and when this vital organ is pounding along at 200 beats per minute and assorted members of the medical fraternity are glued to the monitors; when my GP tells my spouse that if ‘anything happens’ between the surgery and hospital, he should pull over and dial 999 – ‘no heroics’; the prospect of death seems unusually close! What’s more, as I am now officially at greatly increased risk of sudden death, heart attack, stroke or other cerebro-vascular disasters, my mind is focusing rather more acutely on what I would choose to happen to me, if I were able to influence anything. And what control I wish to presume over the outcomes. Hmmm.
This is a personal matter for me to ponder, and to some extent share with my loved ones. But the thing I’m carrying away with me from this little skirmish with serious illness is the kindness of strangers. These doctors and nurses who have never seen me before, who will probably never meet me again, who treat hundreds of thousands of assorted odd-bods, have treated me with such friendly efficiency, and respect and dignity and warmth. They’ve even returned expressly to voice their pleasure at my recovery. I’ve been both touched and humbled.
The NHS might indeed often get a bad press – even from its own practitioners! – but when it’s a matter of life and death they can certainly pull out all the stops. I am hugely in their debt. They went well beyond the call of duty for me.
Moral mazes
Well, I’m counting myself lucky this week that the people who came to the launch of Saving Sebastian on Tuesday were kindly folk, asking reasonable questions, and not trying to trip me up or tear holes in my arguments.
Blackwell’s bookshop hosted the event this time: the right kind of bookish atmosphere; comfortable for lone people who didn’t know anyone else; lovely supportive friendly staff. And it meant we got a big slot in one of their windows – without a photograph of me too which pleased my mightily. That very day there was a two page spread in the Edinburgh Evening News with THREE pictures of me on one page! Horrors.
Here’s Luath‘s Director, Gavin MacDougall, displaying it – with some glee too by the look of it!
But back to the audience and their kindliness … I couldn’t help comparing it with the ferocious questioning of witnesses on the Moral Maze the other day where the participants and witnesses were discussing organ donation. On the panel: Melanie Phillips, Michael Portillo, Claire Fox, Anne McElvoy. All brilliant. All incisive. All very challenging. Which is why they’re chosen, of course.
It was a fascinating debate and I recommend listening to it. But it was also rather unnerving. It made me realise the power of eloquence, and the dangers of clever sophistry. And why I’m not good at these kind of confrontational events myself.
My instinct would have been to be especially gentle with the first witness, Henry, a young man who’d had two kidney transplants already. The panel had no such qualms. He was clearly an ardent campaigner for donation but even his motives were called into question: ‘Are you not avoiding the obvious way to increase the number of organs, which is by the act of persuasion? By morally motivating your fellow citizens?‘ Persuading is exactly what he does do, I’d say! And I’m quite sure he’d be a terrific advocate for the cause in real life. The genuine voice of experience can be much more powerful than theoretical argument.
And even the fluent and erudite Professor of Practical Philosophy at Oxford University, Janet Radcliffe-Richards, who was not in the least intimidated by the combined power of the inquisition, was dealt a low blow after she’d gone off air, when one of the panellists accused her of being ready to kill people off who weren’t actually dead. (Although the chairman, Michael Buerk did give that wholly unfair side swipe a gentle reproach.)
It was great listening though and the questions have been haunting me ever since:
Should elective ventilation be permissible to accrue a store of organs for transplantation?
Could you justify taking the organs from someone in a persistent vegetative state?
Are the rights of potential donors who are dead or dying and the rights of potential recipients of organs morally equivalent?
The Welsh Assembly is moving towards a Bill changing the law to an opt out one – it should be in effect in 2013. Is this a good step or not?
Would you give an organ to a complete stranger just because it feels like the right thing to do?
My current book is about organ donation so these issues are close to my heart and mind right now. But other sleep-depriving matters recently in the news have been bugging me too. Things with no easy glib answers.
Should someone who eats herself to a state of gross clinical obesity (40 stone) be entitled to an expensive package of care to enable her to carry on living her self-indulgent life?
Is it ever acceptable to lie to patients to cover medical mistakes?
Should a woman who has paid to have breast implants inserted for cosmetic reasons be entitled to corrective surgery on the NHS if the implants prove faulty and endanger her life?
Should there be limits set to the age at which women have babies, given the discovery that women possess a potentially limitless supply of ovarian stem cells which can be converted into mature eggs in the laboratory?
I’m not going to be running out of subject matter any time soon! But if you come across anyone in the process of inventing a 48-hour day, do let me know.