NHS
Sobering realities from the Covid-19 frontline
I love the idea of a story about a detective hunting lost triangles! A man whose imagination conjures up that plot for his children has my ear!
A doctor who lets his small daughter paint his toenails lurid colours during a pandemic and leaves it on – It’s a little piece of home to take to work, a talisman to protect me and a token to remind me – gets my attention.
One who’s fearless enough to spell out unpalatable facts about our health service in the face of repeated political assurances of world-beating everything, gets my vote.
And when that medic is so incensed by the government’s spineless response to Special Advisor Dominic Cummings’ blatant disregard for instructions to the nation during lockdown, that he tweets a photo of himself in full PPE, stating that if Cummings doesn’t resign, he will, and then does so, has my heartfelt respect.
That man is Dr Dominic Pimenta, Specialist Registrar in cardiology. His story in Duty of Care begins in London in January 2020, when he becomes increasingly aware of a tsunami of disaster heading this way. It’s the stuff of his nightmares.
The book is certainly not comfortable reading. It exposes a stark picture of our country woefully lagging in health care provision:
The simple numbers are so bad they speak for themselves; at present, we have the worst A&E waiting times on record, the worst operating waiting times and the worst record on hitting targets. Even life expectancy is on the decline. We are short-staffed by a figure of around 100,000 staff, including 40,000 nurses. We also have one of the lowest number of critical care beds, general hospital beds and doctors per head of all the 37 countries in the Organisation for Economic Co-operation and Development (OECD). If we were an army, we would be a band of bedraggled, starved and exhausted soldiers. And that was all the case before any sign of coronavirus.
Now, I must confess that I personally have a lot of sympathy for our leaders trying to steer a course between many competing demands, balancing livelihoods against lives, damned if they do, damned if they don’t. It’s all too easy to criticise from the sidelines, or with hindsight. I cringe watching opposition MPs constantly carping about the decisions of government, knowing full well they aren’t going to be held accountable themselves. But this man, Dominic Pimenta, is a medical practitioner, and he had his eyes wide open from the outset. He isn’t scoring political points. So when he catalogues a litany of failings – incompetence, mendacity, lack of transparency, disregard of WHO advice – which have led to thousands of people losing their lives, thousands losing loved ones, thousands developing serious health problems, thousands having vital treatments postponed, thousands suffering serious mental ill health, then we ought to sit up and take note. These are desperately serious consequences indeed.
We could see the pandemic unfold, in high definition, live, 24/7, before our very eyes. And yet, for too long, we did nothing at all.
But in spite of his acute awareness of the true picture, shining through is his pride in the NHS: they responded magnificently to an overwhelming situation. He outlines convincing detail of their titanic struggle, their frustrations, their failures, as well as their triumphs and heroics.
With the right mindset, we are capable of incredible things.
Amen to that.
His own personal energy and determination to make a difference are exhausting to contemplate:
– writing articles spelling out the coming danger
– tweeting analysis and warnings
– publishing in the national press
– appearing on live TV shows
– campaigning for change
– garnering signatories for public appeals
– establishing a charity, HEROES, (now rebranded as Healthcare Workers’ Foundation) for the protection and support of healthcare workers
– attracting celebrity support
– designing prototypes for PPE (personal protection equipment)
– setting up a second organisation, SHIELD, to bring industry leaders and experts together in the creation of innovative solutions to meet the demand for PPE, including cutting edge ‘printing hubs’ …
all while working as a clinician way outside his own comfort zone – at the frontline in ICU – and trying to be a husband, father, brother, son, uncle, friend, in unprecedented times. His manic activity leaves one fearful for both his mental and physical health, but as he says himself, the problem was so vast, it would never feel as if any level of effort was enough.
In Duty of Care he leaves the story at the end of the first lockdown, knowing a second and possible third tsunami are coming. Since he published it, we have all entered that predicted second wave and are dealing with its consequences right now. This week the death toll in the UK passed 62,000. I feel fairly confident we’ve not heard the last from this extraordinary ma, but I leave you with his own parting shot:
So stay informed, stay safe and be kind.
Whistle blowing
To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.
Prof Sir Liam Donaldson (former CMO England)
Whistle in the Wind has to be the most disturbing book I’ve read this year – and probably not best tackled when we’re all rather dispirited about the rising Covid numbers, and increasing restrictions on our freedoms. Hey ho! Once started I couldn’t go back.
It tells the story of one NHS senior consultant surgeon’s battle to get his hospital/Trust to take action in the face of a catalogue of failings and dangerous practices in his place of work – abysmal clinical standards, gross imbalances in workload, extremely poor judgements, shirked responsibilities, dysfunctional relationships, financial irregularities. But the ‘guilty parties’ resented Peter Duffy drawing attention to their deficiencies, and mounted a deliberate campaign of victimisation and counter accusations against him.
At the time, the Trust’s website declared that no whistle-blower would lose their job or suffer any detriment if they spoke up to identify genuine patient safety concerns – a claim made by most large organisations nowadays. But the reality was far from the promise. Even more unbelievably, the same Trust had recently had its Midwifery Department found guilty of gross and shocking failings, a fact plastered over the media, but senior management nevertheless still appeared complacent and apathetic. Ranks closed. Honesty and truth were stifled.
Hugely daunted, Mr Duffy nevertheless eventually reported his concerns to the Care Quality Commission whose job it is to oversee safe and effective practice in health and social care settings. Until I read this book, I thought they were indeed the go-to organisation for action and a fair independent hearing. But in his case, they didn’t even attempt to corroborate his account. And furthermore, they specifically state that they will take no part in protecting the individual whistle-blower. Who knew?!
Retaliatory action against Mr Duffy escalated, and included not only malicious, false, fabricated and covert accusations – defamatory emails and letters claiming he was both racist and a bully, and had fraudulently obtained money to which he was not entitled – but also docking a substantial sum of money owed to him, and eventually loss of his job. Accusations against him were sent to the police as well as senior management. He even received a phonecall warning him that the consultants he had reported were ‘utterly committed to revenge’. He felt ‘thoroughly hated and despised’.
In spite of his senior status and established good reputation, no one in any of the organisations set up to deal with such situations seemed to be paying any attention to his legitimate and proven concerns. There was no feedback, no support, no action.
How this man coped with seeing continuing incidences of neglect, malpractice, avoidable harm or deaths, on top of the personal vendetta against him, I really don’t know. I once blew the whistle in a much more low-key way and suffered from the aftermath of the ensuing hostility and injustice for years. Reading this book stirred the embers of that horror quite stressfully. Finally, even Mr Duffy had no appetite for submitting reports of sub-optimal care which went unheeded; he felt intimidated and frightened by the hostility and retaliation.
By now the toxicity within the hospital – ongoing rudeness, aggression, hostility, dysfunctional behaviour and relationships, collusion, incompetence, cover up, neglect, dangerous practices – together with his own fear of some act of revenge, led to his health suffering seriously. Sleeplessness and high anxiety levels led to him suffering cardiac arrhythmias, ending up a patient himself.
But his conscience and professionalism would not allow him to turn a blind eye when the lives and dignity of patients were at stake. The General Medical Council‘s position is, after all, unequivocal:
Doctors in particular have a duty to act when they believe patient’s safety is at risk, or that patient’s care or dignity is being compromised. Our guidance sets out our expectation that all doctors will, whatever their role, take appropriate action to raise and act on concerns about patient care, dignity and safety.
He felt the weight of this duty keenly.
Colleagues and friends, however, seeing how he had been treated, were reluctant to expose themselves to the same retribution. Even when his case came to an Employment Tribunal, disclosure was limited. Witnesses were warned off from supporting him; they could neither appear nor have their witness statements seen by the Tribunal. And just four working days before the case was heard, the Trust issued an intimidating letter, telling Mr Duffy he was doomed to lose his case, and they would be pursuing him and his family for costs estimated at £108,000. However, if he would just agree to drop the case immediately in its entirety, remain silent, and agree to a non-disclosure clause, then they would not pursue costs.
To his great credit, he did not give in to these strong-arm tactics. And he was eventually exonerated, but the triumph was something of a pyrrhic victory. Even though this case was deemed an across-the-board failure on the part of the Trust and the clinicians concerned, nothing much has changed, Mr Duffy laments. Systemic failures are still ongoing; lives are still put at risk avoidably; whistle-blowers are still treated as lepers. Furthermore, he and his family have paid a colossal price for his integrity, courage and commitment to patient safety. In a massive understatement, he says he still struggles to believe the tactics adopted to silence him. I recognise that sense of incredulity and bewilderment all too easily.
The NHS, regulators and the law, all repeatedly claim the importance of safeguarding and speaking out to protect others; and they have a clearly stated duty of care to clinicians and patients. They offered this particular whistle-blower neither care nor protection. I can well imagine writing this book was cathartic for its author – at last he could present his case in its entirety. And I thank him sincerely for doing so. It was, in the end, therapeutic for me too – putting me clearly into the camp of ‘committed, responsible, caring individuals’ who summon up the strength to stand up to those who hurt or bully the vulnerable. The fact that it’s not a literary masterpiece, adds to its feeling of authenticity. It’s an unvarnished, from-the-heart, account. I can only admire the persistence and courage behind it, and wish the Duffy family well in the future.
The front line: then and now
Health Minister and Conservative MP, Nadine Dorries, was the first member of parliament to be diagnosed with Covid-19. This was back in early March … at a time when there were only 382 reported cases in UK, only 6 people had died. Halcyon days, huh? Less than two months later, we’ve already exceeded 26,000 deaths!
The news about Ms Dorries triggered a memory: I’d read somewhere that she was a trained nurse, and intrigued, I’d bought two of her ‘nursey’ novels in a coffee shop on my way to Wigtown, Scotland’s National Book Town a couple of years ago, stuck them on my shelves, and promptly forgotten about them – The Angels of Lovely Lane and Christmas Angels. Time, methinks, to dig them out and read them … a kind of tribute to the nurses today working so hard to care for people with the virus in a very different world.
I must confess neither the genre, nor the style of writing, are ones I’d normally go for, but there were aspects of these books that gave me pause for thought and sober reflection. These nurses were practising not long before I trained; their experiences resonated with me. Rather like BBC1’s drama, Call the Midwife.
Reading about and recalling those days made me so grateful for all that modern medicine and social care can offer today. How far we have come from those days when
– the NHS was in its infancy
– antibiotics were wonder-drugs
– women had limited career options
– smoking was the norm
– lecture notes were written on typewriters using carbon paper
– rubber tubing was boiled before being inserted into various orifices
– patients were lifted manually
– doctors were revered and all powerful
– women died or were imprisoned following illegal abortions
– ten days bedrest was de rigeur after a simple D&C; three weeks after childbirth
– nurses wore starched collars and frilly caps, always kept their hair off their face tucked inside their caps, lived in hostels with rigid rules, and were all known by their surnames
– silver buckles on petersham belts denoted qualifications
– the Irish were openly discriminated against …
Compare all that with communication, technology, medical expertise, opportunities, science, in 2020. What would have happened if the dreaded coronavirus has struck then?
In her fiction centring on Liverpool in the 1950s, Nadine Dorries has captured a world I knew, and for a few days took me away from the uncertainties and restrictions and anxieties of our present situation, to a bygone era. Memories both happy and sad. But overwhelmingly reasons to be devoutly grateful for what’s available to us today, and the amazing work our front-line staff are doing – and are able to do – to beat Covid-19.
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.