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An open letter from a doctor to Jeremy Hunt

Your plans are neither safe, nor sustainable, nor morally okay. 

“Make the care of the patient your first concern.”

This is the cardinal rule of Good Medical Practice, the handbook issued to every medical student by the GMC at the dawn of their training. Ask any doctor: we have this rule as deeply ingrained throughout medical school as any physiological action or pharmacological mechanism. We probably mumble it in our sleep.

And we try to. We try so damned hard. Along with the nurses, the allied healthcare professionals, and all the auxiliary teams – we do what we can with meagre staffing levels and stretched resources pitted against relentless “efficiency savings“. We work and work and work, in a miasma of demoralisation that has only thickened over the past weeks and months as the true depth and breadth of the cuts has become horrifyingly apparent.

The patients are more numerous and sicker than ever before; partly due to the ageing population, but also because the patients getting admitted to hospital have been disproportionately disadvantaged by the decimation of health and social care provision both in hospitals and nationwide in the community. The estimated funding gap for adult social care this decade? £4.3 billion.Charity funding cut by £1.3 billionpersonal care cutmental health services cut disability benefits cutcarers in crisisbenefit caps inexorably tighteningall welfare increasingly inaccessible to the most vulnerable members of society: the unwell, the poor, the young, the disabled.

Given the above, it is indisputable that the actions taken by this government and the last have made the British population sicker.

The knock-on effect on healthcare resources is both predictable and inevitable.

Vulnerable, isolated older people are arguably the worst hit; the sterling work by Age UK shines a light on the shameful state of things for this demographic. These are the patients who bounce in and out of hospital and “bed-block“, often due to multiple morbidities and complex psychosocial needs.

Hospital admission should always be a last resort. Unfortunately, in so many cases, things are so bad in the community that last resorts are all we have.

Throughout my years as a junior doctor, I have become heartbreakingly familiar with the phrase “we don’t have capacity at the moment” from the various theoretically excellent community-based services designed to manage patients wherever possible in their own homes. There aren’t enough nurses, enough midwives, enough healthcare assistants, enough technicians, to safely run such services for as many patients as need them – so those patients stay in hospital. There aren’t enough GPs to provide enough emergency appointments to give everyone who requests one an urgent medical review – so those patients come into hospital as well. There aren’t enough days in the week or hours in the day to ensure flawless care for every patient who seeks help. There are never enough.

Healthcare professionals still strive to make the care of all these patients our first concern; far above our concerns for our own physical and mental health. In my first job as a junior doctor I unintentionally lost 8kg in three months, my BMI dropping to an unhealthy 17.2, because I was regularly working 14 hour shifts without a break. Any food grabbed was eaten whilst poring over blood results or typing discharge summaries with the other hand. I’ve lost count of the number of times my incredibly supportive husband has said “you’re too ill to go to work – take a sick day” and my first thought has always been: “yes if I worked somewhere else, but this is different – I’m not as sick as the patients, and they will suffer if we’re even more short-staffed”. Patients don’t want sick doctors, but most of them would rather that than no doctor at all, and that is essentially what it comes down to; short-notice cover is rarely arranged due to budget constraints, and instead the remaining staff stretch themselves thinner to try to cover the gaps. These examples are just from my early career – I know of countless others, because healthcare professionals make many larger sacrifices than these in the name of patient care and the public good every single day.

It is not safe.
It is not sustainable.
It is not morally okay.

You are correct that medicine is a vocation with myriad non-financial rewards; you are misguided if you think systematically disenfranchising the workforce won’t make people leave.

I’m referring to the move to change the definition of antisocial working hours, so that evening and Saturday work up to 10pm will be valued the same as weekdays 7am-7pm (the core hours many doctors work at baseline, albeit often involving multiple hours of unpaid overtime). I’m referring to the proposed stripping of the financial parity incentive from GP training – arguably one of the specialties in which recruitment is most in crisis. I’m referring to the recent toxic rhetoric surrounding weekend working, apparently designed to foster the attitude that doctors are at best lazy, at worst negligent. Summary of these proposals here.

Commonly heard from the most senior medical staff: “At least I’m retiring soon.”

Commonly heard from the most junior medical staff: “Have to admit I’m increasingly tempted by working overseas.”

I’m a born-and-bred British graduate of a medical school which regularly ranks in the top 5 in the country. I already had a BSc therefore didn’t get any help with paying my tuition fees; I took a loan and used the savings my father left me when he died, and I still amounted significant debt (I couldn’t have afforded to retrain if the fees had already been £9k per year). My university place was competitive, with approximately 8x the number of applicants than studentships available, and the cost of training me was approximately £300k. I was highly motivated, I worked very hard to get here, and I am devoted to both the NHS and to this country. And yet in the light of recent developments, I am considering working abroad. What an absolute waste of resources that would be.

It is in vogue at the moment to talk about “the patient’s journey“, to focus on how improvements could be made to the narrative of their illness: prompter diagnoses, minimising unscheduled care, maximising doctor-patient concordance in management; better outcomes, fewer recurrences and – as always – lower costs. “Customer satisfaction” will always vary, and the nature of illness means that disappointment, fear and anger will inevitably be factors in some people’s experience of the NHS. But the fact is, even if you make your journey from A to B via the smoothest possible route – in the shortest possible time – the experience of travelling in a creaking overcrowded bus running on low-budget fuel will always be more stressful than travelling in a well-maintained vehicle. At risk of labouring the metaphor, none of us are asking for the NHS to be a sportscar. But we wish for our patients to be able to make their journeys in a vehicle that promotes individualised care: that means more staff, more beds, more resources.

None of your proposals for 7-day non-emergency-care service address this unmet need. (We already run a 24/7/365 urgent care service, as you may remember from taking your own kids to A&E rather than wait for their GP practice to open after the weekend.)

As doctors, we are trained in the art of deduction: the ability to pick out important signs and symptoms from the background noise of normal physiology, to find a meaningful pattern in a group of data; to see not merely stars, but constellations. It is difficult not to look at your history, Mr Hunt, and to examine the statements you have made and continue to make, and come to certain conclusions:

1. You do not intend to keep the NHS free at the point of use
2. You intend to make this more palatable to the general public by systematically defaming and devaluing healthcare professionals – divide and conquer, if you will
3. You are willing to sacrifice the existing NHS workforce on the altar of “efficiency savings”, irrespective of the consequences

If I have come to the wrong conclusions here, please do not hesitate to correct me. My suspicion is that you would be unable to provide evidence to support a rebuttal of the above impression.

If this were about points-scoring, I would leave it there, but it is about so much more; so many people’s lives are being detrimentally affected, and frankly endangered, by the decisions you are making and the policies you are pushing through. I find it difficult to believe that anyone could lack compassion to such a devastating degree as it seems, from the outside, that you do.

So I will finish instead by making a request. I ask you to take a leaf out of our book, Mr Hunt: please, for all our sakes, prove me wrong, and make the care of the patient your first concern.

This article originally appeared on Left + Write

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How did I, obsessed with non-places, not know about the Trafford Centre?

My wife had booked us all in to a showing of the latest Bond film at the IMAX Cinema at the Trafford Centre. “Why the Trafford Centre?” I taxed her. She looked at me as if I were a complete ass, but refused to enlighten me. 

Last year I bought a copy of J G Ballard’s last novel, Kingdom Come, a dystopic tale of the near future in which bored suburbanites descend into anomic violence as they retreat inside a giant shopping mall. Predictably, I bought my copy at the Bluewater shopping mall in north Kent, on the outskirts of London. Bluewater held the title of Britain’s biggest shopping mall for a number of years and it is surpassing large: a huge circular corridor that has become a destination. I asked a police officer where the Waterstones was and discovered she was a good old-fashioned bobby-on-the-beat – her beat having been, for seven years, to walk slowly around and around . . . Bluewater.

But I wasn’t fettered by Bluewater’s surly gravity, any more than I was galvanised by rampant consumerism. Novel purchased, I took a cab over the soaring Queen Elizabeth II Bridge to Essex, where I alighted at Bluewater’s twin establishment: the Lakeside shopping mall in West Thurrock. I headed for the Lakeside branch of Waterstones, where I . . . well, you guessed it: I returned my copy of Kingdom Come. This surreal little exercise was undertaken for the BBC Radio 4 documentary Malled: Sixty Years of Undercover Shopping, and I’ve detailed it here purely in order to illustrate this point: I have more than a passing interest in shopping malls.

This is why the events of a fortnight ago, when Family Self went up to Manchester for what is termed, I believe, a “city break”, seemed quite so bizarre. My wife had booked us all in to a showing of the latest Bond film at the IMAX Cinema at the Trafford Centre. “Why the Trafford Centre?” I taxed her. “It’s in Trafford, which is five miles from the city centre.” She looked at me as if I were a complete ass, but refused to enlighten me. My revelation came later, when we were wandering the rococo halls of the Trafford Centre, marvelling at the lashings of gold leaf applied to the serried columns as our soles slapped on the Italian marble flooring. My wife couldn’t believe that one such as I, obsessed by what the French philosopher Marc Augé has named “non-places”, didn’t know about the Trafford Centre.

But I didn’t – it was a 207,000-square-metre hole in my map of the world. I knew nothing of the bitter and protracted wrangling that attended its inception, as successive planning applications were rejected by ever higher authorities, until our Noble Lords had to step in to ensure future generations will be able to buy their schmutter at TK Maxx and then sip their lattes at Starbucks without having to brave the harsh Lancashire elements. Did I feel small as my savvier spouse led me through these storied halls? You bet your waddling, wobbling, standing-still-on-the-travelator bum I did. How could I not have known about the great central dome of the Trafford mall, which is bigger – and statelier – than that of St Paul’s? How could I have been unaware of the Orient, Europe’s largest food court, with its seating for 1,800 diners, served by a plethora of exciting outlets including Harry Ramsden’s, Carluccio’s and those piquant bun-pushers, McDonald’s?

Actually, the Orient completely bowled me over. The Trafford Centre’s imagineers point to the nearby Manchester Ship Canal as influencing this wholly novel and utterly weird space, which is formed by a sort of Möbius strip of 1930s ocean-liner design, being at once superstructure – railings, funnels, tables arranged to simulate the deckchairs on a sun deck – and interior. However, nothing like this ever cruised by Runcorn. Not that I object to this, any more than I objected to the cluttered corridor full of orientalism – noodle bars, sushi joints, all-you-can-eat Chinese barbecues – that debouched from it and led us back into the weirdly glistering main retail areas, with their ornamental griffins and neoclassical columns bodged up out of medium-density fibreboard.

The Trafford Centre’s imagineers also make great play of design features – such as the aforementioned griffins – that are meant to tie the humongous mall to its hinterland (these are the heraldic symbols of the de Traffords, who used to own hereabouts), and to the north-east’s proud industrial heritage. But this is all ornamental balls; the truth is that the Trafford Centre’s ambience is so sumptuously wacky, it could quite reasonably be twinned with Las Vegas.

While the rest of the family went in search of retail opportunities, I watched the Mancunians process. It occurred to me that if there were any influences at work here – besides the Baudrillardian ones of hyperreality and simulation that underpin so much of the contemporary built environment – it was the presence of a large British Asian community. The only people who didn’t look out of both place and time, wandering about among all the gilded pomp and crystalline circumstance, were women wearing saris, shalwar kameez and burqas. Tracksuit bottoms and hoodies just didn’t cut it – although, I concede, come the breakdown in civil society anticipated in Kingdom Come, this pseudo-sportswear will come into its own as the perfect pillaging outfit.

Next week: Lives of Others

Will Self is an author and journalist. His books include Umbrella, Shark, The Book of Dave and The Butt. He writes the Madness of Crowds and Real Meals columns for the New Statesman.

This article first appeared in the 26 November 2015 issue of the New Statesman, Terror vs the State