If the assault on the NHS by the Tory government could be said to have an upside, it is that doctors have been prompted to communicate with the wider public about what they do, and how, and why. This is a profession long characterised by its stiff upper lip, by respect for patient confidentiality and by an overwhelming lack of time (as these books make clear, uninterrupted urination is a luxury for an NHS doctor). Public relations have not been a priority – presumably doctors felt it was safe to assume that their work spoke for them.
Then Jeremy Hunt came along and changed all that. Both of these accounts of life as a junior doctor, so different in tone and approach, are the products of the same outrage about the Health Secretary’s treatment of the profession. Adam Kay, who left medicine in 2010 and has since become a comedy scriptwriter and performer, was prompted to rescue his old diaries from the shredder after Hunt launched his attack on junior doctors in 2015. “The public,” Kay realised, “weren’t hearing the truth about what it actually means to be a doctor.” His brutally funny new book is an attempt to remedy this.
It is worth reading just for the jaw-dropping tales from the obs and gynae (“brats and twats”) front line, involving bodily fluids, unlikely items recovered from orifices and things that patients say (“I slept with three guys last night. Will one pill be enough?”). But the gags leaven a bleak reality of dire working conditions and night shifts that make “Dante look like Disney”.
Rachel Clarke’s account is shorter on the jokes and longer on the devastating polemic. It is essential reading for anybody who cares about the future of the NHS and wishes to understand what the dispute between Hunt and the junior doctors was really about. Clarke is a journalist-turned-medic who was at the forefront of the 2016 protests, at one point camping outside the Department of Health hoping to secure an audience with Hunt (he sneaked out through the back entrance).
One thing comes across clearly in both accounts: the resentments behind the dispute had been building up for many years. Hunt was aiming to win support for the government by renegotiating doctors’ contracts and reducing the NHS wage bill. But when he did this by casting aspersions on doctors’ professionalism and publicly accusing them of causing 11,000 deaths per year by refusing to work at weekends, Clarke writes, he “inadvertently unleashed years of festering discontent and rage”. It was not just about weekend working but about chronic understaffing, which had long pushed doctors to their limits and beyond. Britain has fewer doctors per head than almost anywhere else in Europe; we have 2.8 per 1,000 people, while Greece has 6.3. Hunt was pushing seven-day working, without adequate funding, on a system that was already creaking under the strain.
While reading these books, I thought many times of that often-cited analogy for how caring works: on a plane you are instructed to fit your own oxygen mask before that of your child, as you are only capable of looking after somebody else if you have looked after yourself first. Successive governments have run the NHS on the opposite principle. Medics are expected to care for patients selflessly, while their own most basic needs are disregarded. The extent to which they have been willing and able to do this is remarkable.
To go back to that urination issue: both Clarke and Kay describe long shifts covering rota gaps during which they routinely don’t have time to piss, let alone sleep or eat. Clarke is bleeped on her pager five times during one aborted attempt to wee; Kay is summoned by a house officer concerned that a patient hasn’t passed urine for nine hours. “I tell him I haven’t passed urine in the last 11 hours because of people like him wasting my time.” On another occasion, Kay is bleeped awake at 3am “from my first half-hour’s shut-eye in three shifts to prescribe a sleeping pill for a patient, whose sleep is evidently much more important than mine… I arrive on the ward to find the patient asleep.”
The pay does little to compensate for these privations, or reflect the level of responsibility given to a junior doctor (confusing terminology, as many junior doctors are not that junior at all). Both Kay and Clarke describe working endless hours for free to provide adequate care. At one point, Clarke does the maths and realises that the net benefit to her household of her gruelling hospital job is zero; her costs outstrip her income, as she has to pay for childcare while she works extra hours unpaid.
Kay and his soon-to-be-ex-partner continue to rent while their friends ascend the housing ladder; he observes drily: “The parking meters outside the hospital are on a better hourly rate.”
Many of the most socially beneficial professions are underpaid and undervalued. But the corrosive effects of the government’s failure to care for doctors have wider consequences for everyone who comes into contact with the health service. The biggest casualty, as Clarke points out, is the quality that brought the NHS into being: compassion. In her despairing analysis of the Mid Staffordshire hospital scandal – which she attributes largely to understaffing – Clarke argues that such working conditions “grind away relentlessly at our capacity for kindness and threaten the survival of the NHS itself”.
Doctors don’t want to work in a system that is inadequate and unsafe. The exodus of young doctors from the NHS has worsened year on year since the 2010 general election; now only 52 per cent stay on after their first two years of training. Kay left after a traumatic incident; Clarke, too, temporarily gave it all up but couldn’t quite bear to leave the profession she loves and now works in palliative care. Her conclusion is that the NHS is broken: it no longer has the funds to keep up with rising demand. The only reason we don’t feel this as an immediate existential threat is our ability to live in denial of suffering and death. “Perhaps it is only when you or your family are smitten that you fully appreciate – with relief and gratitude – the NHS is there.”
Missing from these accounts of NHS collapse is the way that the Tories have taken a similar approach to other professions across the public sector. I worked briefly at the Department for Education under Michael Gove, where the strategy was to take an equally aggressive approach to teachers; Theresa May did the same with the police when she was home secretary.
There is a grand political project going on here, which seeks to demoralise this country’s front-line workers and undermine confidence in the public sector. Once this has been achieved, the field lies open for private companies to step in and fill the gap. It hasn’t been easy for our beleaguered and exhausted public servants to fight back. But books such as these are ammunition in that battle. I hope there are more of them.
This Is Going to Hurt: Secret Diaries of a Junior Doctor
Adam Kay
Picador, 288pp, £16.99
Your Life in My Hands: A Junior Doctor’s Story
Rachel Clarke
Metro, 288pp, £16.99
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This article appears in the 10 Jan 2018 issue of the New Statesman, Toddler in chief