The day after AA Gill’s death from lung cancer in 2016, his final piece of writing for the Sunday Times was published, depicting with singular poignancy our paradoxical relationship with the NHS. Ravaged by metastases and painfully aware of his death’s proximity, Gill had learned of a wonder drug – nivolumab – as yet too novel and expensive to be funded by the NHS. Though the immunotherapy could not cure him, he wrote, it was: “a stretch more life, a considerable bit of life. More life with your kids, more life with your friends, more life holding hands, more life shared, more life spent on earth – but only if you can pay.”
Aghast at what the NHS was denying him, not to mention the impact of bureaucratic delays on overall UK cancer survival outcomes, Gill nevertheless insisted: “We know it’s the best of us. The National Health Service is the best of us… It turned out that what really sticks in our hard, gimpy, sclerotic hearts is looking after each other.” With typical acuity, Gill had zeroed in on the peculiarity of a nation that knows only too well the ways in which its health service can fail patients, yet adores – reveres, even – the NHS. If only Michael Ashcroft and Isabel Oakeshott’s 480-page new book possessed one iota of Gill’s analytical verve and elegance of prose. Instead, their latest collaboration is pound-shop diatribe masquerading as quality journalism.
The authors innocently insist their mission is purely objective: “to strip away the spin and uncover the true state of the NHS: the good, the bad and the ugly”. In an attempt to pre-empt any concerns on the part of readers that his gut instincts may prejudice him against collectively-funded health care, Ashcroft – the former deputy chairman of the Conservative Party and British-Belizean pollster who has amassed a £1.257bn fortune – vigorously strives to demonstrate otherwise.
The book opens with the noble statement that he is donating his author royalties to charities supporting NHS England – perhaps less of a sacrifice for billionaires than more typically impecunious authors. Then, in paragraph one, he reminds us that he helped instigate a campaign that led to the Queen awarding the entire NHS workforce the George Cross in recognition of our “heroic” pandemic efforts. (An entirely empty and political gesture – not least when so many NHS staff remain scarred by what they have endured, yet feel pressured to grit their teeth and carry on.)
At this point, I should declare my hand. I am an NHS palliative care specialist, traumatised Covid frontline doctor, hater of cant and fervent believer that, in the words of the late medical anthropologist, Paul Farmer: “What happens to poor people is never divorced from the actions of the powerful”. I also happen to believe that the NHS – though flawed, threadbare, and currently failing too many patients to count – is an act of radical kindness, of collective generosity, that does indeed represent the best of the British people.
Ashcroft and Oakeshott purport to feel similarly. “We take it as a starting point that the NHS is one of this country’s greatest assets,” they enthuse. “It would be mad to let it wither away.” Next, they define their methodology, deliberately eschewing individual patients’ stories on the grounds that these, “are almost all both entirely representative and unrepresentative of the NHS today.” Instead, they explain, they will focus on evidence from experts who are “clearly better placed” to make the sort of generalisations that illuminate the debate, unlike, “individual patients who are personally grateful or aggrieved”.
So much for patient-centred care: in this book, patients seem marginalised from the outset. But – in direct contradiction of their stated methodology – Ashcroft and Oakeshott immediately go on to describe one patient’s story after another. And guess what? Each of these carefully curated pieces of testimony is wholly negative in nature. Not a single positive patient experience is depicted.
There’s the 59-year-old who dies from an undiagnosed ruptured abdominal aortic aneurysm, and whose case allegedly epitomises “the sort of low-level bad care that takes place every day in the NHS alongside care that is fair, good or outstanding”. There’s the octogenarian who has taken an overdose of paracetamol on top of her pre existing heart, liver and kidney failure and who may – or, more likely, may not – have died from being given penicillin in hospital, yet who is presented unequivocally as a failure of NHS care. There’s the Bengali patient who doesn’t speak English, suffers cancer bone pain, and who is “arbitrarily” moved from a ward where he had settled in well to an “unsuitable” ward where the human side of his treatment is missing.
For a book that claims “not to denigrate the NHS but to act as a critical friend”, this skewed selection of patient case studies is tedious. Worse, the stories are shoddily reported. If you must use an individual case of substandard care to trash an entire healthcare system, then at least take the trouble to find out what the medical terms involved in that case actually mean. Peritonitis is not, for instance, as the authors claim, “inflammation of the inner lining of the stomach” but refers to the entire abdominal cavity from liver, spleen and stomach at the top, all the way down to bladder, ovaries and appendix at bottom. Getting these basic facts wrong is lazy.
The most notable example of selective reporting is the authors’ decision to use an interaction between one particular patient and surgeon to paint a lurid picture of NHS end-of-life-care in general, which they suggest is as callous as the decisions of the Roman emperor in the film Gladiator, who “signals who lives and who dies with a casual thumbs up or thumbs down”. In the Isle of Wight, where the patient, a grandfather of nine, lived, there is – the authors claim – “a creeping sense that some elderly people are being quietly written off”. Too few clinical details of the patient’s case are provided to determine whether or not this dramatic conclusion is warranted. What is striking, however, is how casually Ashcroft and Oakeshott leap from one sketchily outlined case to the grandiose conclusion that: “there was nothing very unusual about what happened here. No great drama: just the NHS casually underperforming and devastating another family.”
In this superficial romp through the NHS’s failings, I spotted all the tired old tropes: incompetent managers, vested interests, venal doctors, bottomless money pits, health tourists, British Medical Association apparatchiks, comically inept IT. Afterwards, like someone forced to binge-read the Daily Mail, I felt desperately in need of a restorative purging.
Most telling are the author’s proposed solutions to NHS failure. We should address understaffing not through a properly costed and funded workforce plan, but through a Dad’s Army of volunteer NHS reservists. We should use apps to magically eliminate NHS “bed-blocking” (a phrase I detest, and that stigmatises patients). We should sell off swathes of NHS real estate. Bash money-hungry consultants into submission. Oh, and target the obese (as opposed to the obesogenic society they inhabit) since obesity is not an acceptable “lifestyle choice” and the body positive movement “should be recognised as grossly irresponsible”.
This is, in short, a spectacularly disingenuous book. Its core is the authors’ neoliberalism and their thinly disguised loathing of collective responses to individual misfortune. Ashcroft and Oakeshott are clearly infuriated that the NHS reliably tops polls of what makes the British most proud, bitterly lamenting the population’s “wilful deafness” to the NHS’s flaws. Apparently, it has never occurred to them that you can be achingly aware of how urgently the NHS needs improvement while remaining committed to the principle that everybody, especially society’s most vulnerable members, deserves to be scooped up and supported when disease, injury and catastrophe strike.
The real reason we cherish the NHS is obvious, isn’t it? As the author Mark Haddon once wrote: “I love the NHS because we pay for it with our taxes, and because the care we receive is the same whether we’ve paid a million pounds or nothing… The true worth of the NHS is not that it saved our family. It is that it would make the same effort for every family, even if that family were destitute.”
Ashcroft and Oakeshott may have hoped to disguise their rampant individualism, but the pages of this nasty book are absolutely steeped in it.
Life Support: The state of the NHS in an age of pandemics
Michael Ashcroft and Isabel Oakeshott
Biteback, 480pp, £20
Rachel Clarke’s most recent book is “Breathtaking: the UK’s human story of Covid” (Abacus)
This article appears in the 16 Mar 2022 issue of the New Statesman, Russia’s War Goes Global