Happy Birthday, NHS, and Thank You

In July 2011, I was working in a hospital in Mwanza, a city in northern Tanzania — I was a fourth year medical student on a short elective placement, taking a period of time to experience healthcare in another country before my final year started and with it finals and job applications. In my brief time in Tanzania, I fell in love with it; with its land and people and culture; and in return it taught me a huge amount about a world wider than I’d known existed, and about my own privilege and the things I’d been taking for granted for the past two and a half decades.

On my last day, my supervising consultant asked me about how healthcare works in the UK. I explained it to him in, more or less, the words of the leaflet that was sent to all UK households in the lead up to July 5th 1948:

“It will provide you with all medical, dental, and nursing care. Everyone — rich or poor; man, woman or child — can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a “charity”. You are all paying for it, mainly as tax payers, and it will relieve your money worries in time of illness.”

He asked a few questions about how it worked, about how the tax system worked, about what happened to the young and the retired and the sick and the unemployed. I tried to answer his questions. I quoted the principle that those of us who champion the National Health Service hold to be true: the principle of a system of universal healthcare, delivered free at the point of need.

He said with a kind of wonder: “But that’s a marvellous thing.”

*

It is a marvellous thing.

The NHS is a marvellous thing that until that point, that day, I had been absolutely sure of and had taken absolutely for granted, like the sun coming up.

And today it celebrates its seventieth birthday.

There’s been a cultural shift in the years since I returned home that summer, seven years ago. The shift of government to be meaner, less welcoming, more inward looking. The elevation of voices that are hostile to evidence and expertise, and the collateral silencing of experts and professionals. The consequences of austerity. There was a time in my adult life when I never thought I’d have to fight for the NHS. There are days now when that seems as if it was an awfully long time ago.

I have had reason to be grateful for the National Health Service for many years — among other things, I am the daughter who only ever had a father because of a kidney transplant performed by the NHS and the child who is alive because of maternal and neonatal services provided by the NHS. But my reality is also that as an adult, I have experienced the NHS almost entirely as a doctor who lives her life at the coalface of medicine.

That changed earlier this year.

There is a story to be told here. It is a story that has been told in waiting rooms and during difficult phone calls and alluded to piecemeal on social media. It is a story that I’ve been needing to tell in its fullness, and today seems the time to tell it.

This is the story of my mum’s death.

And it is also the story of how I ended up in the cafeteria of a strange hospital late at night, thanking God and Nye Bevan for the bold and miraculous hope of a system of healthcare for everyone, paid for by everyone, and delivered free at the point of need.

*

On January 31st, 2018, my mum celebrated her sixtieth birthday. It was a Wednesday. I was at work. I’d sent her a card and flowers. I checked my emails at lunchtime, and had one from her letting me know the five person dinner she had planned for that weekend had grown somewhat in the planning of it and that I should plan to make chicken curry for twenty people. I rolled my eyes and sent her a shopping list (“chicken breasts — enough for hungry people”). I arrived in Newcastle that Friday evening, and we had a nice evening and a nice Saturday together, watching television and fantasy house shopping on the Internet and preparing food. For once, we managed not to have a row about anything.

A few hours before her guests started to arrive, she started to feel breathless. She had had asthma for most of her adult life, and had had a bad winter of coughs, colds, and chest infections, but had been well for the last week or so, better than she’d felt in months. She was adamant that she didn’t need to see an out of hours GP or go to the emergency department — after all, people were coming. She would use her inhalers and have a lie down and be fine.

She wasn’t fine.

It eventually became clear even to her that her salbutamol inhaler wasn’t going to do the job this time, but by that time she had become so short of breath she wasn’t able to speak more than a few words and she wasn’t able to stand up on her own. And, of course, by that time, her living room was full of people. As I was dialling 999, she was still trying to find the breath to ask her sister if she was sure it was okay for her to go to hospital when there were all these people in the house expecting food and a party.

Paramedics from the North East Ambulance Service arrived with lights and sirens, and for a little while it seemed as if it all might settle down with a nebuliser and some oxygen. My memories of the next few minutes are incoherent and are in flashes: from her oxygen levels starting to climb, to her being on the floor with her head between my knees so I could help manage her airway until extra hands arrived, to another four paramedics thundering up the stairs, to us being kicked out of the room, to the moment when I heard someone say that they had lost cardiac output.

And that was when I was unwillingly thrust into a role that I’d never prepared for: being someone whose role in the massive machinery that makes up the NHS was to be not the doctor. The last time I had been at work, which at this point seemed like a lifetime ago but was in reality only two days earlier, I had been the cardiac arrest team leader. Now, I was the relative. I was the person panicking on the other side of a wall, waiting, waiting, waiting, with my aunt and my stepsister and my mum’s husband, and I was listening to someone else run my mum’s cardiac arrest in the next room. I had sent a text message to my family back in Glasgow when I’d left the room, which meant I had a timestamp, and, let me tell you, when you’re a healthcare professional who’s listening to someone else do CPR on someone you love, a timestamp is the worst imaginable thing to have. Because I knew when it had been twenty minutes, and when it had been thirty minutes, and when it had been forty minutes. And I can’t turn off the part of my brain that knows what it means when someone hasn’t had a cardiac output for forty minutes, even if they have had the best possible quality CPR anyone could ever have had. There were nine paramedics and a doctor in the house by that time, not counting me. I couldn’t turn that part of my brain off even when that someone was my mum.

When they got her back. When they carried her down the stairs of the house I grew up in. When we all breathed again, for a few minutes. The thing I remember about it was that the first paramedic came back, to make sure that all their mess had been cleared up and that we wouldn’t come home to find syringes or Guedels on the floor. And when I tried to thank her, she said to me, “It isn’t over yet.”

My mum had exemplary care after she left her house that night. She was taken to the resuscitation room in the emergency department, and then almost immediately to the intensive care unit. My family and I were told exactly what was happening. I don’t think any of us slept when we left the hospital, but I don’t think any of us doubted that she was being left in safe hands and given world-class healthcare.

The days that followed that night were some of the longest of all our lives, but we never had reason to doubt that.

The life of an ICU visitor is a strange one; it exists in its own part of the time-space continuum. I had never spent any significant time in a high dependency area of a hospital in a context that didn’t involve me carrying three bleeps and a jobs list the length of my arm. It turns out that for other people, time in those parts of a hospital is about waiting, and watching, and wondering. It was about all my family — my family of origin, the ones who had already been there, and my other family, the ones who’d dropped everything to drive to me from Scotland when they got that first text message — camped out in a corner of the waiting room, telling stories and drinking too much hospital coffee and waiting for news. It was about sitting on my hands so that I would stop trying to react every time something bleeped, and getting to know all of the nurses, and trying not to think too hard about what I thought I already knew.

We waited for four days.

Do you have any idea how much an intensive care bed costs for four days?

At the end of the fourth day, we were given the results of the investigations she had had to determine how much of her brain function had survived when she had had an out of hospital cardiac arrest on her bedroom floor.

The answer was: not much, not enough to be taken off a ventilator, not enough for her to ever have anything like a meaningful recovery.

It’s like I said. I hadn’t been able to turn off the part of my brain that knew what it meant when someone hadn’t had a cardiac output for forty minutes. Not even when that someone was my mum. Maybe especially because that someone was my mum.

In the next 24 hours, she had some of the highest quality palliative care I’ve ever had the privilege of witnessing. She had time for everyone who loved her to come and see her, to say the things they needed to say. I spent part of that time telling her that I wasn’t sorry about the times we had argued; just because she was dying didn’t mean she hadn’t been wrong all those times. She would have expected nothing less of me. As a family we asked to explore the possibility of organ donation; something that ultimately wasn’t possible but that the transplant coordinators did their best to facilitate for us and for her. She was comfortable and looked after, and there was nothing that was too much trouble for the nursing or medical staff. In the dark hours before dawn, I remember being brought a cup of coffee by Sister and her apologising that it was too strong. “Don’t you dare apologise, it’s 5am, it’s fantastic,” I said.

My mum died a little after lunchtime on Friday 9th February, peacefully, with dignity, surrounded by the people she had loved.

*

I have a lot of memories of the week before she died. I’ve written here about only some of them.

One of the things I remember most clearly is from just 24 hours after she was admitted to hospital. I was sitting in the hospital canteen. I was alone for a few minutes. My memory is in some ways the answer to that question about knowing how much an intensive care bed costs for four days, because the answer is that I don’t know, and that I still don’t know.

My mum had the best possible chance at life and the best possible death, and all the way through she had access to the best healthcare in the world.

It was free at the point of her need, just as it had been for her whole life. We have been charged no money for the care she had. We will never be sent a bill or expected to write a cheque.

That moment in the canteen of the Royal Victoria Infirmary was when I thanked God and Nye Bevan for the bold and miraculous reality of the NHS.

*

On July 5th 1948, the Secretary of State for Health visited what is now Trafford General Hospital and met the first patient of the National Health Service, a thirteen-year-old girl called Sylvia Diggory. Later, she said, “Mr Bevan asked me if I understood the significance of the occasion and told me that it was a milestone in history — the most civilised step any country had ever taken.”

It isn’t perfect. There are things that we can do better. There are always things we can do better. There are things that go wrong, and those things should be taken seriously. There are days when working in it the whole enterprise feels as if it’s held together with a piece of string, the power of cake, and the goodwill of its one and a half million employees.

In spite of that, I still believe that it can be everything that Attlee and Bevan wanted it to be; that it is an aspirational thing that at its best represents the best of us.

And it is worth me saying this:

That my mother and I agreed on nothing, politically, but this, this we agreed on.

I work for the NHS. I will always work to make it better, to make it into the best possible version of itself, and I will always work against the unscrupulous and uncaring whose only goals are devaluation and privatisation.

But today the National Health Service celebrates its seventieth birthday, and all I am today is grateful for everything it stands for and for that week when it was a very real light in the most terrible darkness.

It is a marvellous thing.

It is a miracle.

And it can and should be the very best of us.

Have We All Survived Changeover?

*clears throat*

Doctors.

How are you all doing?

It’s just about a month now since changeover. I hope that’s time enough for you to have figured out where the toilets are, and how to get hold of psych on call in the middle of the night, and which of your seventeen computer passwords is the correct one to make a CT scan happen. It’s not quite enough time yet to have unlearned the learned response for the way to do things in your old hospital, though; your hospital, where you knew everyone’s name and you knew the protocol for prescribing vancomycin without asking a pharmacist, two nurses, and an FY1. It’s not quite enough time for your new hospital to feel quite like your hospital yet, or for you to not still feel just a little bit at sea.

FY1s, have you stopped needing to suppress giggles yet when you tell people that you’re a doctor? Are your seniors being reasonable and helpful? Are you getting to teaching? Are you remembering to eat and drink? Are you okay? If you are not okay, have you found someone to talk to about that?

I am sort of aware, FY1s, that it would be comforting if I let you believe that the confusion and weirdness of August changeover is inversely proportional to seniority and that it gets less weird and confusing after you’ve done it a couple of times, but, for many many reasons, that would be a lie.

In August, there are new medical registrars who have never had to be the med reg before. FY2s have just completed their first month of being the SHO, and that’s a big step up. All over the NHS, junior doctors have started new training programmes and been given new responsibilities and some are doing it in new Trusts or Deaneries that are entirely foreign to them and where their support networks are not. August is scary as hell. This is why we all walk around the whole month looking like Sputnik just landed on our heads. And for the record, I’ve been working in my Trust for four years and I’ve been working mostly at an SHO-equivalent level for those same four years, and August is still scary as hell. I’m a quarter of the way through this rotation, and I still have not learned everyone’s names or the intricacies of my very specialty-specific and very new-to-me computer system or how a kidney, you know, works.

FY1s, let your comfort if you need it be that every year from now until the end of time we are all in this particular period of weirdness together.

So, therefore, how are the rest of you doing? Are your seniors being reasonable and supportive? Have you found your educational supervisor yet? Have you worked out who exactly it is that you’re on call for? Are you even as we speak lost in the rabbit warren of interventional radiology in a hospital whose layout you still do not quite understand and need one of us to come let you out? (Is that one just me?) Do you need a hug?

Welcome. Pull up a patch of floor. We’ve got cookies and coffee and mutual terror and spare copies of Cheese and Onion.

Change

It’s changeover day on Wednesday. I went to the supermarket after work today, and almost without thinking about it I did the sort of grocery shop you do when you’re about to go onto a run of nights. I haven’t done nights since the Commonwealth Games, but in my new job I’m starting on Team Nightshift.

In this job, as a trainee, a year is a long time to stay in one place. I’ve been here through the FY1s and SHOs switching jobs in December and again in April, and through the registrars changing over in February. And now that everyone is moving again, it’s time for me to go too.

People keep asking if I’m looking forward to leaving, which isn’t a question with a straightforward answer. I’m looking forward to starting my new job, but I’m not exactly looking forward to leaving this one. I’ve grown comfortable in it where I am. It’s been a long time since I’ve been the new girl; even on my weekend locums, it’s mostly been going back to jobs that I’ve done before and places where I’ve been remembered. I’m going to be brand new on Wednesday, in a hospital and a department that I’ve never worked in before, and, due to rota complexities, am going to be brand new all over again next Monday. My most oft uttered words for the next fortnight are going to be a variation on, “where are the venflons?” or maybe, “where are the toilets?”.

This time of year is weird for more than just the FY1s.

The job I’m going to is the beginning of the training post that I wanted all along. It will be good for me, and it is the next step in the journey of what I really want to do with the rest of my life.

My gap year came on me unexpectedly, taken for geographical reasons rather than career reasons. I’ve learned a lot about haematology and developed a lot of transferrable skills; I’ve passed two parts of my MRCP, I’ve audited some things, some of them important things; I’ve worked with some brilliant people; I’ve run a marathon; and I think, maybe, in a roundabout sort of way, I’ve figured out what I do want to do with the rest of my life. Not a bad year for a year that I hadn’t really been looking to take in the first place.

The first Tuesday in August is always a bit bittersweet, I think. I’ve liked this job and I’ve had a long long time to get settled in it, and that makes it just that bit more unsettling than usual. But it’s time to move on.

“Scarecrow,” said Dorothy. “I think I’ll miss you most of all.”

Four Hours in A&E

I was driving home last night when I heard on the Radio 4 evening news that one of the top stories was a failure of emergency departments in England over the last week to meet the fabled “four hour target”.

The four hour target, which was introduced by the Department of Health in 2003, states that 95% of people attending emergency departments in the UK should be seen within four hours.

Or that’s what I hear every time there’s a news item relating to this target, so let’s clear up a couple of things.

And the first thing is that the four hour target states that 95% of people attending emergency departments should be triaged and seen and treated and moved out of the department within four hours.

I’m not quibbling the rights or wrongs of the target; we could go round and round on that forever. It’s an arbitrary number. It’s been the same arbitrary number for eleven years. That allows us to measure and compare and I suppose gives part of the impetus to improve performance. It has as much value as any other number that might have been chosen, which is to say that it has enormous statistical value and absolutely no moral value.

The target is what it is, but if we’re going to let the media take the NHS to the cleaners every December for a target that it’s failing to meet then I think they should be obliged to talk about that target as it is.

Even with those parameters, the four hour target was achieved for 91.8% of people attending emergency departments in England in the first week of December.

And that figure says something, but it doesn’t say that 8.2% of people attending English emergency departments last week were still in the waiting room at the four hour mark.

We don’t have any December figures for emergency departments in Scotland yet, but the media presume that they will be comparable with England. Last weekend, I was the receiving medic for an inner city Scottish hospital. I spent the first weekend of December trapped in ED (and I do mean trapped — I ate only because my FY1 delivered lunch and caffeine to me, which probably qualifies as abuse of one’s juniors on my part). I cut through the waiting room a lot. That less than 10% of patients were in the department for longer than four hours is fairly remarkable to me.

So far as I can tell, the patients who are well enough to be discharged home straight from ED are not the ones for whom the target falls down (although it isn’t difficult for me to envision a situation in which that process as a whole could take longer than four hours). The target falls down for the patients who are seen and, having had their treatment started, need to be admitted to the hospital.

There is a bed crisis in hospitals in the UK. I don’t know if you’ve noticed. It hasn’t been caused by doctors or nurses or AHPs, who consistently work their socks off and then some. From what I’ve witnessed, it is for the most part being caused by inappropriate attendance at ED less than politicians would like us to believe. It is being exacerbated by those same politicians, who bafflingly seem to think that closing hospitals and reducing the number of available beds is the way to fix it.

(Spoiler: It’s not.)

If a person needs to come into one of those beds, they will be found one.

If the specialty to which they need to come does not have a bed available right now, two things will happen.

First, we will come to you.

You’re having an asthma attack? We’re not going to withhold oxygen and nebulisers until you get to the respiratory ward. You have a raging infection? The cupboards in ED have antibiotics too.

Second, we will keep you in a place of safety.

And it breaches the four hours and governments don’t like it and patients don’t like it and the media sort of love it, but emergency departments are a place of safety. And are better for patient safety than transferring unstable patients to a non-ED bed across a city, or giving a less sick patient a higher priority for a bed than a sicker one merely because of waiting time, or discharging patients inappropriately. And the days when those things are true are more frequent than anyone who works for the NHS would like them to be, so when they are true we do the very best we can with what we’ve got and we go home at the end of the day knowing that we worked for the good of our patients and not for obedience to a government target.

Promises and Prayers

On 5th July 1948, the National Health Service launched in England and Wales.

As a country, we had been nudging towards the establishment of universal healthcare for decades. The first real step had been taken by David Lloyd George in 1911 with the passage of the National Insurance Act. The real conversations took place against the backdrop of the Second World War, culminating in 1944 with the publication of the White Paper by Henry Willink, the then Minister for Health. And when the war was over, it was the son of a Welsh coal miner who brought together the ideas of the last thirty years into a vision of a body that would provide healthcare to all, irrespective of their social class or employment status or origins, paid for by everyone as they were able and in return delivering healthcare free at the point of need.

That was 66 years ago tonight.

Tonight, I remember Nye Bevan whose dream became a life-saving reality.

I give thanks for my colleagues in the NHS and for those who went before us. I give thanks for the joy of spending my days in its service. I remember with gratitude and hope and sorrow and joy all those who have passed through the doors of my corner of the NHS, for lives lived and lives lost and lessons learned. I give thanks for my life, too, and for the lives of those whom I love. I pray that we will not be blinded to our faults and imperfections, or afraid to do better.

The future of the National Health Service has never been more uncertain. It has survived through economic crises and political “reform”, and yet the threats to it loom larger than ever before — all the larger for so often being insidious and only visible in the corner of our eye.

And with profound thanksgiving for all that it is and with fear for all that it must not be allowed to become, I remember these words from the revised Hippocratic Oath:

I will respect each of my roles, as expert, communicator, scholar, partner, manager, teacher, professional, and health advocate.

I recognise that I have responsibilities to humankind that transcend diktats and orders of States, and which no Legislature can countermand.

I will oppose health policies that breach internationally accepted standards of human rights.

Wishlist for 2014

These are not resolutions in the proper sense, partly because I think that if I were to make a New Year’s resolution in the proper sense, it would look something like “fail slightly less at functioning as an adult person”, and I am probably not alone in that.

However, in 2014, I hope…

  1. To continue having gainful employment in this job that I love in this city that I love.
  2. That the Commonwealth Games will make everyone else in the world see why I love it.
  3. To see the continued passage of equal marriage through the Scottish Parliament, and to see the first same-sex marriages in England and Wales.
  4. To run the Great North Run again, a bit quicker and with a bit more proper training and this time to raise money for Kidney Research UK.
  5. To make more time to read more.
  6. That we will end the year as we began it, with Scotland in full communion (if you will) as part of the United Kingdom. #bettertogether
  7. To pass my blasted exam at some point, be that in two weeks or four months or eight months.

And, although these are still not resolutions in the proper sense, being more political than that, I also resolve:

  1. To make quite a lot of noise about marriage equality at the 2014 General Synod of the Scottish Episcopal Church.
  2. To continue to work for the good and the best interests of all my patients, no matter who they are or where they come from, in accordance with the founding principles of the National Health Service and with an oath that I swore one rainy day in July. (Screw you, Jeremy Hunt.)