The festival of Britain

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Britain. 1950.

Cities are still pock-marked by rubble-filled bomb sites. The country is peppered with disused airfields and military bases. There is still rationing, and compulsory military service. The Cold War is heating up. The Morris Minor is the family car of choice.

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The Labour government, which is about to lose out to Winston Churchill’s Conservatives in the 1951 general election, has nationalised the rail networks and the coal mines. British Airways is under government control. King George VI is sits on the throne, and will rule for two more years before being succeeded by his daughter Elizabeth. As well as being King of England, he is the head of a shrinking empire that still includes many African and Middle Eastern countries.

The first commercially available programmable computer won’t be launched for another year.  The first email won’t be sent for a decade. No one has heard of rock and roll – Paul McCartney is 8 years old. The first commercial mobile phone is more than 20 years away from launching.

The government decides to fund a celebration of all things British – the Festival of Britain. And, in Twickenham, a group of women put together a tapestry consisting of 100 squares, each square with a picture and text representing a year from 1851 to 1950.

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Detail of the tapestry

Some years were easier than others to assign. 1914 to 1918 was dominated by the Great War, with events like the invention of the tank and Armistice Day. Technology and transport feature heavily, with the Wright Brothers, Louis Bleriot and Amy Johnson each getting a square (see above). 1928 celebrates equal voting rights for women.

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Just two years after its inception, the square for 1948 is given to the “National Health Act”, with the word “FREE” dominating the square. It’s clear that people recognised the nascent NHS as something special, even when it was only two years old.

Of course, predicting the future is a tricky business. The decision to give 1948 to the NHS may be uncontroversial in retrospect, but the square for 1949 was allocated to the Brabazon, a huge propeller-powered airliner designed to revolutionise trans-Atlantic travel. There’s a reason why you’ve never heard of it – only one prototype was ever built, and development was quietly abandoned in 1952. The prototype was sold for scrap.

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Brabazon prototype

The NHS has aged better than the Brabazon – it is approaching its 70th birthday. It’s not in such bad nick, for a near septuagenarian. Let’s hope it has many more years to live.

The tapestry is on display and can be viewed for free in London’s Royal Festival Hall foyer.

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Collective Abrainia

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It’s been a pretty strange few weeks in the world of politics. Theresa May is about to become Prime Minsiter of the UK, and her key virtue seems to be that she hasn’t said or done anything stupid in the last month. All she needed to do was keep quiet and wait for her rivals to come down with politically fatal collective abrainia* and sabotage each other and themselves.

Amidst the huge publicity around the EU referendum and Brexit, there has been another referendum and another resignation that has largely slipped through unnoticed. Unless, that is, you are a junior doctor.

The achievements of junior doctors during the last year have been remarkable. Without giving up their (quite demanding) day jobs, they have organised and fought a campaign including unprecedented strike action. They have maintained public support while up against a Government spin machine working at full tilt, helped by a compliant majority of the media. Doctors have attended marches, written blogs and made videos, appeared on TV and written articles in newspapers. They set up a table outside the department of health and manned it for weeks waiting for Jeremy Hunt to appear for negotiations. During strike action, they set up free classes to teach CPR to grateful members of the public. And doctors everywhere have engaged the public in this debate and helped to educate them about the issues.

After months of political to-ing and fro-ing, of strikes and marches, of the Government sitting down to negotiate, walking away, then returning, it was finally announced that a compromise had been reached. And then, the shiny new improved version of the contract, which was agreed between the government and the BMA junior doctors’ council, was put to the vote among junior doctors…and was rejected by 58% to 42%.

Johann Malawana, the chair of the BMA junior doctors’ council, who led a moderate and reasonable fight against the original unfair contract, has followed David Cameron’s example and resigned. He had supported the new contract as a reasonable compromise, but he couldn’t persuade his electorate to agree. The metaphorical removal vans are drawing up outside BMA House as I type.

Some no-voters have genuine concerns (for example that the new contract will discriminate against women, and that limits to working hours will be poorly policed), but many were fuelled by non-specific anger. “Is this really what we’ve been fighting for?” was the collective response to a contract that seems underwhelming, and similar in many ways to the original hated proposal.

What next?

nobody knows

Much like the vote for Brexit, doctors who have voted “no” have voted for the unknown over the known. They have not voted for any particular alternative, because none has been presented.

Hunt has said he will impose the contract. There is still the question of whether this is legal, and a group of doctors are mounting a crowd-funded legal challenge. The new chair of the BMA junior doctors’ council has said that strikes are back on the table.

A separate question is whether Hunt will stay in charge of the NHS under a new PM. Doctors will be hoping that the answer is no. If he goes, his replacement will inherit a mess.

A new person in charge of the Department of Health, with a new Prime Minister above them, could go some way to repairing the huge breakdown in trust between doctors and the Government. Rebuilding some of the bridges between medics and politicians that Hunt has napalmed in his tenure as Health Secretary should be their first priority. Once that is addressed, they could move on to dealing with the more trivial issues such as the ongoing financial meltdown in the NHS and understaffing in many hospitals.

I hope that the contract dispute can be resolved, and junior doctors can all get back to doing what we signed up for. But after the month we’ve just had, it would take a braver person than me to make any predictions.

 

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* Abrainia: an illness in which the sufferer, usually a healthcare professional politician, behaves as if lacking a brain

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A Walking, Talking Miracle

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It was a normal working day, and I received a very normal phone call. A new patient needed to be admitted by a doctor, and that task would obviously fall to me, as the newest and most junior member of the surgical team. I looked at the clock – half past four. This would hopefully be my last job of the day.

Up on the ward, I glanced at the patient’s details. His name didn’t mean anything to me, but I saw that he had come in for a hernia repair the following day. Most hernia repairs are done as a daycase, so I guessed if he needed to come in the night before the operation he must be quite frail. I looked across at his age. 42. Odd.

He didn’t look frail or sick. We ran through the surgical details quite quickly. When it came to asking about his past medical history, he answered the question quite oddly.

“I don’t have any health problems now” he told me, “but I used to have cystic fibrosis”.

I learnt about cystic fibrosis at school, and again at medical school. It’s a genetic disease, caused by inheriting two faulty copies of a specific gene. People with the condition suffer from a build-up of mucus in the lungs, and tend to suffer from repeated chest infections. Antibiotics and physiotherapy help, but I had thought the underlying condition was incurable. I asked for an explanation.

He told me that during his teenage years and as a young adult, he had spent almost half of his time in hospital on heavy duty antibiotics. He was not expected to live many more years. After a particularly bad infection, during which he nearly died, he was offered a lung transplant. He pulled through the operation, and had never looked back. Since he had been discharged after his transplant, he told me, he hadn’t spent a single night in hospital. “Each morning” he told me “I wake up, take a deep breath in, and feel lucky to be alive. I’m a walking, talking miracle”.

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Modern medicine is pretty amazing. We have drugs that can render you unconscious so you don’t object to being opened up and fixed. We have (for now) drugs that can get rid of unwanted bacterial freeloaders. We have drugs that kill off cancer cells, but spare their healthy neighbours. We have telescopes that can peer into pretty much any orifice and take samples of your internal organs. We can feed wires into your arteries and open up blockages. Often, we can fix damaged organs with medicines or with surgery.

But if we can’t fix what is broken, we now often have the option of giving you a new one. Kidney failure..? Have a new kidney. Liver failure..? A liver transplant. Severe burns..? A skin graft. Your pancreas, heart, lungs, even limbs can be transplanted.

Of course the surgery, in someone who is usually pretty sick to start with, is dangerous. Transplants usually require the recipient to be on life-long medication to prevent the new organ from being rejected, and the new organ may not last forever. But it is still one of the most amazing things that modern medicine is capable of. I left hospital that day with a renewed sense of wonder at my job.

You might donate a kidney to a loved one, but in the world of transplant living donors are the exception rather than the rule. Each transplant might represent a miracle for the person receiving a new organ, but many transplants are born from tragedies. In England, only about 60% of people who could donate an organ actually do so. Often, if they haven’t expressed any advance wishes, the decision is left to their families. It must be an agonisingly difficult decision to make.

In Wales, the law recently changed so that consent for organ donation is assumed, unless someone has chosen to opt out. Opt-out rates are very low, and the number of transplants has jumped up by around a third in the six months since the new law came in.

It’s a small good news story, at a time when they are rather hard to come by.

 

If you live in the UK, sign up to the organ donor register here. Unless you live in Wales, in which case there is no need! Don’t forget to discuss your decision with your next of kin.

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When breath becomes air – Paul Kalanithi

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A book review

This book opens with a stark scene. Dr Paul Kalanithi, a neurosurgeon about to finish his training with flying colours, studies a CT scan. The scan shows a body riddled with cancer. He’s seen hundreds of similar scans in his training. But, he remarks with characteristic economy and understatement, this one is different. It is his own.

After this startling opening, the book looks back to his motivation for becoming a doctor and scientist, inspired by philosophers, poets and writers more than by his cardiologist father. His literary background is clear from his writing style, full of quotes from poems, plays and novels.

With his terminal diagnosis, Kalanithi has time to confront his imminent death. All that he has worked for, for so many years, is snatched away by his ill health, just when it seems within his grasp, but he still wonders whether he should feel grateful for his cancer, as an answer to his constant self-questioning about the meaning of life.

His reaction to his cancer diagnosis is to re-evaluate his priorities in life. He is frustrated by the lack of a precise prognosis. If he had only months to live, he might spend it entirely with his family. If he had a year, he would write a book. If he had ten years, he would keep pursuing his medical career. In the end, he does all these things. He has a baby, conceived by IVF while he is having cancer treatment. He doses up on painkillers, and goes back to finish his residency as a neurosurgeon. And he writes his book, this book, in snatched hours between shifts in the operating theatre, between cancer treatments, in waiting rooms waiting to see his oncologist, and on the chemotherapy unit.

The doctor-patient relationship occupies a lot of his thoughts in the book. As both a patient and a high-flying doctor, he sees things from both sides. A resident he encounters forgets to prescribe one of his cancer drugs, and then refuses to rectify his error because it will mean admitting it to his boss. By contrast, Kalanathi’s oncologist, Emma, gets almost everything right. She is optimistic and practical, and it is she who correctly predicts that he may wish to return to operating after his first cancer treatment. But later, after he has a bad reaction to a chemotherapy treatment, she recognises his need for emotional rather than practical support. Having steadfastly refused to give him any survival statistics, she comes out with the line that he still has five good years. He knows she is lying, but is still grateful.

“There we were, doctor and patient, in a relationship that sometimes carries a magisterial air, and other times, like now, was no more, and no less, than two people huddled together, as one faces the abyss”

That “abyss” is something that we can only learn about from second-hand experiences, as people who have entered it don’t tend to write about it. Doctors, and particularly neurosurgeons, have more second-hand experience of death than most people. Kalanathi finds that his experiences can’t tell him what he wants to know about death itself. But the way he faces his mortality tells us a great deal about life, and how to live it.

Paul and his partner have put off having children until the end of residency – after his cancer diagnosis, knowing that his time is short, they decide to have a baby.

Don’t you think saying goodbye to your child will make your death more painful?” asks Lucy. “Wouldn’t it be great if it did?” he replies.

In an email exchange with a friend, he quips that he’s already “outlived two Brontës, Keats and Stephen Crane. The bad news is that I haven’t written anything.” He sets about fixing this in the time he has left, and his elegant memoir is the result.

The book begins with a jolt, and it ends with a jolt. Abruptly, Kalanithi’s wife takes up the pen, and describes his last few days. He didn’t know how little time he had left, and neither do we as his readers. The loss of his voice, after getting to know and like him over the course of the book, hits home just as hard as the details of his death, laid out with a bare simplicity that perfectly complements the style of the rest of the book.

The shortness of the manuscript is bittersweet – there were certainly many more words he would have liked to have written. But his diagnosis forced him to make every one of them count.

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Winning the battle and losing the war

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I can recall the exact moment I first heard about the new junior doctor contract.

I barely believed what I was hearing. Pay cuts, after years of pay falling behind inflation. Barriers to unsafe working hours removed, after they had proved so successful. Discrimination against women, from one of the few UK employers that offered equal opportunities. Could it really be true?

If that same person had told me that the dispute would lead to the first all-out strike in NHS history, I would not have believed it. I would not have expected the Government to push a flawed contract so hard. And, if they did, I would not have believed an apolitical bunch of junior doctors could be so united.

But, here we are, after the all-out strike. To the surprise of the Daily Mail, and the Health Secretary, the NHS is still standing.  Our NHS colleagues covered expertly.

The unanswered question on everyone’s lips is – what next?

Here are some things that could happen now…

  1. More strikes

The last two days have proved the concept – an all-out strike by junior doctors can be achieved, without endangering patients on those days. So, why not have more?

Here’s the downside. For each strike, lots of planned operations, tests, appointments and scans have been cancelled, to focus on covering for the striking doctors. This disruption is necessary to keep emergency patients safe, and of course, a strike has to cause disruption to be effective. But the more strikes there are, the more people this will affect. What about the person with cancer who needs to see a doctor and start urgent treatment? What about the man with critical coronary artery disease whose heart bypass is cancelled?

If the junior contract as it stands is dangerous for patients, then  some temporary inconvenience to them now can be justified by their long term gain when the contract is fixed. But an all-out strike has already failed once to generate a reaction from Government, so why would a second one help?

And doing the same thing again risks losing the attention of the public. Top Gear gets fewer viewers when it’s repeated on Dave, and it was clear from the previous set of strikes that the Government (and the media) was less interested in repeats.

  1. Escalation

The all-out strike didn’t persuade the Government to back down. Another all-out strike probably won’t either. So, is there an argument for doing something bigger?

Some doctors think so. One junior doctor resigned live on television recently, and others have published their resignation letters on facebook and twitter. Mass resignations have been talked about. Not everyone will resign, but even a small proportion of resignations could make services very difficult to run properly.

There are other ways action could be escalated. An all-out strike that included nights and evenings would be much harder to cross cover with consultants. There has been talk about an indefinite strike.

But escalation comes with a downside too. The higher the impact of the action, the more damaging it is likely to be for patients. So far, the public support doctors. Raising the stakes further is a gamble, and the goodwill, once lost, will be hard to get back.

  1. Ceasefire

What will another strike achieve? It doesn’t seem likely to force the Government back to the negotiating table. There is no “nuclear option” that wouldn’t harm patients, which we won’t do.

In that case, perhaps further strikes would have no great benefit and the logical thing to do is to cease hostilities. But a temporary ceasefire doesn’t clearly lead to a resolution.

 

Winning the battle, losing the war

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Looking into the Abrainia crystal ball, I see a drawn-out series of strikes, perhaps supported by the public and other NHS workers, but steadfastly ignored by the Government.

I see doctors refusing to back down, but refusing to escalate to any action that actually will harm patients.

I see a Government closing their ears, humming loudly, and pretending that they can’t hear. I see politicians who regard backtracking after a strike in the same way they regard negotiating with terrorists. Give an inch, and suddenly the whole public sector will be on strike. Better to make an example of the junior doctors, even if it drives them away from the NHS.

I see significant numbers of doctors leaving training, or declining to take up training posts. I see applications to medical school falling. I see the understaffing on all of our rotas getting steadily worse.

I see the Government triumphantly winning the battle and losing the war, imposing the contract while significant numbers of doctors walk away to look for a job where they are more highly valued. I see the chronically underfunded Health Service losing the goodwill of the people who hold it together, while the politicians celebrate in Westminster.

I see a generation of doctors profoundly disillusioned and disengaged from helping the Government build what we all want, which is a first-class health service.

 

“Your future is whatever you make it”

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It doesn’t have to be this way.

Jeremy Hunt himself has claimed that the two sides were “90% agreed” (although he is not famed for his judicious use of statistics). The BMA representatives have repeatedly asked for more talks.

There must be a solution that is acceptable to both sides. But that solution can’t be found without more negotiation.

Someone needs to stop acting like a politician, and start acting like a leader. Someone needs to step forward from this mess and break the impasse. Mr Hunt? Mr Cameron? My hopes aren’t high, but please prove me wrong.

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Conveyor Belt

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“I’m just going to pop in a drip and take some blood tests.”

To me, my voice sounded hollow and nervous, but Lisa, my patient, nodded and even seemed impressed. But then, she didn’t know I had only been a doctor for 3 days, and today was my first day on-call. She didn’t know that, if I did put a drip in her arm, it would be only the third time I had performed this procedure successfully.

It took me five minutes to find someone who was free to show me where all the supplies were kept, and another five minutes to pick out all the bits and pieces I needed. I carried my little tray back to Lisa and put a tourniquet around one of her arms. I watched happily as her veins began to swell. This looked quite easy after all. I selected a vein and wiped it with a sterile alcohol wipe. I opened a drip and gripped it with my right hand. The tip of the cannula seemed to be oscillating, and I realised my hand was shaking. Without waiting to think about it any further, I stabbed the needle into her arm. Lisa winced but said nothing. Rather to my amazement, I saw a flash of blood in the shaft of the cannula. I was in a vein. Sweating slightly, but elated with my unexpected success, I eased the needle back towards me, sliding the plastic tube surrounding the needle forwards into the vein. I’m a pro.

BEEP BEEP! BEEP BEEP!

I had only been carrying my pager for 3 days, but already I was aware of its peculiar ability to go off whenever it was most inconvenient. It seemed to know when I was sitting down to eat lunch, or using the toilet, or performing a sterile procedure. I could see the flashing light on the display, but the screen of the pager was obscured by my trouser pocket. This call would just have to wait. I hoped it was nothing urgent.

The next stage was to remove the needle and plug a syringe onto the drip, which I could use to take the blood test. The syringe I needed was sitting on my tray, still in its sterile plastic wrapper. Not good.

“Um…hold still, very still” I told Lisa. Letting go of the cannula with the needle hanging precariously out of the back, I used both hands to open the syringe. Lisa did as she was told, and the needle stayed in place. Having opened my syringe, I pulled the needle out. Immediately blood began to stream out of the hole onto the bed sheet. Fumbling and panicking, I plugged the hole with the syringe. A 4 inch blood stain on the sheet was evidence of my incompetence. Lisa looked at it with polite interest. “Was that meant to happen?” she asked me.

“Oh, yes, actually that’s a good sign.” I told her, improvising. “It means we’re definitely in a vein.”

“Oh, that’s good” said Lisa, apparently reassured. I wondered if she was on drugs.

BEEP BEEP! BEEP BEEP!

I glanced down again at my flashing pager. By contorting my body I managed to catch a glimpse of the screen and recognised the number – one of the surgical wards. Then I looked at my hands in their blood-stained latex gloves, then at Lisa’s arm with the drip and syringe hanging off it. I would just have to finish quickly and answer.

I withdrew a blood sample and swapped the syringe for a plastic cap, in the process leaking even more blood onto the sheet, which Lisa now accepted as normal.

Finally, I picked up the adherent dressing for the cannula and peeled off the cover.

BEEP BEEP! BEEP BEEP!

I didn’t even look at my pager this time. The dressing had stuck to my latex gloves, and I couldn’t get it unstuck. I excused myself and found a nurse to stick the cannula down while I answered my pager.

 

“Hello, it’s the on-call doctor”

“mmm…doctor” said a voice I didn’t recognize. “mmm…can you come up to ward 20?”

I waited for the voice to continue but it did not.

“What for?” I asked.

There was a pause. “Can you come up to ward 20?” repeated the voice.

I was getting a little irritated. “I’m actually quite busy at the moment. I’m just in the middle of seeing a patient in A+E. I’ll get to the ward as soon as I can manage.”

I was going to put down the phone, but the voice stopped me.

“Mmmmm. Doctor, you need to come to the ward now” it told me.

“What’s the problem?” I asked again.

“It’s about Mrs Stevenson” replied the voice pointedly, as if this would make everything clear to me.

“What’s wrong with Mrs Stevenson?”

“Mmmmmmm…” said the voice, in a slightly lowered tone, as if it was about to tell me piece of highly secret information. “I can’t say” it continued. And she put the phone down.

Naturally, the ward in question was at the opposite end of the hospital to A+E. Hospitals are odd places out of hours. My shoes squeaked on the plastic floor as I walked across the empty entrance hall under the modern windmill sculpture hanging from the ceiling, which was slowly rotating for only my benefit. The only sign of life I could detect was the waxing and waning of an electric mop, somewhere out of sight. It seemed oddly peaceful, but I had a presentiment that would soon change.

I cast my mind back to the patients on the ward. I had been there recently, and none of my patients had seemed likely to suddenly deteriorate. A couple of hours earlier, my colleague Hector had handed over his patients to me before leaving the hospital. He had seemed troubled by something, but he told me everything was fine.

I headed for the ward, walking fast but carefully, trying not to break into an undignified trot. Nothing creates panic like the sight of a running doctor. What kind of unspeakable problem was waiting for me? In my head, I rehearsed the list of medical emergencies I had learned for finals. Anaphylaxis, cardiac arrest, respiratory arrest, status epilepticus. But it was a surgical ward, so I should expect a surgical emergency. Pancreatitis? Necrotising fasciitis? An acute abdomen? Whatever it was, how was I going to cope with it? I’d been working as a doctor for less than 3 days. I checked my notebook for the reassuring contact details for my senior colleagues. I would find out what the problem was and then ask them what to do.

I arrived, panting slightly, at the ward in question. I could smell the familiar aroma of faeces and disinfectant, but I could also detect the scent of overcooked hospital food, reminding me that the patients were eating their dinner. I looked around for the urgent problem that couldn’t be communicated over the phone. All the patients I could see seemed well. Drips beeped gently. Hospital knives and forks tapped on hospital plates. A television was blaring out the theme tune to a quiz show. Someone was snoring with impressive proficiency.  An elderly man with a dirty white beard, nicotine stained around the mouth, wearing anti-thrombosis stockings and a hospital gown that gaped indecently at the back, shuffled past me towards the bathroom, wheeling a squeaky drip stand.

Where was the emergency? Where were the nurses? I caught sight of a nursing assistant disappearing into the sluice room and called out. She clearly had urgent business with a bedpan and didn’t stop, but yelled “Constance” at a volume that was impossibly loud, given her petite figure.

Constance was the largest woman I had ever seen. As I tried not to gape in astonishment, she waddled down the ward towards me in what must have been several nursing uniforms attached together.

“mmmm.mmmm… doctor?” I recognized the voice and also the economy of words from my telephone conversation.

“What’s the problem?” I asked, trying to sound irritated rather than scared.

Constance glanced around the ward as if searching for eavesdroppers. A couple of non-descript people were sitting outside one of the side rooms, but no one seemed to be paying attention. Constance was clearly not satisfied.

“Follow me” she instructed, and she set off down the corridor almost touching both sides simultaneously. I followed her involuntarily, pulled along by her gravitational field. She stopped outside a door labelled “store-room” and I followed her in. There was only just room for both of us, along with several boxes of cardboard bedpans, a couple of broken wheelchairs and a portable hoist. I was still thinking about the patient waiting in A+E, and was really starting to lose patience.

“What’s going on?”

“It’s Mrs Stevenson” said Constance, in a hushed voice, indicating the room opposite with the two visitors sitting outside.

“What about her?”

Constance paused. “She’s dead.”

I replayed in my mind the peaceful scenes on the ward when I arrived and compared them with what ought to happen when a patient was found dead. Why was no-one trying to resuscitate Mrs Stevenson? Where were the real doctors?

“Have you called the cardiac arrest team?” I asked.

“Oh, no.” answered Constance.

I started to go out of the room to call them myself.

“No, she was expected to die, and she was not for resuscitation. She was admitted with an ischaemic bowel, and she and her family refused surgery. We were keeping her comfortable. We just need you to certify her dead.”

As she continued talking, my mind drifted off. This was the unspeakable emergency? I thought of the patient waiting in A+E. She was alive (at the moment) and probably in pain. I wanted to be looking after her. And anyway, how was I supposed to certify someone dead? I knew the theory, but I had never even seen a dead person before, aside from the formaldehyde-preserved cadaver I had cut up in medical school.

As my mind drifted back to Constance, she seemed to be concluding her speech by telling me about a different patient who was suffering with diarrhoea. With some effort, I made the mental connection that this other patient needed to be looked after in a side-room to avoid her diarrhoea spreading, and therefore there was some urgency in liberating the side-room being occupied by Mrs Stevenson, who was hovering in legal no man’s land between the alive and dead state and could not be moved to the morgue until I certified her death.

Constance directed me to the room opposite. The two relatives seemed to have left. I put my hand out to knock on the door, but suddenly realized there was no point. Mrs Stevenson presumably was not going to answer. Then again, presumably there was some chance that she wasn’t dead. I knocked gently.

“Come in” said a voice. I jumped. When I entered the room I found a sombre scene. Four or five family members were grouped around the bedside. Some had clearly been crying, others were grieving in a more understated way.

“I’m one of the medical stu…doctors” I stuttered. “I…” I wasn’t sure what to say next.

I’ve come to certify her dead wasn’t right, as it implied there was no doubt.

I’ve come to check whether she’s dead didn’t sound very compassionate.

Had they even been told that she was dead? I glanced towards the bed, with the shrivelled pale figure that only seemed to take up a fraction of the space. People seem to shrink when they die. I glanced back to the relatives. Several sets of red eyes gazed back at me. The silence stretched on until I felt I had to break it.

Suddenly, I had a moment of inspiration.

“Would you be able to wait outside for just a few minutes?”

To my relief, nobody argued, and the group of mourners filed silently out. The last man, as he disappeared out into the corridor, said to me over his shoulder “I hope you do better than the last doctor”. Then, before I could ask him what he meant, the door closed and Mrs Stevenson and I were alone. The last doctor?

The main lights were off, and Mrs Stevenson was illuminated only by the reading light above the bed, which was set on the dimmest setting. It felt like a vigil. The dark, still atmosphere made me shiver, and I reached across and switched on the main lights. For a moment nothing happened, but then the fluorescent tubes gradually flickered and hummed into life, changing the atmosphere from chapel into morgue. At my first glance, I could see that she was dead. There was no colour in her face, and not a flicker of movement. I called her name and reached out to shake her shoulder. She was cold, and I found myself withdrawing my hand as if I had been burnt. Telling myself off, I put my hand back on her shoulder and gave her another gentle shake. Then I felt for a pulse in her neck, forcing myself to wait a full ten seconds before taking my hand away again. I listened to her chest and noted there were no breath sounds and no heart sounds. Finally, I wanted to check whether her pupils would respond to light. Her eyes were closed. Fighting my sense of revulsion, I lifted up her left eyelid. Her eye stared up at the ceiling. She had startlingly bright blue eyes that might have belonged to a child, but they looked somehow cloudy, like a fish eye on the fishmonger’s slab. The pupil did not react to my torchlight. I released the eyelid, and watched it slide slowly down to cover the eye again. It didn’t close completely, and I had to help it closed. The silent room and the cold skin were getting to me, and I couldn’t bring myself to check the second eye. I almost ran out of the room, remembering to switch off the main light again, and ignored the clustered family as I headed back to the nursing station to write in the notes.

When I opened the notes to write my entry, the cryptic comment about the “last doctor” was explained. In slightly shaky handwriting that I recognized as Hector’s, an entry was written at 5pm, a couple of hours before I was called. Asked to certify death. No breath sounds. Silent chest. I can feel a pulse. There was a gap. Unsure if patient dead. Please ask on-call doctor to review later. I remembered Hector’s sweaty and worried face as he told me that he had nothing to hand over and dashed from the hospital, having felt a pulse in a patient with no heart sounds and asked the nurses to call me to review a patient who, deep down, he knew was already dead. I toyed with the idea of photocopying the entry to blackmail Hector when he became a famous cardiologist, but I decided it would contravene patient confidentiality. Anyway, I had living patients to see. I wrote my entry and headed back to A+E.

At 8pm I passed the pager to the doctor who was covering the night shift. She looked smart, and she smelt of freshly washed hair. I was gently self-conscious about my sweaty wrinkled shirt. I handed over the things I hadn’t managed to finish with a pang of guilt, and she was gone with the pager. I sat still for a moment to savour the guaranteed peace, then I gathered my strength and headed towards the door. The main hospital entrance was shut, and I had to leave through the emergency department. As I passed through, I could hear familiar hospital sounds. There was the urgent bleeping of pagers and the routine hum and beep of blood pressure machines and drip machines. I could detect a loud asthmatic wheeze nearby and the more distant sound of retching. A high pitched voice, perhaps a child, cried out in pain.

I walked past these noises, reminding myself that, until tomorrow at least, they were not my responsibility. The sun was just disappearing behind the doctors’ accommodation block. A thin crisp crescent of moon stood out in the faded violet-blue sky and a few scattered clouds were highlighted with disappearing traces of pink. It was a beautiful summer evening and I felt refreshed by the light breeze. I breathed the cool air deeply into my lungs and enjoyed the sensation of stale sweat evaporating coldly from my skin. It was nearly 9pm. I knew that the sensible thing to do would be to head back to my room, grab some food, and get some sleep – I had to be back at work in 11 hours’ time. But my mind was racing, and somehow I knew that sleep would not come easily after the day I had just finished. I headed to the local pub, a regular haunt for hospital staff, where I thought I might find some friends.

Hector was there, with Amy, another medic I knew. I settled in the vacant chair with my pint and a packet of crisps that would be my dinner, Amy had what might have been water, but might have been a gin and tonic, and Hector had whisky. They hardly looked up when I arrived.

“I didn’t know you drank whisky” I said to Hector.

“I don’t” he said. “I’m going to the bathroom”. And he abruptly got up, and walked away unsteadily. It occurred to me that he and Amy had finished work three hours ago, and these might not be their first drinks.

I looked around the pub. I could make out clusters of nurses, some still in uniform. I could see a few people that looked like civilians. Relatives, I thought. Maybe a few patients getting a sneaky pint. Inwardly, I wished them well. Finally, I could see some groups of doctors. These were the seasoned pros. The old hands. The veterans. They didn’t care that they had just seen a dead old lady. They were not fazed by the wounds they had stitched, the vomit they had neatly sidestepped and the urine puddles they had trodden in. They looked relaxed and happy.

Amy brought me back to reality. “You look terrible” she told me. “What happened. Did you kill someone?”

“No.” I paused. “I don’t think so, anyway. It was just a tough day. Non-stop.”

“Don’t worry” said Amy. “Just 362 more days to go”.

My feelings must have been quite apparent, because Amy almost smiled. “I’m on-call tomorrow, so I guess I’m about to find out what it’s like” she told me. “I think it’s time to call it a night”. She got up to leave.

I still had half of my pint. I wasn’t quite ready to leave, so I sat alone watching the others in the pub, and drinking. One of the veterans detached himself from the gaggle and swaggered over to me. As he got close, I recognized my direct boss in the surgical team. For the first time since I’d met him, he looked freshly shaven. His tired and stained tie had gone, and instead he was wearing a fashionable shirt open at the collar to reveal a thick matted mane of chest-hair. A cigarette dangled between the fingers of his left hand.

“How are you doing!?” he almost shouted. “Good work today! Come on over and meet some of the guys.”

I looked over at his group of happy relaxed doctors, and I knew I wasn’t one of them yet. My head was throbbing gently, and I wasn’t ready to pretend.

“Thanks. I’m shattered, and I’m about to head home and sleep. Next time it would be great. Sorry.”

He shrugged. “Sure thing. See you.” And he swaggered away.

I put down my pint glass with the last inch of beer, and went to use the gents. As the pressure of the beer faded away, I heard a familiar sound that reminded me of the wards. Someone was retching in one of the cubicles. I smiled faintly. This time I didn’t need to get involved – it wasn’t my responsibility. As I washed my hands, the retching stopped, and I heard a sound that could be best described as a whimper. I swung the door open to leave and stepped back out into the pub. Suddenly something clicked in my brain. I hadn’t recognized the retching, but the whimper sounded very familiar. And Hector had never returned from his trip to the gents.

I poked my head back into the gents. A gentle groaning was audible.

“Hector?”

The groaning stopped abruptly, and there was silence in the cubicle for a while as Hector considered how to respond.

“Uh – yeah” he said. “Uh – I’ve just been a bit sick. But I’m ok. I just…I’m just…I can’t seem to get up.”

I swung open the cubicle door. Hector was sitting on the ground next to the toilet, with his head at the same level as the bowl. He looked pale green, but he smiled weakly at me. I considered the irony in surviving my first day on call with unstained clothing, and being vomited on by a colleague in the pub after work. Then I put this thought to one side, helped him up, and we staggered back to our accommodation.

“Ian”  he said with drunken sincerity after I had deposited him on his bed. “I’m not sure I can do this whole doctor thing.”

“Why not?” I asked

“You know, I have always been pretty good at exams. In fact, I quite enjoy them. But the worst thing that can happen in an exam is that you don’t pass. But suddenly, we are looking after real people. And the worst thing that can happen if we get it wrong is… When I was asked to certify that woman dead this afternoon I couldn’t do it. I mean, she seemed dead, but I couldn’t get out of my head the idea that I would certify her and she would wake up. Or be buried alive.” He paused. “In the end I just ran away and left you to deal with it.”

“Don’t worry” I told him, with as much authority as I could muster. “You’ll be fine”.

I left Hector lying fully clothed on top of his bed and walked across to my own room in the next block. It seemed difficult to believe that I could feel so physically tired from just one day of work. I stood under the shower for 15 minutes, cleaning off the sweat, the smell of disposable gloves, disinfectant and plastic aprons but most of all cleaning off the cold and shocking touch of death.

After my shower, before going to bed, I stood by the window of my room and breathed in some cool summer air. The sky was now a deep purple colour and some stars were visible. To my left, I could see the entrance to the emergency department. A solitary ambulance was unloading a patient, and I wondered if she would be coming my way in the morning. In the strange illumination from the blue flashing lights, I caught just a glimpse of a pale and wrinkled face with grey hair. It looked suspiciously like Mrs Stevenson.

———-

This is a work of fiction

———-

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Nobody Expects the Contract Imposition

Standard

 

inquisition

“Amongst our weaponry are such diverse elements as spin, dodgy statistics, ruthless inefficiency, an almost fanatical devotion to the private sector, and nice red uniforms”

 

Back in September Abrainia published “Contract Killers”, a summary of the contract being offered to junior doctors.

It covered who junior doctors are, how much they earn now and how the mysterious banding system works. It covered some of the safety issues with the contract – in particular how it scrapped the banding payments that act as a brake on hospitals overworking their doctors. It covered how it would adversely affect women and people doing research. And it covered how the new contract would inevitably be a pay cut for many doctors, with those working the most out of hours shifts losing out the most.

That was before the BMA balloted for strike action, before 98% of respondents voted in favour, before the two strikes, and before the negotiations that have led to the announcement by the Government that they will impose the contract in August.

The contract that is now apparently going to be imposed is not quite the same contract that was suggested by the DDRB, and that I discussed in Contract Killers. Have the strikes, and the two months of negotiating achieved anything? The BMA believes the new contract offer is still not good enough. But we should also look for ourselves at the offer we can’t refuse.

 

What has changed in the new new contract?

Pay:

The fundamental pay shift between the current and the new contract is still the same.

At the moment, junior doctors get a basic salary plus an additional banding payment, which is calculated as a percentage of their entire salary. The percentage depends on their out of hours work. So a brand new doctor in their first job after qualifying would currently earn a basic salary of £22,636 per annum. If they work a decent chunk of their hours during nights and weekends, they might get 40% “banding” on top of their basic salary, meaning total pay would be £31,690 per year.

In the new contract, doctors will be paid a higher “basic salary”. For instance, a newly qualified doctor will now get £27,000 per annum (up from £22,636 now, and from £25,500 in the previous offer). But this will be offset by a complete change to the way they are paid for out of hours work. Instead of getting an extra percentage of their whole basic salary, they will get paid an extra percentage on a per-hour basis for just the work that is out of hours. So, if 20% of their time is outside normal working hours, they’ll get a 30-50% higher rate for just those hours. That brings the total salary to around £29,000. The Government would like to call this a payrise, but in this example the total salary is actually down by over £2500 per year.

This “better deal” is still not going to be a better deal for everyone. The exact calculations are different for each doctor (an updated pay calculator by Dr Bishop can be found here). It will be great for people who don’t work weekends (have you wondered why you haven’t heard anything about dentists protesting against the new contract?) but the doctors in emergency specialties (the people who look after you when you have your heart attack on a Saturday night) will still lose out.

Since doctors are going to be paid extra just for the specific hours they work outside the normal working week, it is important to define which hours those would be. And the latest version of the contract still wants to call Saturday a normal working day. Which, as everyone knows, it is not.

 

wembley

Some people enjoying a normal working day

Pay protection:

Jeremy Hunt has repeatedly claimed that no doctor will have a pay cut with the new contract. He has also claimed that the contract is “cost neutral” – in other words, the amount the NHS spends on junior doctors salaries won’t change with the new contract. Of course, as Andrew Marr pointed out recently in an interview, you can’t give some people a pay rise, and keep overall spending the same, unless some people also get a pay cut. So this is nonsense – it couldn’t possibly work.

The explanation is that the latest shiny new version of the contract includes something called pay protection. If a doctor’s salary would fall on the new contract, they will be paid their old salary instead, for up to three years.

This means that the introduction of the new contract won’t actually be cost-neutral – in the short term, it will cost the Government more than the old contract, as some people get a pay rise, and those who would have had a pay cut are kept on their old salary.

Great, you may think. Problem solved! And yes, pay protection helps. It means that doctors who have a mortgage to pay won’t suddenly find they can’t keep up with their payments. It means that many of the older and more senior “junior” doctors will never suffer under the new contract, because they will no longer be junior doctors by the time it kicks in. But the fact that pay protection is necessary proves that the new contract is not a better deal. The older junior doctors worry about the mess they might be leaving behind for their successors. The people who lose out will be the junior doctors of the future.

 

Safety:

Banding payments serve two separate functions. One is to pay doctors for the out of hours work they do. The other is as a safety valve for doctors and their patients. If doctors find they are being forced to work more than their official hours, the hospital has to increase their banding payments (which, remember, are a percentage of their whole salary). This is a big financial punishment for hospitals that overwork doctors, which was very common in the past.

The previous new contract, as set out by the DDRB last year, had very little to say about this. The new new contract has a lot to say – there are multiple layers of bureaucracy suggested to replace the banding system as a safety mechanism. Hospitals will have a “guardian” of safe working, assessing “key performance indicators” feeding “multisource feedback” to a “board level director”. What does this all mean? I don’t know. Will it work? I don’t know that either. But if doctors are overworked, under the new contract it will be much less of a costly problem for hospitals. It will still be just as costly for the patients who are seen by an overtired doctor.

 

Fine tuning:

There are some other details that have shifted in the latest version of the contract. People taking time off to do research will now get some extra pay, acknowledging their greater knowledge and experience. Top-up payments will be made to some specialties that struggle to recruit enough doctors, and more details have been released on this. There is a flatter nodal pay structure (which is as dull as it sounds, but will be helpful for part-time workers). These are all small moves in the right direction.

 

The bigger picture:

Junior doctors don’t like the new planned contract. They don’t like it for a number of reasons. Once pay protection wears off, they think it will be a pay cut. And salaries have already been frozen, not even keeping up with inflation, for many years, while the cost of training to be a doctor is increasing year-on-year. They think it robs them of their power to insist on safe working. They think it undervalues the sacrifices they make when they give up their evenings, nights and weekends for their job, and that hospitals will use it to make them work more antisocial hours for no increased pay.

It is less bad than the previous version, but less bad doesn’t seem good enough.

And part of the problem is not the contract itself, but the way it is being introduced.

Trust, goodwill, and the nuclear option

In a parallel world somewhere, a wiser Health Secretary than Jeremy Hunt might have handled the introduction of a new junior contract a bit differently. He might not have begun by laying into doctors, accusing them of lacking vocation and professionalism, and laying thousands of extra deaths at their door. He might not have followed this up by announcing the imposition of a disastrous contract, pay cuts for many, penalties against those doing research or working part time, and the demotion of Saturdays to normal working days, leading to strikes and protest marches. He might have spoken to a few junior doctors about their concerns, rather than running away from them.

In that parallel world, after some genuine negotiation, he might have come up with the latest version of the contract as a starting point. And junior doctors, recognising that the NHS needs to move forward, might have considered it. Some parts would have caused concern – like the Saturday issue, and controls on over-working doctors. There might have been some constructive criticism. Perhaps some further negotiations would have been needed. But strikes? Protest marches?

A couple of weeks ago, there was a cautious hint of optimism in the air. Negotiations were progressing. Hunt was staying away. Perhaps a solution could be found…perhaps Wednesday’s strike would be the last… and then (in the media, of course) it was announced that the contract would be imposed. BANG. What Hunt himself called “the nuclear option”.

Any negotiation needs trust and some goodwill on both sides. You have to believe what you’re told across the negotiating table, you have to believe there will be some give and take. There were signs that was starting to happen, until Jeremy pressed his red button.

What next?

What would an acceptable contract for junior doctors look like? I think it could look quite similar to the offer that’s currently on the table, next to the big red button, a ticking timer and a diagram showing the fallout zone.

If I was in charge of the Government team I would take the nuclear option off the table, and agree that Saturdays are part of the weekend. And then, with a little reshuffle for Mr Hunt, we might be heading towards a speedy resolution.

Since I’m not running the Government, the future is a little less certain. There may well be more strikes, or a legal challenge in the courts. Some hospitals might ignore the new contract and stick with the old version – it seems very few hospital bosses support imposition, despite what was originally claimed.

Meanwhile some doctors have simply had enough, and are walking away.

There are more twists and turns to come in this saga.

 

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