Doctors owe it to patients to tell the truth: the NHS is in terminal decline | Rachel Clarke

Like church and state, medicine and politics are traditionally seen as a queasy mix. The last thing you want in your flimsy hospital gown is some zealot with a stethoscope trying to sway your vote. Doctors, at the bedside, should clearly stick to doctoring. But – in a world of ever more outlandishly spun health statistics – where, outside of clinical encounters, do the limits of doctors’ duty to act in our patients’ best interests lie?

I made the sobering discovery, in my first few weeks as a doctor, that serving patients in the modern NHS was at least as much to do with advocacy as medicine. It has to be, in a system that’s stretched beyond breaking point. With resources so scarce, speaking out counts.

Once, I actually stalked a professor, in sheer desperation to provide an inpatient with decent care. He did a double take at the steely-eyed junior doctor, sat perched outside his clinic, fired up to plead her patient’s case. With everyone run ragged, overwhelmed by patients, no one had believed me or cared enough to act when I’d insisted my patient was suffering from a rare diagnosis, adult-onset Stills disease, that had left her heart swamped in fluid, her temperature soaring, her circulation so fragile it might need intensive care. “Please,” I begged. “Just see her for yourself.” As the pre-eminent professor of rheumatology in my hospital, he was the one man I knew who might act. And he did. He confirmed the diagnosis and whisked my patient off to his specialist care, possibly saving her life.

When almost every statistic about today’s NHS depicts a system quietly imploding around us, advocacy writ large has never mattered more. Doctors, like nurses, bear daily witness to the facts behind the spin. Our testimony is a vital corrective to a government hell-bent on airbrushing away the truth about today’s underfunded NHS. We look the patients in the eye as they languish on trolleys in hospital corridors. We apologise, shamefaced, to the families whose loved ones are stranded in hospital, because no social care exists to support their safe discharge home. We turn away the elderly who sob in A&E because the pain in their hip is beyond endurance, yet who haven’t even made it on to a waiting list for surgery. If we turned a blind eye and kept our heads down, would Hippocrates nod his assent?

Having to break bad news to a patient is never easy. But unflinching conversations are a cornerstone of good medicine

The state of the NHS in 2017 demands that doctors speak out about the human cost of underfunding since it clear our political leaders will not. Only this week, Theresa May made an election manifesto commitment of 10,000 more staff in mental health. Unfunded, needless to say, but also – more audaciously – a promise made on the back of the 6,700 mental health staff already culled since the Conservatives came to power in 2010. It’s this kind of political doublespeak that compels doctors to challenge loudly the government line that – despite the most brutal funding squeeze in NHS history – everything is going swimmingly.

In microcosm, we already know what happens when cost-cutting is prioritised above patient care. The scandal of Mid Staffs – a stain upon the history of the NHS, in which patients in their thousands were subjected to inhumane care – arose when one hospital trust strove to slash costs by millions. Yet currently, the government is enforcing £22bn of “efficiency savings” across the NHS, while insisting excellence of care can somehow continue.

Doctors should call out this claptrap for what it is. We are, after all – perhaps more than anyone – trusted to tell unpalatable truths. In this case, the hard medicine is more taxes. A world-class health service requires world-class funding. Either we provide the budget to fit the health care we want, or we cut the NHS to fit the amount we’re willing to spend on health. With a government too cowardly to confront this simple truth out loud, doctors should force an honest debate.

Yet – with a few notable exceptions (Taj Hassan and Neena Modi, for example, the presidents of the Royal Colleges of Emergency Medicine and of Paediatrics and Child Health respectively), the medical establishment is loath to rock the boat. Where is the joint statement from the Royal Colleges, for instance, urging increased taxation to bring our NHS and social care spend to at least the levels of Germany and France? Where are the hospital medical directors brave enough to speak out in public against the ever more fanciful diktats from on high to keep on delivering as their funding dries up?

Having to break bad news to a patient is never easy. But unflinching conversations are a cornerstone of good medicine. Nationally, doctors should be telling it like it is: without more money, our NHS is in relentless, terminal, and wholly avoidable decline.

Doctors owe it to patients to tell the truth: the NHS is in terminal decline | Rachel Clarke

I’m a doctor, not a gatekeeper turning ‘health tourists’ away | Rachel Clarke

What better way of diverting attention from the government’s failure to address NHS underfunding ahead of the autumn statement than to turn up the heat on immigrants? You know, those hordes of NHS-clogging health tourists who come over here, steal all the GP appointments and make you wait half the night in A&E. Makes you sick, doesn’t it? No wonder our poor NHS is struggling.

Except, as Chris Wormald – the Department of Health mandarin whose comments have dominated front pages – knows better than anyone, the cost of so-called health tourism is a drop in the ocean of NHS spending. An estimated £200m a year is spent treating people who have travelled to the UK with the deliberate intent of obtaining free healthcare to which they are not entitled. That’s a mere 0.3% of the overall NHS budget.

Wormald, addressing parliament’s public accounts committee, revealed government proposals to clamp down on “health tourism” by requiring all NHS patients to prove their identity with two forms of identification, including a passport, before being allowed to receive hospital treatment. It is difficult to believe that the department’s most senior civil servant made his remarks – on the eve of Philip Hammond’s first autumn statement – in all innocence of their likely media impact, and without the blessing of his political masters. He even told MPs: “It is quite a controversial thing to do, to say to the entire population: you’ve got to prove your identity.”

This is not starry-eyed naivety. I know better than most what a ‘health tourist’ looks like

I’ll say. The UK has a long and grubby history of politicians and newspaper editors exploiting Britons’ love of the NHS to indulge in migrant-bashing; and it is something I, as an NHS doctor, am heartily sick of. I am a clinician, not an immigration officer. My job is to care for my patients irrespective of their race, religion, sexuality or nationality.

This is not starry-eyed naivety. I know better than most what a “health tourist” looks like because they are, on occasion, my patients. One, a young woman, was brought by her parents to my hospital from a country in sub-Saharan Africa where her rare auto-immune disease had gone undiagnosed and untreated. She arrived paralysed, mute and covered in sores. She left healed, whole and independent.

Yes, she cost the NHS tens of thousands of pounds. Indeed, you might claim her parents “took the NHS for a ride”. But, in a cradle-to-grave health service founded on tolerance, humanity and inclusivity, I will continue to treat my patients according to need not insinuation.

It’s not that I object to the policy per se, but to its exploitation for political ends. The truth is, the timing of this announcement is straight out of the Trump school of media management – using migrants as collateral damage to cover for the real reasons why the NHS is in crisis. If fiscal responsibility was really the issue here, why is the government not flexing its muscles with forgetful pensioners? After all, the NHS loses more money on missed GP appointments than it does on health tourism. Similarly, the NHS spends £200m a year more on stationery than it does on health tourism – but waging war against feckless pencils just doesn’t quite have the same resonance with the Ukip contingent.

Exploiting anti-immigrant feeling to distract the public from the catastrophic impact on the NHS of this government’s year-on-year underfunding is as irresponsible as it is cynical, potentially fuelling a narrative that stokes anger and hostility towards non-British nationals. Only this week the Daily Mail blamed dangerously long ambulance waits on the unprecedented demands from “migration, the ageing population and patients dialling 999 as they cannot reach their GP”, claiming: “Some paramedics have also reported pressure from migrants who either do not register with a surgery or do not know where to find a walk-in centre.”

In fact, as anyone who works on the NHS frontline is bitterly aware, it isn’t “health tourists” but the government’s £22bn of cuts during this parliament that is decimating our ability to deliver safe, quality care. Our wards are missing doctors and nurses: we’ve never known such a dangerous mismatch between our numbers and those of our patients. This year, whole emergency, paediatric and obstetric departments have closed because of a lack of medics. Now entire hospitals are slated for closure up and down the country.

In this context, it is disingenuous for Wormald to intimate that, alongside migrants, NHS staff like me might be part of the funding problem, with our lackadaisical attitudes towards squandering taxpayers’ money on treating any old Tom, Dick and Harry: “We are not here to criticise NHS frontline staff,” he said, “but what we want is a culture of everybody who works in it to understand financial rigour. We need a culture where we are more careful with the tax pound.”

Perhaps. But from my frontline staff perspective, what patients need more than anything is a culture of candour from the NHS’s political custodians. The longer they deny – or distract from – their dangerous and draconian cost-cutting, the more fearful for our patients my colleagues and I become.

I’m a doctor, not a gatekeeper turning ‘health tourists’ away | Rachel Clarke

These leaks show Jeremy Hunt’s deception over the seven-day NHS | Rachel Clarke

It’s 4am. When your heart arrests and the emergency call goes out, what you really don’t want is a doctor whose first response to your crisis is a silent stream of expletives. You don’t want the person racing to your bedside to be so exhausted they can barely think straight. And you definitely don’t want them to be pumping your chest while wondering what to do with the patient pile-up threatening to overrun the unit from where they’ve just sprinted.

I don’t want those things either – but I’ve been that doctor and I’ve been that callous. I don’t know a single one of us who hasn’t. There’s an ugly truth about the NHS frontline right now that health secretary Jeremy Hunt would dearly love to airbrush away. We, the doctors and nurses at the sharp end, increasingly feel we are bearing witness to its slow, relentless disintegration. Daily, we are fighting against a breaking system and though for us that may be soul-destroying, for our patients – in so many different ways – it is potentially life-threatening.

The government would have you believe that not only is the NHS flourishing, but that it is being safely steered on its way to becoming the world’s first “truly seven-day” health service – an all-singing, all-dancing bonanza of unprecedented weekend care. Without any new doctors for these new weekend services. Or extra nurses. Or extra resources, in fact, of any kind.

But in private, as incendiary documents leaked to the Guardian and Channel 4 News now reveal, Hunt’s own department admits the lack of funds and staff for a seven-day NHS may derail the glib promises of last year’s general election manifesto. In its unpublished risk assessment of the seven-day policy, the Department of Health’s own working group admits that workforce overload means it may simply not be possible to find sufficient “skilled/trained staff” to safely deliver the new service. Worse, says the secret “7 Day Services Governance Group”, the objectives of this centrepiece of health policy, “are not fully agreed upon, but delivery has started”.

Imagine committing millions of pounds of precious NHS cash to a new service you know you lack the staff to run safely, and whose point – extraordinarily – you haven’t quite decided upon. Imagine the extra child mental health beds or groundbreaking new cancer drugs upon which you could be spending that money, had you not already committed to something so sketchy.

No one who actually works in the health service is remotely surprised the staff aren’t there: we can barely keep patients safe over five days, let alone seven. But for a doctor such as me, who could be hauled before the General Medical Council were I not to practise evidence-based medicine, this admission by the department that it doesn’t even know what it’s aiming for with the seven-day charade destroys Hunt’s efforts to portray himself as a patient safety champion.

My world is one of junior doctors squabbling to grab the last remaining space in which to see new patients, essentially a store cupboard with a couch squeezed inside; of trolleys deployed in corridors as de facto beds, flanked by foldaway screens that barely protect the patient’s dignity; of ambulances sitting idle outside the hospital, unable to deliver their blue-lighted occupants because A&E is crammed to bursting point.

On becoming a doctor, I was fully prepared for the blood, the gore, the death, the slog, but not – it turns out – for the shame of it. Increasingly, my eyes cannot meet those of the patients and relatives marooned under strip-lights, waiting and waiting to be seen. And it’s not just embarrassment. Head down, cheeks burning, I’m trying to avoid becoming the arbitrary target of an enraged family member who needs someone, anyone, upon whom to vent their spleen.

When Robert Francis published his report detailing the horrors patients endured in the now-defunct Mid-Staffordshire NHS Trust, the then prime minister, David Cameron, told a stunned parliament that the report was a “cry from the heart” for “quality, vocation, compassion” in our health service. Three years on, I can tell you that those values are being purged from the NHS by a government that has chosen, year on year, to shrink the share of GDP it spends on our health service. Overstretched doctors and nurses are as demoralised and exhausted as it is possible for a workforce to be. And what many of us now fear is Mid-Staffs writ large – this time on a national scale.

Only a politician who’s singularly out of touch – or driven by an ulterior motive – could possibly pretend the NHS is healthy. This year’s “winter” crisis has started in August. Doctor shortages are forcing A&Es to close. Whole populations in some parts of the country are being denied all but emergency care. My friends are quitting the profession they love in droves. Nurses on my ward are often in tears.

What many of us now fear is another mid-Staffs disaster writ large – this time on a national scale

As a junior doctor, the public exposure of the fatal vacuity of Hunt’s seven-day soundbite ought to make me feel vindicated. Instead, I feel sickened. For over a year, Hunt spun the line that our resistance to his new junior doctor contract was about nothing but grubby self-interest and our grasping obsession with Saturday “overtime”. The truth is, what prevents more doctors from working at weekends isn’t contractual limitations, it’s that there simply aren’t enough of us, and we’re already spread too thinly. We’d all love a seven-day NHS.

Hunt has refused to come clean on the multiple flaws and limitations of the policy he so fervently championed. Perhaps he thought Francis’s duty of candour didn’t apply to health secretaries.

To be perfectly candid, the NHS frontline these days is threadbare, scrappy, perilously understaffed and barely held together by legions of nurses, doctors and allied health professionals. I’m afraid there is no question of any of us being able to do more. I long for the government to choose honesty, not empty rhetoric – actions, not words – and inject the funding so desperately needed to give our health service a fighting chance of survival.

These leaks show Jeremy Hunt’s deception over the seven-day NHS | Rachel Clarke