The health of nations — a forensic look at the NHS

Staff at the Intensive Care Unit of West Middlesex University Hospital during the Covid-19 pandemic, 2020 © Stuart Franklin/Magnum Photo

The pandemic has profoundly tested the resilience of health systems around the world. But so bound up is the NHS with the way British people see themselves and their nation that its performance has attracted particular scrutiny.

The taxpayer-funded service has long provided people not simply with healthcare, but a sense of pride and identity, its place in the collective psyche sometimes described as akin to a national religion.

Its acolytes’ faith can be sorely tested however. Years of under-investment meant that, long before the pandemic, it was struggling with a perilous mismatch between demand and resources. While at its best it delivers world class care, it is capable of shocking lapses.

This mixed picture is the backdrop to two timely new books. One offers the expansive horizon of a senior politician, the other the necessarily constrained, but vital, perspective of a single frontline clinician.

In Zero, Jeremy Hunt, who served as health secretary from 2012 to 2018, shows us that there is more than one way in which a politician can make their mark on the health service.

Many politicians, put in charge of the world’s fifth biggest bureaucracy, and the ultimate train set for those with a messianic streak, have been unable to resist full-scale structural overhauls.

Appointed after he had feared his cabinet career might be coming to a premature end, Hunt found a different animating goal: the elimination of avoidable deaths in its hospitals. It changed “the direction and purpose of [his] life”, he writes.

This is not a conventional politician’s memoir. Indeed Hunt is not really the protagonist of this book at all. That role goes to a cast of people who, through the most wrenching of personal circumstances, have been forced to fight on behalf of loved ones killed by what surgeons call “never events”: a sadly inapt moniker given the 150 people who, he relates, die avoidable deaths each week in the NHS.

Hunt, on the evidence of this book, is a natural storyteller with an eye for the poignant detail. When a woman who has lost her young son to undiagnosed sepsis arrives to meet him she is clutching a teddy bear; he discovers it contains her dead son’s ashes.

He scored a number of successes, which he does not forbear to mention — he is after all a politician and one who, if the Westminster rumour mill is correct, has far from ruled out the possibility of running again for his party’s leadership.

But I found the book overall characterised by a willingness, rare in Hunt’s profession, to interrogate his own decisions. In part, this is a necessary act of propitiation. Given his status as the UK’s longest-serving health secretary the reader is naturally inclined to question why he was unable to translate his analysis of what ails the service more effectively and consistently into action.

The reflectiveness seems genuine, rather than calculated, however — and never more so than when, while researching the book, he arranges to meet a junior doctors’ leader who spearheaded a rash of strikes, which scarred his time in office.

While many in the profession will take issue with his unshakeable belief that he was right to press for the contract changes that formed the juniors’ casus belli, his attempt to understand why he failed so signally to communicate their importance comes across as sincere.

The book has weaknesses. One of the biggest criticisms that could be lobbed at his stewardship was his failure to prepare better for a pandemic. We glean few new insights into how this happened beyond an acknowledgment that “groupthink” led to an overly-exclusive focus on planning for a severe flu outbreak.

I would also like to have known more about how the safety of the UK health system compares with others. Hunt gives tantalisingly few examples of best practice elsewhere that might have provided the basis for improvements in the NHS.

Overall, this is an impressive and readable account, shorn of partisan bombast or score-settling. One ends the book with little confidence that the kind of tragic events he chronicles are close to being fully stamped out, but his determination to leave the health service safer than he found it has surely placed him on the right side of history.

While Hunt’s canvas spans the entire NHS, in all its complexity and imperfections, A Fortunate Woman is a delicately drawn miniature that invites the reader to view the NHS from the vantage point of just one rural GP.

The book is a bold undertaking, inspired as it is by one of the most beloved and influential books about the practice of medicine, A Fortunate Man by the eminent critic John Berger. Polly Morland, the author of this quasi-sequel, discovers a copy of Berger’s book as she is clearing the house of her frail mother who is moving to a care home. With a shock of recognition, she realises it is set in the remote rural valley where she has made her home and decides to contact the successor to the “fortunate man”.

The comparison between the two books is not always kind to Morland’s work. While her writing has power, it rarely rises to the lyricism and profundity of Berger’s.

Judged on its own merits and removed from the shadow of its predecessor, it is nevertheless a compelling read. Where the doctor of Berger’s book, pseudonymised as John Sassall, is a singular and charismatic figure, Morland’s doctor comes across as a self-effacing and empathetic medical everywoman.

As in Zero, it is the human stories that stick in the memory: the elderly lady with breathing difficulties who tells the doctor in great detail about her protracted planning dispute with a neighbour and whose symptoms, lacking an obvious physical cause, seem the product of loneliness and anger; the young transgender woman with whom she spends part of an appointment watching a YouTube video on how to apply eye shadow; the nine-year-old girl with terminal leukaemia who confides to the doctor about the letter she has secreted for her mother to read after her death.

The most powerful section follows the onset of the pandemic, which imparts an intensity to her narrative that it may otherwise have lacked. The doctor must now navigate a world in which she can no longer rely on the direct human contact that has served her well for so many years. One patient, whom she had called into the surgery almost as an afterthought, is revealed to have life-threateningly low oxygen levels. He survives but she is haunted by how close she came to failing to recognise the severity of his symptoms and, in her telling, the terror and dislocation of that period come vividly alive.

Ultimately, the thread that binds Zero and A Fortunate Woman (and indeed A Fortunate Man) is the vital importance of preserving and elevating the human connections between doctor and patient amid time and budgetary pressures that threaten to reduce all therapeutic encounters to the transactional.

The shared lesson of these two volumes is that providing this quality of care cannot and should not rely on exceptional people: the doughty fighters for justice that populate the pages of Zero or doctors as extraordinarily dedicated as Berger and Morlands’ GPs.

As Morland puts it: “[I]f you deem these things to be desirable, you cannot simply wait for a hero and hope.”

Zero: Eliminating Unnecessary Deaths in a post-pandemic NHS by Jeremy Hunt, Swift Press £20, 320 pages

A Fortunate Woman: A Country Doctor’s Story by Polly Morland, Picador £16.99, 256 pages

Sarah Neville is the FT’s global health editor

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