Alexis Hutson

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Rachel Clarke's Your life in my hands

10 August 2017

Screen Shot 2015-08-19 at 15.03.54Prof. David Sowden's summer book review - Rachel Clarke - Your life in my hands. 

If you aren’t aware of this book then you’ve probably been very busy indeed, away somewhere or otherwise distracted as it has attracted a great deal of attention. All, or at least all the reviews that I have seen, have been positive; indeed some have seemingly run out of superlatives.   Consequently, when asked to review this book I began the task with some trepidation conscious of Theodore Roosevelt’s famous dictum:
It is not the critic who counts, not the one who points out how the strong man stumbled or how the doer of deeds might have done better. The credit belongs to the man who is actually in the arena; whose face is marred with sweat and dust and blood; who strives valiantly; who errs and comes short again and again; who knows the great enthusiasm; the great devotions and spends himself in a worthy cause and who, if fails, at least fails while bearing greatly so that his place shall never be with those cold and timid souls who know neither victory nor defeat.
There is no doubt in my mind that junior doctors find themselves in an entirely unacceptable working and learning environment created by incompetent and disingenuous politicians, and that the NHS faces threats on a previously unimaginable scale. After all John Major has been quoted as saying that “the NHS is as safe as a pet hamster in the presence of a python” with reference to certain government ministers. The question for me is - does this book offer unique insights and add to the wider NHS debate? Screen Shot 2017-08-10 at 16.34.14 So with that in mind ……… Rachel Clarke’s book is an attempt at literary counterpoint; seeking to juxtapose reflections on her early career in medicine with the junior doctors contract dispute. I’ll be honest, I don’t think it really works very well. Counterpoint seeks to combine simultaneous voices to create a uniform, coherent whole, in this case there are two clear stories but little coherence. Clarke’s description of key elements of the junior doctor’s contract dispute are excellent and make compelling if depressing reading, as does her analysis of the extent to which 'spin' was used by the Department of Health to undermine the moral high ground occupied by the junior doctors, and the evidence to support their case, in the early and ensuing phases of the dispute. She eloquently highlights the anger within the profession at these ill-considered, dishonest and malign soundbites. She writes: that the junior doctors strike in 2016 “ignited a war of words so toxic….. that their corrosive legacy will take years to repair [if ever?]”. In the context of rota gaps Clarke raises the key issue, that Hunt and his blinkered political cronies chose to ignore, with elegant simplicity; doctors “cannot be in two places at once”. Equally telling: “we have reached the point at which the NHS’s greatest asset – its staff- has become terminally exhausted”. She cogently portrays Hunt’s fallacious allegations over the variation in apparent mortality rates during the 7 day week (abetted by Professor Sir Bruce Keogh, who should have known better) and points out how he manipulated the media and sought to “cure problems he had fabricated” as one of the central tenets of his dispute with junior doctors. What is missing, from my perspective, is the longer view that might legitimately highlight the abject failure of politicians, of all political hues across more than 20 years, to address the inability of the NHS to ensure its second purpose; that is, that there are enough, appropriately trained staff in the right places to meet the growing health needs of the population across the geography of the UK. Labour, Conservative and coalition governments have all failed the public to some extent. Jeremy Hunt is just another Secretary of State who doesn’t really understand the tasks that the UK electorate has expected of the NHS and of government. To paint Hunt as uniquely villainous, whilst extremely tempting, is a temptation that should be avoided since it implies others got it right. Admittedly, Hunt deserves opprobrium because he has got it so wrong but it remains on a scale of underachievement matched by many others. Clarke does, however, provide a unique insight into Hunt’s zealous pursuit of 'patient safety' by virtue of a private meeting they had. It is clear that Hunt has an almost messianic belief in his (unevidenced) vision of what the causes and solutions to patient safety issues are in the NHS. If nothing else this book highlights the catastrophic dangers of a proselytising politician whose actions are determined by faith and belief rather than understanding and rational analysis. Screen Shot 2017-08-10 at 16.32.41 The remainder of the book is taken up by reflections on Clarke’s mature entry to medicine, and her early career as a doctor. Her prior career was as a journalist and I’m afraid I found her descriptions of her medical career just a little cloying, and overly dependent on language that would not be out of place in the wider media but somehow just don’t work that well in a book written by a qualified doctor. Her language is just too hyperbolic at times; for example, when describing anatomy classes she refers to “the supreme violation that dissecting a human corpse would feel like”. Her exposition on the importance of kindness is innovative but I’m not sure she made nearly as much of this as she could. Her exploration of its derivation in the Old English noun ‘cynd” and its link to kinship is significant. But what she doesn’t then explore is how that kindness can be expressed effectively in a way that does not immobilise doctors in a swamp of sentiment and emotion. Later in the book she almost reaches a conclusion but segues away from it – the rational conclusion being that doctors can learn to act out kindness to an extent that the vast majority of patients cannot differentiate from genuine emotional engagement without a level of unsustainable professional/personal cost. I think Clarke’s editor needs to take some of the blame as it is almost as if he (it was a he) encouraged a level of emotional description that would appeal to the tabloids and would cement Clarke as a genuinely empathetic character and worthy of sympathy. Of course, she and the rest of the junior doctors caught up in this unnecessary dispute deserve our wholehearted support and respect but I’m not sure this book is an especially constructive way to either mark out the parameters of the dispute or the current career’s and lives of junior doctors. In conclusion, I think this book is worth a read to understand how government’s can and do manipulate a media that is increasingly influenced (indeed owned) by people who detest socialised medicine and who support corporate greed. Unfortunately, she doesn’t offer too many suggestions as to what the medical profession can and should do to regain its ability to genuinely influence policy about the NHS. However, much of the rest of the book could be pithily summarised as follows:
It appears that some politicians have no understanding of the great dedication with which doctors and nurses, especially in their training years, regard their job, dedication without which the whole service cannot run. These politicians [especially Hunt] understand only the market model for the provision of services that was the basis for Lansley’s  2012 Heath and Social Care Act. Treating junior doctors according to this model has led to the unresolved dispute over their contract and since then a spectacular and never previously seen loss of morale. Dr Gervase Vernon wrote in the BJGP (July 2017 page 309) 
Your life in my hands by Rachel Clarke. ISBN : 978 1 78606 451 6 Metro Books Prof. David Sowden MBChB, FRCGP, FRCOG, FFSEM, FAoME, DCH. Now retired. Formerly : Dean of Post-Graduate Medical Education East Midlands (2000 – 2012) Director of Medical Education England (2008/09 and 2012)