Rachel Clarke

The palliative care doctor and bestselling author talks about how the government is failing the NHS

The palliative care doctor and bestselling author talks to Jonathan Lis about how the government is failing the NHS
Dr Rachel Clarke

In the space of a few years, Rachel Clarke has become, if not a national treasure, then perhaps the nation’s conscience. One of the country’s most prominent doctors, she has written three books, appeared on Question Time, boasts nearly 300,000 followers on Twitter, and for many people – me included – is one of the central public figures of the NHS. She specialises in palliative care, but has profound insight into the health service at its core. Crucially, she is also able to explain it to others.

“For the Tories, the NHS will never be seen as a vote-winner”

For those of us not working in the health service, the problems can seem literally indescribable. Many of us have experienced the difficulties as patients; luckier people simply read and hear about them. So what is it like to actually live them as one of the workers keeping it afloat? And what can we do about a service so visibly breaking?

I meet Clarke over a Zoom link to her house in Oxfordshire. It has been another week of headlines about strikes and ambulance waiting times, and a new row about patients bypassing GPs for self-referrals – the latest brainchild of Labour leader Keir Starmer and his shadow health secretary Wes Streeting. The situation seems so overwhelming that I decide to jump straight in. What is wrong with the NHS, and can it actually be saved?

“I find it very frustrating to see the narrative at the moment, which tends to be ‘Right, that’s it, performance is so bad now, there is no way of resolving this.’”

Clarke gives such a comprehensive response that she speaks for almost ten minutes. She makes clear her opposition to simple binary thinking – that the NHS needs either more money or reform. It is desperate for both. Above all, she says, it needs the people who work in it. “Lots of people are burnt out, voting with their feet. People who once loved the NHS, felt it was a privilege to work in the NHS, are so desperately demoralised by their conditions of work, they can see no future, no improvement. They’re often quitting for their own sanity. And also because they realise they can earn more if they go and, for instance, work in a local retail job where they get paid more and don’t have to deal with the stresses and strains of literally looking into the eyes of someone as they die on a trolley in a corridor.”

She is quick to offer solutions, too. One big problem, she says, is the split between GPs and hospitals. “We’ve got primary care operating very often with different computer systems, different-structure staffing, and it can be so difficult to make hospitals and GPs seamlessly work together. Too often patients slip through the cracks. So, for example, we may send a dying patient home from the hospital, and maybe the patient or their family call a GP or the paramedics one night, and they don’t even have access to the patient’s notes and the latest information about their illness, because the computer systems don’t speak to each other. And that’s insane. And if I was suddenly secretary of state for health, one of the first things I would do would be invest in a proper single NHS fit-for-purpose computer system, and at a stroke suddenly all patients’ continuity of care would be improved.”

For Clarke, this is about who we are as a society. “We’re a rich enough country to provide everyone with a decent level of healthcare. And anyone who pretends otherwise is saying something pretty radical about how uncivilised a country they are happy enough to live in.”

Throughout our discussion, she is happy – perhaps even eager – to be political. “I find it very frustrating to see the narrative at the moment, which tends to be a lot of people saying, ‘Right, that’s it, performance is so bad now that it’s clearly a fundamental problem, there is no way of resolving this.’ And I think that’s at best defeatist and at worst, a deliberate argument to undermine the NHS from first principles in order to do away with it and move to something built by private providers. And, you know, in the current governing party there are lots of individual MPs and ministers who would dearly love to see this last bastion of socialised public service done away with.” She points to the Conservatives’ systematic underfunding of the NHS over the last thirteen years (which has squeezed wages) and near-total absence of long-term capital investment (which has run down infrastructure and equipment).

Can it really be true that the Conservatives want to privatise the NHS? “When you look at the track record… it is impossible to conclude anything other than that this is calculated and deliberate with an end in mind. The only alternative to that conclusion is that somehow successive Conservative governments haven’t noticed that standards have been falling on all of the key NHS performance metrics year upon year. And I don’t understand how the same party can be in government over all that time, look at that data, know exactly what that data translates into in terms of real people, and do that accidentally. They have to have reached the conclusion that they will run things down to such an extent that, in the end, they won’t have to be the bad guys who say, ‘the NHS is unfit for purpose,’ they will have persuaded the British public that the NHS is unfit for purpose, precisely because they have engineered that. They’re running it down so that in the end, the public become so frightened and so angry that they’re not getting the healthcare they need, and will come to believe there’s no alternative, that we have to move to a different system. And I think that is despicably cynical.”

“I literally just want to be able to work in a system that enables me to care for very vulnerable people as best I possibly can”

But it seems so stupid, I say. The NHS is more than just incredibly popular, it is approaching a national religion – and free access on demand is the first article of faith. How would it be in the Tories’ political interest to knock it all down – or even to let it gradually disintegrate?

“Well, it’s interesting,” Clarke replies. “I spoke to a former Conservative health secretary recently about this. And I made this point, you know, ‘You will be wiped out in the next election if you are seen as the party that is destroying the NHS.’And they said to me, ‘What you have to understand is for the Tories, the NHS will never be seen as a vote-winner, only a vote-loser, and therefore the party isn’t really interested in making it work in the long term. We win elections on safe stewardship of the economy.’ To which I said, ‘What about doing the right thing? I am seeing patients dying in corridors before my eyes who can’t even get a bed in a hospital.’ And there was silence.”

Have the Conservatives simply lost the plot then?  “Even their ambition is negligible. I don’t understand the political strategy. I can only think it’s very naïve because the British public still, despite everything, loves the NHS. Even though increasing numbers of people are not happy with NHS performance, there is still overwhelming public support for the principles of the NHS. And therefore you’re just throwing away an election if you pretend you can ignore that and hope the problem goes away.”

While she talks, I think of the ministerial nobodies who pass through the Department of Health, treating the NHS either as a political football or as a staging-post to a more glamorous job in Cabinet. She acknowledges the contrast. “Anything for which the public feels genuine affection is going to be hijacked by politicians. A politician wants nothing more than some of that sincere, spontaneous public affection. They want to wrap themselves in it.”

Clarke is intensely political, but is she, in her criticisms, party political? “I literally just want to be able to work in a system that enables me to care for very vulnerable people as best I possibly can, whether that system is provided by a Labour or Conservative government.”

It strikes me this argument is also used by proponents of private healthcare provision – that it doesn’t actually matter who supplies the service, provided patients are treated effectively and don’t pay for the privilege. Clarke insists the comparison doesn’t hold. “First and foremost, if private companies are providing healthcare because they have a contract with the NHS, for instance, then you have introduced the profit motive into healthcare. And you as a patient are suddenly in an environment where the bosses of that environment want to make money out of your illness. You have been reduced to a means of enriching a shareholder.”

Regulation wouldn’t help either, she says, any more than the regulation designed to stop UK private water companies “pumping entire oceans of human effluent” into our seas and rivers. “You only need to look at the other examples of privatised public services to think, do I really want that company looking after my granny? The healthcare equivalent of Thames Water and their monumental rivers of shit?”

Boris Johnson at a coronavirus press briefing in 2020. Rachel Clarke says that delays in the second and third lockdowns caused thousands of avoidable deaths. Creator: Stephen Harvey / No10 Downing Street © Crown Copyright, 2020

It’s a characteristically on-the-nail answer. There’s an absolute precision to Clarke, as though her brain has compiled and edited elegant prose a split second after I’ve requested it. It doesn’t surprise me that she used to be a journalist. In fact, she only trained in medicine in her 30s. A few years after qualifying, she gained national prominence in the junior doctor dispute of 2015, which spawned her first book, Your Life in My Hands.

“Boris Johnson has blood on his hands to a factor of tens of thousands of lives lost”

Speaking to Clarke, I quickly understand how she has gained such a formidable profile in her second profession. She radiates not only calm and warmth but a steely kind of righteousness. This is a good person who believes in something good – wholly, completely – and heaven help anyone who stands in her way.

We broach Brexit, which she agrees greatly damaged NHS staffing, and then turn to the second, much harder gut-punch, Covid. It was during the pandemic that I became aware of Clarke, when her furious, despairing tweets seemed to give voice not only to her profession, but to a political opposition.

She does not hold back on the government’s failures from that time – particularly its delays in bringing the second and third lockdowns. “Unlike March 2020, the first wave of the pandemic, we knew it was avoidable. We knew that the thousands of people we were seeing dying were avoidable deaths. They did not need to happen. If we had been locked down, those thousands of people needn’t have died. I remember seeing a son, a father, a grandfather, three generations from one family dying one after the other because they socialised at Christmas encouraged to do so by the government. Worse than terrible death in a pandemic is avoidable terrible death. Boris Johnson has blood on his hands to a factor of tens of thousands of lives lost.”

When she mentions the failures of PPE provision, and Matt Hancock’s preposterous claims about throwing rings around care homes, her voice quietly thunders. She is livid that, even now, ministers’ discourse “is not conducted in order to learn lessons, it’s conducted in order to spin the government response as successful, spin away any hint of culpability or failure and pretend that every decision made was the right decision.”

Mural by Ian Berry on an NHS surgery in Walthamstow, London to commemorate clapping for key workers on Thursdays during the pandemic. Photo: Loco Steve/Flickr – (Cc-By 2.0)

And yet Clarke is keen to highlight something positive: the weekly round of applause. Yes, it was cynical for politicians to have enthusiastically applauded nurses while voting against pay rises for them, and ministers steadily exploited and tainted the event – but that is not the memory that stands out. “Oh God,” she exclaims, “it meant everything when it began. I remember so vividly the first clap. I didn’t really know anything about it. I was so busy at work, but I happened to be arriving home, pulling into our drive at eight o’clock. And as I got out of the car, I could hear this kind of clanging of pots and pans from our village. And my husband and kids were standing in the drive and my son was banging a hockey stick against the wall and my daughter was banging a saucepan dementedly in her pyjamas. And I suddenly thought, ‘oh my God, this is that thing, the NHS clap’. And literally I got out of the car and burst into tears, and couldn’t stop crying, because it felt like this incredibly spontaneous expression of genuine grassroots thanks for all the key workers – not just NHS – who weren’t locked down, who were out there, potentially risking our lives in the pandemic. It meant everything because it was just a simple, honest, sincere message of thanks from the people we were trying to help.”

“I couldn’t stop crying, because it felt like this incredibly spontaneous expression of thanks for all the key workers”

Can we take anything from that today? “Yes, society is fractured and riven by huge disputes about lockdowns, vaccinations, all of those things. But the fact is, it was real. When we were in a crisis and when nobody knew if they could die from this terrible new illness, we helped each other and we set up our little WhatsApp groups in our streets so that the old age pensioners who couldn’t get their food and their prescriptions got them because we delivered them. That’s real and it matters and it says something really important and powerful and optimistic about human nature, and tells me that when push comes to shove people are decent and they step up and they do the right thing. And no cynical decisions taken by politicians in a pandemic can ever undo that. That was a real spontaneous impulse that said something beautiful and remarkable about the people we are.”

Even though Clarke criticises the political response to Covid, she can sympathise on a personal level with ministers from that time. “I think that although mistakes were clearly made in March 2020, you would have to be a very arrogant individual to condemn those mistakes and say that you wouldn’t have made them yourself. I mean, I would not have wanted to be prime minister or chief medical or chief scientific officer making those decisions. People were trying their best, everybody. However, there are two things that are unforgivable. One is failing to learn from your mistakes. The other thing is not being honest with the public.”

Is there not a difficulty, though, that politicians sometimes can’t be honest? In March 2020, for instance, nobody could admit that, without a vaccine in sight, we might have to lock down for years, or face a vastly higher death toll. She is sympathetic on that specific point, but less so on the general one. “I think the relationship between politicians, media, social media and the public makes it hard for politicians to tell the truth because the risk of being honest is you just turn into tomorrow’s viral moment on Twitter. However, some politicians use that as an excuse. It is perfectly possible to be a politician who tells the truth over and over again and still be successful in politics. You wouldn’t make gaffes if you were being honest, you would be acting with integrity.”

“An essential part of the job is to build a relationship of trust with this patient, helping them feel that I am their advocate”

I ask briefly about her relationship to Labour, and in particular her angry reaction to some of Streeting’s recent criticisms of doctors. “GPs get enough bashing from government ministers and diatribes in the Daily Mail, they really don’t need any more from the Labour party,” she replies. “However, I think his ambitions for a genuine ten-year plan for the NHS are good and commendable, that’s what we need. For all my hostility towards Wes Streeting for the specific issue of attacking doctors, at least we have a party that is engaging wholeheartedly with the NHS’s future.”

As for the self-referral idea? “Self-referral happens in all kinds of ways, it’s not a new phenomenon. So, for instance, if you have a gynae problem, you might self-refer to a gynae clinic and have nothing to do with your GP in order to do that. Yes, be radical, come up with ways of making the NHS more efficient. I am desperate for those, they will help patients. But don’t do it in a completely moronic way by pretending that self-referral for internal haemorrhage is an excellent idea.”

The exchange seems symbolic of the ways in which Clarke alternates between thoughtful diplomacy and excoriating directness. It makes me wonder if she wouldn’t be rather a good politician herself. She is adamant that it is not on the agenda. “One of the things I absolutely love about being a doctor is almost the purity of that relationship between doctor and patient. I have a really simple job to do, which is to try to help this patient right now in front of me. And an essential part of that job is communicating skilfully, truthfully, trying to build a relationship of trust with this patient, helping them feel that I am their advocate. And I really love that because it means I get to go to work and at work in the hospital I am just me, there’s no carapace or ‘act’ at all. And I think if you’re a politician, you are inevitably always calculating how your actions or your words are going to be perceived publicly. And that would just complicate everything you’re trying to do.”

All of which leads neatly to her own distinctive niche as doctor and public figure. How does she see that role? As always, she is persuasive. “I am not a spokesperson, I have no democratic mandate at all and I would never want to pretend that I can speak on behalf of any other individual. I’ve always done exactly the same thing in the public sphere, and that is said what I believe the truth is.” She explains how she used her skills as a journalist to oppose then-health secretary Jeremy Hunt during the junior doctors’ dispute. “I never wanted to have a public role, but I had to fight back against the government spin machine. I genuinely believe that speaking out in public, for me, is an extension of my duty as a doctor. And it’s not that I think all doctors should do that, but in the NHS there is a fundamental duty of candour. So when, for example, in the start of January, Rishi Sunak literally denied the NHS was in crisis and in fact continues to deny the NHS is in crisis, I know that’s a lie. And if I don’t speak out about that, I’m allowing the government to dictate a dishonest spin to the public. So I feel a sense of duty to be candid through speaking out, because I ultimately care about patients.”

She is candid, too, about the toll that can take. “It’s much more stressful sometimes than what I do at work. You can get attacked, you know, you can get abused incessantly as a woman on Twitter, for instance. But I care about it. I wouldn’t do it if it didn’t stem from the same motives that make me want to be a good doctor.”

“I am angry because of seeing patients dying who would not have died if the government had made different political choices”

I ask if she worries about making political enemies. “I’m not really interested in those attacks. Ultimately, of course the NHS is political. I care first and foremost about patients getting decent healthcare in this country and there is no way of de-politicising that desire when, as we’ve been discussing, the NHS is used cynically and relentlessly as a political football.”

Does she really not care if the Mail despises her? “No. I honestly can say I don’t care about that. The only way not to be hated by anybody is to be smiley and nice and demure and tentative and gentle in all your opinions about everything. But I’m not.” She seems suddenly to catch alight. “I am angry with every molecule of my being because I am going to work and literally seeing patients dying on trolleys who did not have to die and would not have died if the government and the party in power for the last thirteen years had made different political choices. These deaths are not the way the world is. These are daily avoidable deaths as a result of political choices that the government of the day doesn’t even have the integrity to acknowledge. And instead all they do is turn their faces from the dying and deny that there’s a crisis at all. That’s disgusting and I’m going to do all I can, however futile and tiny and impotent those efforts might be. If that annoys certain members of government or certain newspapers, I don’t give a damn.”

For a moment Clarke’s passion almost silences me. I ask her why she became a doctor. She tells me about her late father, who regaled her with his stories of being a doctor, and whom she hero-worshipped. She slowly fell out of love with journalism and wondered if she had made the wrong choice. “I would get to know people who became interviewees and I would build up a relationship of trust. And I always felt a bit uneasy about that process of trying to persuade people to trust you almost for your own ulterior ends rather than their ends. Whereas now, as a doctor, the process of people entrusting their lives to you, their stories to you, that happens in a way that is purely for them and about them.”

She began medical school and loved everything about it – first the equations, then the patients. “I just found it so fulfilling to be in this relationship with people who are often having the worst day of their life. They’re scared, they’re in pain. The future they thought they had may have been overturned by their diagnosis. And you have this simple but incredibly important job to do, which is try and help them, try and heal them.”

It almost sounds evangelical, but in the purest sort of way: the zeal of changing someone’s life. I ask her why she chose palliative care, but already think I know the answer. When it comes, it moves me almost to tears.

“I absolutely love being a palliative care doctor. Dying patients are often overlooked in the hospital. They often literally don’t have a voice. They’re too ill, they’re too overwhelmed by their illness to advocate for themselves. There’s a terrible anguish to being mortal, to losing everyone you love, everything you love in life, it slips through our fingers whether we like it or not. It doesn’t matter how strongly we hold onto it. That’s a kind of suffering that is an essential part of being human. But there is also an awful lot of suffering that goes with dying that is avoidable, that needn’t happen, if only a patient received good palliative care, was able to talk through their fears with someone. And so, as a palliative care doctor, you can go into a situation and you can literally transform what remains of someone’s life, however short that period can be. And it’s not a specialty that’s about dying, fundamentally it is about living. My job is to figure out with a patient how to enable them to live the time they have left as richly and fully as they possibly can. If that means bringing in a bottle of Southern Comfort, a bag of ice and a glass tumbler from the local Sainsbury’s, we will do that. It’s a branch of medicine where you can be creative and radical and really put the patient and what matters to the patient first. And sometimes, even as someone dies, it’s almost a celebration of life.”

I now have a strong sense of a building crescendo, that she is teaching and I am learning, and even though people have said this before, it feels as if I am hearing it for the first time. “The really important part of palliative care is that when it comes to the end of life, very little matters. No-one wishes they’d worked harder. No-one wishes they had got more accolades and awards. In the end, it boils down to the love and the people you love being around you in the purest and most radical sense. And you see just the ferocity with which people love each other, and the anguish of bereavement is a reflection of how much you love someone. So it’s intense and remarkable and you have the potential to do so much good. And I love it.”

“The really important part of palliative care is that when it comes to the end of life, it’s all about love”

It sounds as though you’ve learnt a lot about life from being surrounded by so much death, I say. “Completely. Nothing focuses the mind quite like proximity to death. You may be the person who’s dying, a family member, or a doctor. I am privileged enough to work with patients who are almost universally recalibrating their entire approach to their existence, they’re figuring out what matters to them, how they can try and bring more of what matters into the precious time that remains to them. And there isn’t a week that goes by where I don’t come away being blown away by an encounter with a patient.”

“What a piece of work is a man,” she concludes, quoting Hamlet. “We have this capacity to be monstrous. We also have a capacity to be exquisitely beautiful and extraordinary, and I see all of that at work because of my job. I’m so lucky.”

Rachel Clarke’s Sunday Times bestseller “Breathtaking” (Metro) is out now

Jonathan Lis s a political journalist and commentator and broadcaster

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February 2023, People

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