What Henry Did Next
To see your first book short-listed for prizes and showered with praise would be achievement enough for any frustrated writer and self-confessed teenage author of second-rate poetry.
Not Henry Marsh.
Do No Harm, published more than four decades on from that outpouring of adolescent angst, is his account of a medical career which has seen Marsh recognised as one of the country’s most accomplished brain surgeons. Moving at a thriller-like pace, the book recounts the decisions he helps his patients to make and the operations he then undertakes – in both cases, often quite literally a matter of life and death. To a non-medical reader, the accounts can sometimes be gruesome, but at all times gripping. And it is being enjoyed in increasingly influential circles. David Cameron recently revealed that the book reduced him to tears when he read it during the Christmas break, though that could be due to the sense of frustration that occasionally breaks onto the page as Marsh finds himself at odds with the worst of box-ticking NHS bureaucracy.
At his home in Wimbledon, from where he cycles to St George’s hospital in Tooting, Marsh greets me wearing a battered pair of leather boots. He does not come across as an obvious medical man, and while he says his wife hates it when he describes himself as an intellectual he adds, with a smile, “that compared to most doctors I am better read and have broader interests, dare I say it…”
Classical music plays in the background, books line the walls, a log fire – the fireplace was built by Marsh himself – crackles, and the doctor-turned-author fixes himself a large gin and tonic and begins to talk. It’s a skill, he jokes a few hours later, which he enjoys and comes naturally to him.
“I always wanted to write, almost to the extent that I became a neurosurgeon so that I had something interesting to write about. I felt I ought to lead an interesting life,” Marsh begins. The youngest of four children - his father Norman Marsh was a lawyer and founder of Amnesty International – Marsh was educated at the Dragon, Westminster, and then Oxford, and admits he was “born with a silver spoon in my mouth, in some ways”. He jokes that his wife complains how “unfair and absurd it is that public school products have this inner self-confidence”, but Marsh's career path was not planned. After studying PPE for two years he dropped out, only finishing his degree after time spent working as a hospital porter in Newcastle. He decided to train as a doctor, and became hooked on his particular specialism after witnessing his first experience of brain surgery. Later on, the diagnosis of a brain tumour in his three-month old son William - successfully operated on – would underline the very real human emotions that his work would deal with and, he says, help him become a better doctor.
“The fact is I went into medicine and surgery, particularly neurosurgery for excitement," Marsh explains. "And it is exciting, because you care for the patients. You're not a psychopath when you become a surgeon, but you don’t go in for pure, unblemished altruistic reasons. You’re a thrill seeker. You don’t go into brain surgery if you’re adverse to risk. Every day is an adventure. So I used to write about it. Because it's often terribly distressing and very painful, but terribly interesting, human suffering is always interesting…”
Do No Harm recounts operations that can go well, or in some cases very, very badly, and its author is brutally honest about the mistakes he has made. Most chapter headings are related to the brain, such as “aneurysm” and “leucotomy”, but towards the end of the book a chapter called “hubris” recounts a 15-hour operation to remove a large, benign tumour which ended with Marsh tearing an artery and leaving his patient in a permanent vegetative state.
However, surgeons – and Marsh admits that he has been involved in a few bad results in recent weeks – have no choice but to move on. “When I had my first bad results, or the first patient sued me, I felt terrible about it for weeks. It was absolute torture. Now it’s still horrible but I feel horrible for a few days, rather than weeks or even months. You know from bitter experience that, well, the patient may not get better but I’ll get over it. You move on. You have to. Bad results are inevitable, but if you're a good doctor, it does hurt. If it didn’t upset you, it means you’re a psychopath and you don’t care for your patients.”
The stories emerged from a diary he has kept throughout his life, a daily duty which he says became a “major psychological outlet” during a “very traumatic divorce” nearly twenty years ago. Marsh would go on to read parts of his diaries aloud to his second wife, writer and anthropologist Kate Fox, and with her encouragement and connections, Marsh found his words at the centre of a bidding war. He admits that he doesn’t “lack for self-esteem” - brain surgeons, he says, can’t be any other way – so it's not surprising that Marsh expected his book to do well.
“I thought it would be a success. I didn’t expect to be maybe quite so well-received. I knew I was writing something unusual. I wrote my diary to reread and I was trying to write something I liked reading myself. I was basically writing it for myself.”
Marsh is not a total stranger to the public eye. In 2007 a BBC documentary covered his work in the Ukraine, where Marsh has been at the forefront of neurosurgical advances for over 20 years, while his controversial decision to keep patients awake while operating made headlines a decade ago. But as he approaches 65, and retirement from the NHS, Marsh finds himself in demand from broadcasters and newspapers alike, not least because of the recent prime ministerial endorsement.
“Oh, delighted. I was very pleased. How could you not be?” he beams when asked about Cameron’s choice of festive reading. So if his book has made it onto the Number 10 bedside table, then what does Marsh hope the prime minister has taken from it?
“I don’t know….” Marsh replies after a pause, before suggesting a bit of the candid self-reflection that makes Do No Harm so compelling. “I would like him to think about the virtues of honesty, saying ‘life is difficult’. Politicians talking about society and invading Iraq and the healthcare as a thing where it’s all just the question of doing the right policy, actually it’s very, very difficult. Why not say that? Maybe they’d get away with it? Most politicians now, particularly Cameron, are not really ideological. They haven’t got a burning vision, they’re not selling a vision. Go back to Gladstone campaigning against the Bulgarian atrocities…”
Do No Harm doesn’t dwell for long on policies and politicians, after Marsh’s editor advised him that people reading his book “in 50 years’ time won’t be particularly interested in the minutiae of the NHS.” However, with Marsh admitting that “this constant permanent cultural revolution going on in the NHS is very demoralising", it's clear that the endless command from on-high rankled.
What the government is trying to achieve is the NHS just becomes a sort of kitemark for all these private companies
“Another grouse I have against the present government is this zero harm crap,” Marsh complains of David Cameron asking US healthcare expert Don Berwick to make "zero harm a reality in our NHS” after appointing him as the NHS Patient Safety Tsar in 2013. Marsh was not impressed. “There’s never going to be zero harm. Nothing is perfect, things are always going to go badly. If you’re inflating the public to have these consumer expectations that they should not have to wait, that they get perfect healthcare, perfect cancer care, without spelling out that actually it’s hugely expensive and they’re going to have to pay more money one way or the other... That’s going to have to happen, because all the indices are the NHS is seriously running out of money and they are going to have to come up with a solution.”
The 'zero-harm' pledge followed in the wake of the scandal at the Mid Staffordshire NHS Foundation Trust, where the death rate was vastly higher than normally expected, but, says Marsh, with an under-resourced health service problems are unavoidable.
“This thing called efficiency savings, which is cuts by another name… how do you measure efficiency in healthcare? Efficiency means producing more of the product at the same quality for a given input. Most healthcare you can’t measure the output quality of care. That was obviously a problem with Stafford hospital. It was probably only one or two wards. Obviously the media reported it badly. Maybe the rest of the hospital was fine. Maybe it was just one or two wards, the geriatric wards, where the patients were horribly treated? I saw nowhere in the media coverage that being a psychogeriatric nurse is a horrible job, and no discussion of 'how do you motivate people to do a rather thankless, unrewarding job?' All of it was demonising the managers and nurses. So how do you avoid that?"
While Marsh regrets that his “minor celebrity status” means his views are sought on the NHS as a whole when his specialty is far narrower, he agrees that “it’s pretty reasonable to say it is under-resourced, it has run out of money, and all the commissioners, and [NHS England chief executive] Simon Stevens are all saying the same… the problem is if you deny that, as the politicians are, I think, and you say it’s all a question of being more efficient and better management, you end up causing more damage, you demoralise people and make a mess of things.”
In some respects, he says, the problems aren't new. "Twenty years ago there was a chronic shortage of beds so in that sense things haven’t changed much. The NHS has always been starved of resources, relatively," Marsh states, before adding that recent changes are worrying. "What’s different is 20 years ago you had a waiting list, and as a senior surgeon you decided who got operated on - you didn't have a manager saying ‘the hospital is losing money because we’re cancelling.’ You were left to get on with it.”
Marsh’s book contains numerous accounts of his run-ins with the management class brought in to run the NHS, and while he insists rather unconvincingly that “part of me is trying to prove to myself I’m not quite as big a coward as I think I am," Marsh admits: “I don’t take kindly to being told what to do. I suppose you could say it’s arrogant. Every twentieth Amazon review says I am unbearably arrogant…”
Senior managers, he says “you never see," before drawing comparisons with essays on economics that he wrote as a student.
“Why is manufacturing business in Germany and Japan so successful and why is British Leyland and Triumph motorcycles going broke? The standard answer was middle and senior management in Germany and Japan, they wear boiler suits and are down on the shop floor and understand the nature of business. In the old British industries you have all these hierarchies of special toilets and boardrooms and the managers are nowhere to be seen on the shopfloor at all. It’s a bit like the NHS now. The NHS is repeating the sins of British manufacturing business 40 years ago.”
While he argues that changing health secretaries or governments go unnoticed on the ward – “It’s a bit like the first world war. You’re in the trenches and what the staff officers are doing doesn’t really make much difference…” – in Do No Harm he writes that governments turn the life of clinicians into a game of musical chairs, with the coalition’s controversial NHS reforms the equivalent of changing the entire orchestra.
“They've changed the orchestras but there still aren't enough chairs!” he shouts. “That's the point. I’m concerned about the number of chairs, I’m not particularly concerned about the music they play." However, while "there are never enough beds", Marsh also complains that "there is an increasing sense of chaos which is a separate issue - in my working life there has been a huge reduction in the authority of the doctors, without a doubt."
Recounting a recent example of his frustrated attempts to allow a patient - who was "perfectly well" - to go home on a Sunday evening, Marsh complains that doctors are "competing with.. speech and language therapists, and occupational therapists and physiotherapists, that all write in the medical notes and are equal to the doctors." The problem, he says, is that "the doctors have been displaced but they haven’t been replaced. All these courses - I haven’t been on them for years - about leadership and things like that… there is really very little clinical leadership. Every day is a chaotic process and, in the background, there are not enough beds. You never know if there are enough beds. If you’re going to run a safe medical service you need surplus capacity, obviously, because emergencies come in runs, but there’s absolutely no surplus capacity at all. So we run chronically at 90/100 per cent bed capacity. Every admission is a major tangle."
But despite his frustrations with the NHS – Marsh pointedly notes that there is no question of competing authority in the private sector, where consultants make the decisions – he is a passionate believer in public service.
“What’s peculiar about this country is the sort of shibboleth…the sacred cow aspect of the NHS, even though what the government is trying to achieve is the NHS just becomes a sort of kitemark for all these private companies, who are just sort of feeding, picking off the profitable bits. I feel very strongly that the Thatcherite Tories, and the Blairites too…I do think privatising it is nonsense. You have to show the profit made by the private companies is justified in terms of better treatment or better outcomes, and that evidence is not there. Full stop. And secondly, if doctors are corrupted by making money, as they are in my experience, and doctors who in theory have a professional ethic of putting the patient first, well for Christ’s sake, businessmen are going to be infinitely more corrupted and will be much more concerned about cutting corners and squeezing as much money out of the system as possible without any deep, ethical concern for the outcome.”
Two markers of civilisation are the number of people riding bicycles and the presence of euthanasia
Marsh’s book also prompts the reader to consider a deeper question. At what point is attempting to prolong life the wrong decision for a patient faced with the prospect of an operation? “The problem with brain surgery is it's not just about life or death, it’s about quality of life. An awful lot of the work is not curing people – you’re hoping to prolong their life. And if their brain is badly damaged you might be prolonging disabled life. So how do you work out how severe the disability is, and how well they well cope with it. Each person is different. The decision making is extremely complicated.”
He recently reviewed “Being Mortal: Medicine and What Matters in the End”, the new book by the American endocrine surgeon – and last year’s Reith lecturer - Atul Gawande, which questions how modern medicine has affected our relationship with mortality. While admitting to some "surgical jealousy" at Gawande’s success, and not entirely enjoying the book and its "rather Spielbergy ending", Marsh says he agrees with much of what he says,
“There is this huge problem. Clearly it makes sense to die at the age of 50 rather than 40, or maybe 40 instead of 30, in terms of bringing up the next generation and maintaining your genes and your DNA. We have this deep inbuilt urge to go on living and avoid death, but to die at the age of 90 as opposed to 80…. The longer you live in these latter years, the more likely you are to get Alzheimer's. It's all game theory. If you get cancer at the age of 75 and don’t have it treated, you will die, you may die miserably, but if you are treated and cured you may well live long enough to dement slowly and be a bloody nuisance to yourself and your family over a much longer period of time.”
Marsh runs every day – “I exercise like mad” – in an effort to keep healthy, and will soon start teaching himself Russian in the belief that learning a language can keep dementia at bay. His own father, he says, “demented rather gracefully, but "I don’t want to be like that…”
So would he turn down an operation if, say, he was diagnosed with a form of cancer in ten, 15 years’ time?
“It’s a moot point if I get some form of cancer in my late 70s,” Marsh replies. “It’s very difficult. I don’t know what I’d say at the time.”
He would, however, like the option to call time on his life if circumstances deteriorated irreversibly.
Marsh “very passionately” supports euthanasia, describing it as "a sign of deeply advanced and civilised society: Two markers of civilisation are the number of people riding bicycles and the presence of euthanasia.”
Luckily Henry Marsh has plenty of projects to keep the brain active. He keeps bees and makes furniture, with his accomplished DIY skills – before I leave he shows me round his workshop and admits, rather ruefully, that he has no more tools left to buy – set to be given a new challenge after he bought a deserted lockkeeper’s cottage in the same part of Oxfordshire in which he grew up. He will also volunteer in hospitals across the globe, but Marsh’s time as an NHS doctor will end early after yet another brush with the rules.
“I was going to go on longer but I handed in my resignation in a hissy fit, when the management threatened me with disciplinary action for wearing a wrist watch. It’s just stupid… Here I am taking life and death decisions every day and putting my patients’ lives on the line. When a fellow doctor talked to me, that was too much."
He doesn't regret his decision, and believe it always better to “leave too soon, from dinner parties and from life itself," and once he quits the front line he insists that he doesn’t want a career in the public eye “at all”. Writing, however, remains a passion.
"I would like to write another book, but it would have to go on being personal stories so, as my wife says, slightly joking, it would have to be ‘What Henry Did Next.’ I don’t know what I’ll do next or what will happen to my life. What I will do with what’s left of my life is very uncertain. But," he adds with a knowing smile, "it’s downhill all the way.”
Do No Harm: Stories of Life, Death and Brain Surgery by Henry Marsh is published by Weidenfeld & Nicolson (£16.99)