Imagine that you desperately needed to warn the British people about the National Health Service. Yours is no armchair free-market critique: you went though med school and served as a junior doctor. Your first-hand experience of the national church has scarred (perhaps traumatised) you.
Yet you have a problem. The only people who criticise the NHS are shadowy figures from right-wing think-tanks, probably funded by dark money. You are a good liberal, with a social circle to match. Your friends won’t take kindly to any suggestion of adopting the reviled American healthcare model, and their eyes glaze over whenever you try to point out that other alternatives exist.
How do you square this circle? If you have a knack for humour, I suggest you could do a lot worse than writing This Is Going To Hurt, Adam Kay’s best-selling memoir of the grim reality of life in the hospital trenches.
So harrowing is each chapter’s depiction of life in this or that corner of the sprawling NHS empire that one gets the sense Kay feared being taken for a critic of it.
Each chapter is therefore topped with a short paean to the virtues of the health service, which provide a sort of rhetorical cover to the author (and perhaps, too, the reader). What you’re about to read may carry the whiff of heresy but fear not, we’re all good Christians here.
In Persecution and the Art of Writing, his seminal text on how authors convey forbidden ideas, the philosopher Leo Strauss wrote:
“[If] an able writer who has a clear mind and a perfect knowledge of the orthodox view and all its ramifications, contradicts surreptitiously and as it were in passing one of its necessary presuppositions or consequences which he explicitly recognizes and maintains everywhere else, we can reasonably suspect that he was opposed to the orthodox system as such…”
Kay is clearly an intelligent man. But the ratios here are a long way from Strauss’s definition of esoteric writing: the contradictions stack up, page after page, with barely a sugar coating of the proper pieties. The message ought to ring like a bell.
But if there was such a message, almost nobody seems to have got it. The book sold very well – enough to spawn a sequel – but it didn’t move the dial of public opinion. What is our hypothetical peddler of heresy supposed to do now?
Salvation comes in the form of another, more benignant state leviathan. The BBC commissions a comedy series based on the book. A very likeable actor is hired to play the charming lead; a prime slot is booked. This is it, a second chance. Books were last century’s medium anyway.
But, risking his standing with hoi ologoi, our heretic strengthens his message. He writes into the show a fictitious doctor and then [spoilers] has her one-up the lead, who quits and becomes a comedian, by killing herself.
Cruel, then, that not even the actress gets the message. “Long live our NHS!”, she tweets. It’s as if the face gazing out from that famous WWI recruiting poster was Wilfred Owen’s.
I hasten to add, for the benefit of any commissars reading, that I am speculating. I have never met comrade Kay; he has confessed no thoughtcrimes to me. His book is the most arresting advertising private health insurance has had since the HSA rabbit, but that doesn’t mean he’s taken out a policy.
It’s not as if there isn’t stuff to object to in it, even without seeking an esoteric interpretation. Black humour is a very human reflex, and people who deal with human misery day-in, day-out can be forgiven for looking for ways to put some distance between themselves and their patients.
To the extent it is forgivable – and his language about women goes some distance beyond that – the dehumanising language belongs to the locker room, or in black jokes cracked with a colleague over a forbidden cigarette in some neglected outworking of the hospital estate. It doesn’t belong in a best-selling book, where millions of future patients will read it and carry it with them when next they need care.
Nonetheless, This Is Going To Hurt is a bleakly funny book, and the bleakest joke of them all is not at the expense of any of the thinly-fictionalised characters, but all of us. The horrors Kay describes are not some faraway warzone: they’re ‘our NHS’. If you can’t afford private medical insurance (something of a luxury even before the cost of living crisis) it’s where you’re going to go when you’re ill.
And if the NHS is a joke, the punchline is bodies. Sometimes it’s a fictive nurse, but most of the time those of real people. Dry data about the health service falling short of the European average in this or that area stands for a lot of unnecessary funerals. (For all Kay’s skill as a humourist, he will surely never match the sheer economy and elegance of the Guardian, which titled an article ‘NHS comes top in healthcare survey’ before dropping in the now-famous line: “The only serious black mark against the NHS was its poor record on keeping people alive.” Unsurpassable.)
Yet nothing changes. We laugh and cringe and wince at Kay’s macabre stories, and then put blue hearts in our bios, recite the catechism of ‘the best in the world’, and pretend that a health service which is already consuming national resources at an unsustainable rate would be fine if only the evil Tories would spend even more money on it.
That leaves our poor, imagined dissident Kay, the tragic clown in the blue scrubs – the man who really did ‘become the joker’ – to try and work out how he can make his point more obviously in the TV adaptation of his 2019 book, ‘Twas the Nightshift before Christmas. Perhaps there’s some gags to mine from that time tens of thousands of people a year were needlessly dying of thirst.
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