Adam Kay’s professional relationship with the National Health Service (NHS)

Adam Kay’s professional relationship with the National Health Service (NHS) was shaped by a tension that never fully resolved: he valued the work of caring for patients and the people who did it, yet the conditions of that work eventually became more than he could bear. His diary moves from the comic disorientation of a new junior doctor through exhausting shifts and institutional pressures to a traumatic event that changed his practice and helped drive him out of medicine. Years later, he remained attached to the work’s purpose and colleagues, and turned his account of the job into a public defence of NHS doctors.

Entry into the service and daily work

On his first day as a junior doctor in August 2004, Kay arrived with new equipment, a new shirt and a packed lunch prepared by his partner, H. His new NHS email address misspelled his name, a small administrative mishap that became an early joke about his own inexperience. The comic tone would recur through his diaries, but the work quickly proved to involve real responsibility: one patient began bleeding, and Kay did not know what to do until his senior doctor intervened. The patient died. Kay changed out of his wet clothes, while the record of the event gave a plain account of the distance between a young doctor’s uncertainty and the consequences of clinical work.

The diaries register both the pressure of the job and the improvised humour with which Kay and his colleagues encountered it. In one shift, a pregnant patient’s alarming symptoms led him to investigate several possible causes and seek a specialist’s advice; the eventual explanation was that she had eaten two large jars of beetroot. In another episode, an emergency buzzer brought staff rushing into a room strewn with dust and rubble after a midwife had pulled the cord hard enough to damage the ceiling. Such incidents made the hospital seem at once serious and absurd. Kay’s humour offered a way to narrate that contradiction, not evidence that the demands of the work were harmless.

Praise from colleagues was scarce enough to matter. After a difficult night, a nurse called at 8 a.m. to say that Kay had done well and was a good doctor. He was exhausted and, startled by the kindness, ended the call by mistakenly saying that he loved her. The episode reveals how much affirmation mattered in a workplace where he felt he had received little since starting. His career also took him into women’s health, including labour and infertility. He saw the work as a chance to help deliver babies and support couples who had difficulty having them, while recognizing that the emotional highs came with the possibility of profound lows.

The rota, training and institutional pressures

The relationship was not only with clinical work but with a system that repeatedly disrupted continuity. Junior doctors moved between hospitals every six to twelve months, often just as they had begun to know their colleagues and workplace. The synchronized changeover, known as Black Wednesday (NHS doctors’ rotation day), made each new post feel like starting school again. Kay notes that death rates were known to rise on that day; his response is darkly comic, but the detail points to the risks of placing many inexperienced doctors into unfamiliar settings at once.

The pressures could reach beyond the rota into friendships and private plans. Kay cancelled attending his close friend Ron’s stag do at the last minute, losing the £400 he had spent and a T-shirt bearing Ron’s face. He had tried to swap shifts, but another doctor could not cover him, and Kay ended up working instead. He recognized that friends struggled to understand why plans made in advance so often had to be abandoned. The incident shows how the service’s staffing demands did not stop at the hospital door: they shaped what Kay could promise to people outside work and made him feel the cost of missing important occasions.

The diary also records an informal workplace rule that responsibility could arrive before adequate preparation. Near the end of one shift, a midwife said she was not signed off to carry out a procedure; Kay said he had not been signed off either. The reply was that doctors did not need to be signed off because they were doctors. In a later handover, a doctor brought in from another hospital to fill a rota gap admitted he had never performed a caesarean section. Kay could see the newcomer’s fear, sent him home and called his boss, anticipating that he would be required to work another twelve hours without pay. Together, these episodes expose a gap between formal training and the expectations imposed in practice: the work depended on people taking responsibility, even when preparation, staffing or support was inadequate.

Trauma, changed practice and departure

The decisive break came after a catastrophic obstetric event. The diary’s account ends in the immediate aftermath: Kay cried for an hour while trying to write his notes, and the hospital sent him home for the rest of the shift. Colleagues were kind and told him he was not at fault and could not have done more. That reassurance did not undo the impact. The event became the last diary entry, and Kay explicitly connects it with the disappearance of the book’s jokes.

He returned to work the next day, but described himself as a different doctor. Afraid that something terrible might happen again, he began favouring caesarean sections even when a baby’s heart-rate change was slight, knowing that some of those operations would not have been necessary. He understood this as a way to reduce the chance of another disastrous outcome, and later recognized the same fear behind senior doctors’ caution. Yet he did not consider himself to have recovered: for the next six months he did not laugh, and his smiles were not genuine. His account distinguishes simply continuing to work from actually dealing with what had happened.

Kay believed that he should have been able to talk to someone and that the hospital should have ensured he received support. Instead, he described a culture of silence that kept help from those who needed it. He asked to work part-time and was refused unless he was pregnant; changing direction to general practice would have required starting training again, and he was unsure he wanted that career. A few months later, he hung up his white coat and left medicine. He did not initially tell anyone the reason. When he told his parents, their response made clear how difficult it was for them to accept his decision; for a time, he could not discuss it, and later simply changed the subject. The departure was therefore not an uncomplicated rejection of the profession, but an exit after a traumatic experience and a period in which he kept functioning without feeling able to recover.

Continuing attachment and public advocacy

Leaving the NHS did not erase what Kay valued in the work. He later became a writer and said that he did not miss the bad days, but did miss the good ones: the doctors he had worked alongside, the chance to help people, and the feeling on the drive home that he had made a difference to someone’s life. He also observed that leaving medicine had become more common among doctors he knew. In his account, people who had once been willing to sacrifice even the morning of their own wedding were now moving abroad or into the City because the work had become so stressful and difficult. His view of the institution thus remained personal as well as structural: he mourned the loss of meaningful work while recognizing the conditions driving people away.

In 2016, after the government began requiring doctors to work harder for less pay, Kay felt compelled to speak publicly on their behalf. He rejected the claim that junior doctors were simply greedy, arguing that their concern was the best interests of patients. The doctors lost their dispute, and Kay saw the government’s public voice overpowering theirs. That defeat sharpened his sense that NHS workers had to explain what their work involved, rather than leave the public to accept political claims unchallenged.

Six years after quitting, Kay wrote his book from the perspective of one doctor, not as a substitute for the stories of all those still working. When he met former colleagues, their recollections of hospitals still showed him a service in a sad state; he also noticed how vividly doctors remembered the worst events, with voices that shook as they recounted them. His appeal to readers follows from both sides of his experience: he respects the people who remain on the front line, but does not pretend that he could endure the job indefinitely. The relationship ends in departure, not indifference. Kay’s continued concern for NHS staff, and his insistence that the public consider the human cost of their work, are the lasting forms his professional commitment took.