Death becomes her

An advertisement in the Evening Standard for clerical assistants in the newly formed NHS attracted the now-famous crime writer PD James in November 1949. It followed an unhappy stint at Ely tax office and the birth of her two daughters.

She applied to Paddington Hospital management committee, was shortlisted and, aged 29, found herself working at the London Skin Hospital in Fitzroy Square at the start of what turned out to be 19 years in hospital administration.

When she left the NHS in 1968 to go to the Home Office she was an established crime writer, having published three novels, Cover Her Face, A Mind to Murder and Unnatural Causes, all of which were adapted for television.

For a writer who thrives on the potential afforded by violent death, the NHS may not have provided quite the breadth of material afforded by the Home Office, 'probably the most interesting and happiest part of my working life'.

But her memories of its early, almost ramshackle, days are an absorbing part of her autobiography, Time to be in Earnest, published last month.

The London Skin Hospital, where she arrived at nine every morning and donned a white coat, had previously been a small specialist hospital 'supported by payments from the patients and by voluntary help and subscriptions, treating a faithful band of patients who seemed neither to expect to get better, nor to much resent the fact that they appeared weekly for some years'.

She adds: 'My duties were simple. Patients attending for the first time were issued with appointment cards and numbers. A numerical filing system had to be instituted, and reports of the number of patients attending submitted, I think monthly, to group headquarters.

'Making the appointments merely meant adding the patient's name to the clinic. The Skin Hospital believed firmly in a policy of firstcome, first-served, and indeed this was generally acceptable to the patients.'

But there was less consensus on other topics. Staff at the hospital 'were fiercely anti-National Health Service, seeing it as the triumph of state bureaucracy over personal charitable service'.

James accepted being paid less - 'simply because I was a woman' - than a man on the same grade doing comparable work. And she doubted her own indispensability in the new scheme of things, in which her duties included recording all letters sent out in a ledger and reconciling the number of stamps used with the number left each day.

'I had the feeling that my job was not strictly necessary or, at least, could be done by existing staff, but there was a general feeling of optimism, of public money liberally available, and a sense that people, no longer working for a charity, need not over-exert themselves.'

But despite the general optimism, and the government's belief that demand would decrease as the nation became healthier, some persistent problems emerged very early on.

'Now that there is so much concern with waiting lists, treatment priorities and the rationing of limited resources, it is easy to forget that not all demands could be met in those heady early days of the service. One of the greatest problems facing the country after the war was tuberculosis.

'Paddington Hospital actually had huts in the hospital grounds where TB patients were nursed, inhaling the not very salubrious air of the Harrow Road. There was a TB waiting list for admission to sanatoria, and another for the young chronic sick with illnesses such as disseminated sclerosis, which only too often had to be nursed in longstay geriatric wards.'

Memories of her mother enduring spasms of atrocious agony from kidney stones to avoid the cost of seeing a doctor made James welcome the NHS unreservedly. And success with the stamp book led to a promotion as committee clerk at group headquarters, which involved taking minutes and circulating papers to the house committees that oversaw individual hospitals. She planned her first book on train journeys from Essex and wrote for an hour each morning before leaving for work.

The King's Fund College for Hospital Administrators in Bayswater played a part in its publication. Selected for a three-month residential course there, James was invited by the head of the college - 'a good administrator but not immune to that particular brand of social snobbery I have encountered more than once in the headmasters of minor public schools' - and his wife to spend a weekend at their oasthouse in Kent.

There she met the actor Miles Malleson, who introduced her to the literary agent Elaine Greene, with whom she stayed until Greene's death.

It was about this time that she began to realise that her husband, Connor, who had returned mentally ill from overseas service, might never be well again and that she might have to support the family indefinitely. This prompted her to enrol in evening classes for a diploma in hospital administration: 'without it any further progress would be impossible'. This covered supplies, building and planning, personnel management, book-keeping and law - the last taught by a rotund, former refugee called Smitoff who acted out all the cases.

Despite glitches with the book-keeping, she passed with honours, gained the regional prize and ended up at the North West Metropolitan regional hospital board, in its offices opposite Paddington Station, where she remained until 1968, taking particular responsibility for the young chronic sick and noting with interest widely differing responses to chronic illness. 'There were families in which a wife or husband was coping with an almost intolerable burden of care and yet could barely contemplate the thought that the partner might have to leave home and be institutionalised.'

But in another case, 'the wife was battering on the doors of the regional board almost as soon as the diagnosis was made, complaining that her husband could no longer get to the lavatory and had to use a bottle in the presence of the children'.

'It was deeply depressing to contemplate a family in which a disabled father was made to feel ashamed because he couldn't get unaided to the lavatory.'

The issue of institutionalisation is one of particular poignancy for James. Among the most difficult memories of a childhood 'lived on a plateau of apprehension with occasional peaks of acute anxiety or fear' were Saturday visits to her mother, who had been compulsorily admitted to Fulbourn Mental Hospital, Cambridge.

She remembers the driveway up to the hospital and the smell of the drug used to sedate patients which permeated everything. 'The visits were always painful. My mother would sit clutching at her hospital dress with restless fingers, looking at us imploringly and constantly reiterating her wish to come home.'

Many years later she found herself trudging up another driveway on Sundays to Goodmayes Hospital, Essex, where her husband spent much of his last years. She was then living with her in-laws in Ilford, where her father-in-law worked as a GP. 'Connor was never unhappy in Goodmayes, but then, as he said, education at a minor public school and subsequent army service prepared one for anything.'

Despite barrack-like wards, the place did offer genuine asylum, James believes. 'Sometimes the care might have been a little rough and ready, but on my frequent visits I saw no unkindness - and much compassionate and sensitive caring, ' she says.

She is unreservedly critical of community care, believing that it immeasurably increased the burden on families.

'When will we learn not to legislate for, or introduce, so called reforms unless and until we have the means to finance them?'

Depressing as the old psychiatric hospitals were, at least they provided respite for the family, and control, care and support for the patient.

'If there is to be community care there should also be small local facilities providing inpatient and outpatient services for emergency and respite care, ' James argues, and hopes these could be attractive and welcoming 'and seen by the patients as true asylum'.

Institutionalisation and mental illness continue to have particular resonance for her. Reading Birthday Letters, Ted Hughes' tribute to his wife Sylvia Plath, who committed suicide in 1963, James commends Hughes' 'dignified silence' in the face of 'years of calumny' and adds: 'No-one who has never had to live with a partner who is mentally ill can possibly understand what this means. Those who have not experienced this contaminating misery should keep quiet.'

But she does not dwell on difficulties. Created a life peer (Baroness James of Holland Park) in 1991, she considers herself, at 78, 'greatly blessed' and is determined to write until she drops. Her concerns with frailty and resilience persist.

An unsuitable job for a woman?

PD James experienced discrimination when applying for jobs in the early years of the NHS.

'When I went before appointing committees in the NHS to gain promotion I accepted that I would have to be not only better qualified than the male candidates, but considerably better qualified. This discrimination was partly because hospital administration was seen primarily as a male career if only to balance the considerable power that matrons then exercised in the hospital world.'

Novel approach PD James' works:

Cover Her Face A Mind to Murder Unnatural Causes Shroud for a Nightingale An Unsuitable Job for a Woman The Black Tower Death of an Expert Witness Innocent Blood The Skull Beneath the Skin A Taste for Death Devices and Desires The Children of Men Original Sin A Certain Justice