The Doctor - issue 29, January 2022

The magazine for BMA members

thedoctor

Issue 39

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January 2022

A profession in need

New GP leader sets out her vision

Can you learn to be wise?

Untangling the intangible

The unequal burden

Tackling inequalities

The hardest winter

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Doctors report from an exhausted health service

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MATT SAYWELL

In this issue In the news Take part in the BMA council elections

4-9 The hardest winter Doctors report from an exhausted health service, as winter takes hold

10-13 Can you learn to be wise?

We all know wisdom when we see it, but what does it really consist of?

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A profession in need The new GP leader on steering the profession through one of its most difficult times

16-17 Report it, improve it A new campaign to highlight exception reporting, which helps junior doctors in England improve safety and working conditions

18-20 The unequal burden A group of doctors tackling health inequalities head on

21 On the ground A doctor’s return to work was blighted by a manager’s insensitive approach

22 Your BMA Only if we look after ourselves can we do the same for patients

23 Viewpoint COVID staff shortages have weakened the NHS, but so have years of under-investment

Welcome Chaand Nagpaul, BMA council chair I would like to take this opportunity to welcome Farah Jameel to her role as chair of the BMA England GPs committee.

In an interview in this issue of the magazine Farah outlines her plans and ambitions for the specialty and the profession. Dr Jameel comes to the role at a time of great difficulty. Staff have delivered remarkable care and a comprehensive vaccination programme during the COVID-19 pandemic, yet been subject to sniping from the media and shown a lack of care and support by Government.

I know Dr Jameel will, as she says, ‘stand up for general practice’ while also placing patient care at the heart of everything she does. I would also like to thank Richard Vautrey, who stepped down from the role of GPC chair in November, for his remarkable hard work and dedication during four years as chair and nearly two decades as an executive member of the committee. Richard oversaw significant investment in general practice and has been a tireless champion for the profession.

The anxiety and accompanying exhaustion of the COVID-19 pandemic have been with us for nearly two years now and staff working across the NHS are burned out and concerned about their services being able to cope.

The BMA will continue to lobby on public health measures but it is also urgent the Government takes action to protect the workforce and aid recruitment and retention of staff. The requirement for doctors to have proper rest and support has never been more crucial and there must also be short- and long-term measures to address the punitive pension taxation system so senior doctors can work extra hours without fear of significant financial penalty.

Last month we wrote to health secretary Sajid Javid on these issues and we will continue to urge ministers to come forward with serious solutions.

The first issue of The Doctor in 2022 also includes a feature about the value of exception reporting for junior doctors working in the NHS and a piece featuring a duo of doctors who have put together a collection of essays bringing together debates and policies which could drive improvements in health inequalities.

Also in this issue of the magazine we ask what makes a wise doctor, with the help of clinicians Sabena Jameel and Chris Turner.

Read the latest news and features online at bma.org.uk/thedoctor Keep in touch with the BMA online at twitter.com/TheBMA

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IN THE NEWS

YOUR VOTE HELPS: Be an advocate for doctors at work

BMA council: vote to keep democracy healthy BMA members are being encouraged to use their democratic rights to ensure the association works for them, as elections to the 2022-26 council session get under way.

Nominations for the next session of the BMA council are now open, with those eager to represent their profession urged to put themselves forward.

As well as encouraging members to stand for BMA council, the council is stressing the importance of voting in the forthcoming election. It will start on 16 March.

Comprising 55 voting members, the BMA council is at the heart of setting the strategic direction of the association and ensuring policy passed at the annual representative meeting is enacted and is also responsible for the formulation of policy throughout the year.

BMA council chair Chaand Nagpaul said that whether standing for election or voting, participation in the association’s democratic processes was critical to its representative function as a professional body, and its strength as trade union.

He said: ‘The BMA is the UK’s only professional association and trade union that advocates on behalf of all medical students and doctors from every part of the medical profession.

‘With that comes a considerable responsibility to ensure that, as an organisation, we are as diverse and well represented as our profession, and that bma.org.uk/thedoctor

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responsibility lies as much with those casting their votes as it does with those seeking election.

‘I would urge both voters and prospective candidates to remember that engaging in our democratic processes is one of the most critical and important things you can do as a member of the BMA.’ Having opened on 10 January, the nominations process will run until 14 February, with those wishing to stand able to self-nominate online.

Changes have recently been implemented to the voting system, to ensure fairer representation from doctors from minority ethnic backgrounds, representational equality for different genders, and a clearer, streamlined ballot paper.

Candidates are directly elected by fellow BMA members and are drawn from across all UK regions and branches of practice to ensure council is as representative of association membership as possible.

Those wishing to stand for election to council are required to read and adhere to the association’s memorandum of understanding before submitting their nominations.

Once verified, election results are published via the online elections system and on the committee web pages.

For more information, visit bma.org.uk/ councilelections or email elections@bma.org.uk thedoctor | January 2022 03

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GETTYIMAGES

Staff are exhausted and many are off sick in a health service battered by almost two years of the pandemic. There is unprecedented demand and a booster programme to deliver.

And all of this as winter takes hold. Tim Tonkin reports

THE HARDEST WINTER ‘W e are asking a lot more of [the NHS] now as we need to hugely step up our vaccination effort and I do believe they up are to the task.’

This was how health secretary Sajid Javid assessed the then imminent commencement of the COVID vaccine booster programme in response to the growing spread of the Omicron variant of the virus on 1 December last year.

Coming at a time when the health service was entering what has traditionally been regarded as its ‘winter pressures’ period, Mr Javid’s acknowledgement that ministers were ‘asking a lot’ may perhaps have been a late contender for understatement of 2021.

Approximately two weeks after the health secretary’s announcement on the BBC’s Today programme, consultant anaesthetist Danny Wong arrived for work at London’s St Thomas’ Hospital to be greeted by the sight of a queue of hundreds seeking booster jabs stretching as far as he could see.

From Dr Wong’s perspective, however, the booster campaign – which aimed to provide third immunisations to every eligible adult in the UK before the end of 2021 – was not simply the latest vagary of the pandemic, but part of a much wider and long-running source of malaise within the NHS, the chronic shortage of staff.

Fuelled by unsustainable working conditions and punitive approaches to pay and pensions, Dr Wong warned that the recruitment and retention crisis could soon mean that the very concept of ‘seasonal pressures’ during winter could soon become utterly redundant.

‘I’ve never seen morale as low,’ says Dr Wong.

‘It’s been quite upsetting to see a lot of trainees I’ve spoken to feeling very exhausted and even the consultants are feeling very tired and despondent, and I don’t know what immediate solutions there are on offer.

‘It’s hard to imagine that things could be worse, but I can’t see it getting much better if they [the Government] don’t roll out strong

TAILBACKS: Staff prepare to remove a patient from an ambulance parked outside Guy’s Hospital, London

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‘My team is very tired, they’ve not taken annual leave for two years’

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EMMA BROWN

practice’s ability to manage patient demand during the approaching winter.

Meanwhile 85 per cent of GPs and 76 per cent of doctors working in secondary care expressed they were either extremely or quite anxious at the prospect of what the winter period would bring.

Based in the London borough of Newham, GP Farzana Hussain says that, while she is concerned about the potential impact of Omicron, she and her colleagues had been contending with levels of patient demand normally associated with winter months from WONG: Never as far back as the summer. seen morale so low She says her practice had had to respond to an influx of patients with respiratory infections and stomach bugs typically seen during colder months, but which took measures to increase recruitment and retention.’ off once lockdown conditions were eased, as well as a Speaking to The Doctor last month, Dr Wong ‘tsunami’ of demand relating to mental health. explained how his trust was already grappling with ‘Back in August we were already facing “winter increased emergency department admissions, delays pressures”,’ says Dr Hussain. in discharges and a rise in the ‘Now we are beyond a level cancellation of scheduled of pressure that I have ever seen ‘A lot of trainees I’ve spoken to elective surgeries. in 20 years as a GP.’ ‘At the moment the mood With Newham suffering one feel very exhausted’ is very sombre, people are of the highest COVID death anxious,’ says Dr Wong. rates during the first wave of ‘Whilst we don’t know what it [Omicron] will be like the pandemic, Dr Hussain says the borough still has a we have a sense of impending doom in a way and we low vaccine coverage rate. The Newham figures up to are not sure that the steps the Government is taking will 5 January show 68 per cent of the eligible population stem the increase. have had their first dose of the vaccine, compared with ‘We do have the added protections of vaccines, but more than 90 per cent of the UK population as a whole. the people coming through to A&Es with respiratory With the arrival of winter, Dr Hussain says her practice failure are unvaccinated, and that has a knock-on effect is now facing an unprecedented amount of patient need on services in as a whole. coupled with the drive to administer COVID booster ‘We are expecting that if the cases [of Omicron] in vaccinations, with Dr Hussain concerned about what the in the community goes to effect this would have on such an extent as to be way already overstretched primary higher than previous waves, ‘We’re not meeting our demand and care services. even if it was a milder form of ‘When the COVID booster I don’t know any practice that is’ the illness, the overall absolute roll-out was announced I had number of people coming very mixed feelings,’ she says. through our doors will probably still be very, very high.’

‘I was proud to be a GP because I know primary care was chosen again because we successfully delivered over ‘Winter pressures back in August’ 75 per cent of the vaccinations during the first roll-out.

Even before the emergence of the Omicron variant, ‘I was, however, also scared because we do have finite mounting pressures on services and a growing sense resources and my team is very tired, they’ve not taken of disillusionment among healthcare staff were annual leave for two years. We are expecting an awful lot being reported. of our NHS staff and I do feel that something will give, so I The findings of a survey of more than 2,000 doctors am very scared for the winter ahead. conducted by the BMA in November 2021 made for ‘I understand why we would be chosen to do the sobering and alarming reading as to the pressure across COVID booster campaign, but in doing so we end up all parts of the health service. displacing another piece of our work and I am not Seventy-eight per cent of all doctors responding sure there is a huge [public] understanding of that at to the survey said that they were ‘not very confident’ the moment. or ‘not confident at all’ about their department or ‘We’re not meeting our demand and I don’t know any 06 thedoctor | January 2022

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SIMON BOLTON

practice that is,’ she adds.

‘It is not a nice place to be, but I know that all my doctors are working at full capacity.’

More work, fewer doctors Working at the absolute limits of staff capabilities and still being unable to meet demand has become a depressing commonality across virtually the entire health service and becomes all the more alarming when examining NHS performance figures.

HUSSAIN: ‘We are beyond a level Staffing data for general practice released of pressure that I have ever seen in

by NHS England reveals that the number of 20 years as a GP’ full-time equivalent GPs working in England fell by 157 between 30 September and 31 October appointments within two weeks falling from 91 per cent 2021, with the BMA warning that the health service had in October 2019 to 88 per cent in October 2020 and just lost the equivalent of 1,744 full-time, fully qualified GPs 81 per cent in October last year. since 2015.

These service pressures, however, are not confined The picture is no better for secondary care with major simply to England but exist to varying extents across all of emergency departments in England experiencing a total the UK’s devolved health services. of 1,336,551 admissions during November last year, BMA Scotland council chair and consultant compared with 1,036,350 in the same period in 2020. geriatrician Lewis Morrison says that while the situation The number of attendances to emergency departments lasting more than four hours from arrival in Scotland’s health service is often viewed as ‘less awful’ to admission, transfer or discharge more than doubled than that of England, many of the same challenges exist north of the border. from 210,250 in November 2020 to 445,794 in ‘In the context of what’s going on generally in Scotland November last year. right now, winter seemed to start in about the third week of July,’ says Dr Morrison.

Six million waiting ‘We [the NHS] came into this pandemic with a The disruption of the pandemic and long-standing knackered, understaffed workforce. Here we are shortages of staff have led to a titanic backlog of 21 months later and it’s actually a miracle that it’s as unmet care. functional as it is, and that more people haven’t either just Data for referral-to-treatment waiting times for left or gone off on long-term sick because of the pressures consultant-led elective procedures in England show that they’re under.’ a staggering six million patients were waiting to begin In the BMA’s November viewpoint survey, 75 per cent of treatment by the end of October last year, with 312,665 of doctors who responded said that their ability to discharge these patients having already waited more than 52 weeks. patients to adult social care settings had become more Cancer waiting times have also deteriorated with difficult over the previous year. the rate at which GP urgent referrals to first consultant GROWING ANXIETY Number of emergency department attendances in England with a wait of more than four hours from arrival to admission, transfer or discharge

210,250 November 2020 Source: NHS performance figures

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445,794 November 2021

Doctors extremely or quite anxious at the prospect of what the winter period would bring

working in 85% GPs primary care working in 76% Doctors secondary care Source: BMA survey, November 2021

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MORRISON: It’s a miracle the NHS is as functional as it is

A northwest-based obstetrics and gynaecology staff and associate specialist doctor who does not wish to be named says delays in accessing treatment have gradually become all too commonplace but worsened after COVID. She says that, while obs and gynae and other surgical specialties did not necessarily experience winter pressures in the same way as departments such as emergency care, the pressure was felt differently.

Citing the example, she says even a couple of years ago, strict measures were taken in all emergency departments to avoid waiting times beyond four hours, and any such prolonged wait was considered a breach of the standard protocol.

‘Whereas now, waiting times beyond four hours is not uncommon at all – emergency department waiting times have gone through the roof,’ she says.

Working in geriatric care, Dr Morrison says he ‘There has been an overnight wait of around 12 hours recognised this situation all too readily, adding that he and and there has been ridiculous waits for ambulance his colleagues often found themselves in the position of services, sometimes an 18-hour wait for the transfer of struggling discharge patients back to their care homes patients between hospitals. owing to COVID requirements and gaps in services.

‘Emergency department patients, if needed to be He explains that, while the pandemic has resulted transferred to different sites, are also being offered the in many care homes becoming more cautious about choice of using personal transport (if well enough and sending one of their residents to hospital, once an older patient was admitted the process for returning them to a not unsafe) rather than wait for ambulances.

‘Since COVID, patients – after being referred from social care setting could vary hugely. primary services – are waiting sometimes up to one year ‘I think the efficiency with which we turn that around before being seen in specialist clinics. There has been an is probably better now,’ explains Dr Morrison. unprecedented wait for essential but routine surgeries.

‘We did have a situation a few months ago, where ‘I recently saw two patients who were booked last year some care homes would take people back within a day or to have surgery but are still waiting for a date,’ she says. so, and others it was taking us four or five days [and] that ‘Patients are thus attending emergency departments has a cumulative system-wide effect.’ directly to seek advice with the hope of having their treatment expedited, and this is causing more pressure ‘Fantasy’ waiting times on emergency services.

Another significant source of concern for Dr Morrison ‘It is becoming indispensable was the level to which to counsel patients adequately governments were being ‘There has been and appropriately while they honest and transparent with an unprecedented are being booked for any the public over the extent of wait for essential but procedures (be it gynaecological the NHS backlog and system routine surgeries’ surgery or maternity). Patients pressures, adding that such may have to be prioritised as per emergency, and hence an approach risked damaging the relationship between there could be an unexpected wait as outpatient or doctors and their patients. inpatient. This is sometimes very frustrating for the ‘We still have waiting-time guarantees in Scotland, patient and for the staff. which are a fiction right now,’ he adds.

‘We can send you a letter saying you’re on a waiting ‘Sickness, long-term sickness, burnout, staff moving list, but the idea that you’ll be seen and treated within jobs or going part-time, are all contributing to reduced 18 weeks for many conditions is fantasy, and yet we have staff and this then creates pressure in areas where oneto-one care is required (eg, the delivery ward) or where a system which still fuels patient expectation.’ quick turnaround is required (enhanced recovery/postAlong with delayed discharges, fears around delayed operative wards). admission to hospitals is a growing concern for doctors ‘Work pressure also affects planned career in primary and secondary care with 85 per cent of GPs development goals for doctors at all levels but maybe and 78 per cent of hospital doctors telling the BMA’s more for the doctors who are not in training. Job plans viewpoint survey that they were more concerned than are changed to facilitate service but this then affects the they were a year ago.

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SIMONS: Training opportunities being taken away

career progression; eg, through certificate of eligibility for specialist registration for the SAS doctors,’ she says.

‘Some modification in the process of employment of staff, recruitment and GMC registration might help in mitigating the staff crisis during times of pressure.’

Weaknesses exposed The perfect storm of chronic understaffing, plummeting morale and lack of capacity across virtually all sectors of the health service, is something Yorkshirebased foundation year 2 Julia Simons also witnesses on a daily basis.

Dr Simons, who only recently returned to work after contracting COVID on 7 January, says the annual demands on the health service during the winter, coupled with the pandemic, had resulted in continue taking away training opportunities unsustainable pressure on the NHS. from junior doctors, it is only going to result in ‘Winter pressures year on year has been an them not being trained in the way they should unsustainable pressure [and] I think that’s massively be to be able to complete their future jobs,’ exacerbated by the limited warns Dr Simons. social care provision and the ‘The other issue that is ‘This is a workforce that bed blocking that creates,’ recurring, and I think really has been dealing with says Dr Simons. demoralising to junior this crisis for two years so ‘Where I’ve been working doctors, is that their leave people are really burnt out’ [we are] continually fighting for requests are being rejected beds to the extent where it becomes a whole person’s on the basis of the staffing crisis. job just to try and find beds, which is obviously not a great ‘This is a workforce that has been dealing use of a qualified nurse’s time. with this crisis for two years so people are ‘A lot of the beds are then occupied by people who really burnt out, and they desperately need are medically fit for discharge, but there’s nowhere to that leave for their own well-being.’ discharge them to because there aren’t the intermediate With many months of winter still ahead, it is care beds in the community for them to go to. impossible to know exactly how the pandemic ‘So on top of having all of the new admissions [of] and the gigantic backlog in unmet care it helped people who have COVID, you also then can’t get people to generate would unfold across an exhausted who don’t have COVID out of hospital because there are and understaffed health service workforce. no care services available to provide for them.’

For Dr Morrison, however, the debate Dr Simons says that, while her own trust was should no longer be about seasonal pressures managing the challenges posed by Omicron and putting the NHS under strain, but an seasonal illnesses, she knew of other trusts in her region acknowledgement from those in power that that have had to cancel all the crisis is one that was years ‘This is the chickens coming non-urgent outpatient activity in the making. till the end of January, to cope ‘This isn’t winter and it’s not home to roost after years of with demand.

COVID. This is the chickens failing to address recruitment and As well as the effects on coming home to roost of years retention issues’ patients, she warned the and years and years of failing high-pressure, working environments junior doctors to address recruitment and retention issues in have been working in for almost two years had left staff healthcare,’ he says. exhausted and often unable to take annual leave.

‘The warning signs about the degree of She adds that doctors in training are seeing this fatigue and burnout amongst the medical difficult situation being further exacerbated by missed profession are pretty loud and clear [and] opportunities for training, something she believes could running both health and social care so close ultimately stunt the professional development of an to the wire before a pandemic means that entire generation of doctors. the whole system is effectively creaking if not ‘We’re now two years into a pandemic and [if we] already broken.’ bma.org.uk/thedoctor

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CAN YOU LEARN TO BE WISE?

BALANCING ACT: Dr Jameel (left) and Dr Turner 10 thedoctor | January 2022

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Wisdom – we all know it when we see it and perhaps we wait for the day we acquire it. But what if it could be learnt, applied, and harnessed to help doctors in their work? Seren Boyd reports

A

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their talk is humorous, selfdeprecating, applied. Most striking of all, it’s optimistic.

Doing the right thing Dr Turner and Dr Jameel arrived at phronesis from different directions.

Dr Jameel was propelled by a question that vexed her during her medical training and still exercises her now she’s a GP: ‘What makes a good doctor?’ She pursued it through her PhD at Birmingham University, and discusses it still with the medical students she teaches there.

‘As I went through medical education, I felt we were missing something: nobody was talking about the values, goals and motivations of medicine,’ she says.

Dr Turner’s journey began at Stafford Hospital.

He became clinical lead in emergency medicine there just before the Healthcare Commission report into the Mid Staffs scandal unleashed a media storm and a period of intense scrutiny and soul-searching.

His starting point was ‘trying to understand the messiness of people trying to do the right thing, and what makes their decisions right for them. No one chooses to make bad decisions’. It would lead him into a fouryear study about phronesis

and ethical decisionmaking in medicine with academics at the universities of Birmingham, Warwick and Nottingham.

Dr Jameel’s primary focus is professionalism; Dr Turner’s preoccupation is governance and organisational culture.

They don’t always agree but their destination is broadly the same: making the right decision for that patient at that moment in that context, and keeping the patient’s needs front and centre.

At least part of the answer, they believe, is phronesis.

‘We are bombarded with different choices, new technologies, resource constraints, information overload, and we need to navigate our way through all

‘No one chooses to make bad decisions’

JAMEEL: ‘Nobody was talking about the values, goals and motivations of medicine’

ED MOSS

terminally ill patient is distressed, wants to be discharged. His wife insists home is the best place for him. You’re not sure your patient has the capacity to decide – but you’re certain his condition will deteriorate if he leaves hospital. What’s the wise thing to do?

Wisdom is notoriously hard to define and harder still to acquire. But we tend to recognise it when we see it.

Traditionally, in medicine, wisdom has been considered the preserve of older practitioners who have spent decades wrestling with dilemmas and developed the rare ability to know precisely what to do and when.

But what if wisdom could be deconstructed, learnt, even fast-tracked?

Sabena Jameel and Chris Turner represent a growing band of academics and clinicians who dare to believe this is possible. And they’ve converged on a small word packed with promise: phronesis.

It’s an Aristotelian concept loosely translated as ‘practical wisdom’, one that combines practical and ethical reasoning: ‘What is the right thing to do, here and now?’

Reassuringly, Dr Turner and Dr Jameel make no personal claims on wisdom.

Despite the big ideas and big words they have bonded over,

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‘Rigid rules and policies provide a degree of comfort, but the situations people find themselves in are complex and nuanced’

‘We know that appbased medicine does not appear to be wise medicine’

these different issues,’ says Dr Jameel. ‘Wisdom adjudicates where values conflict.’

Beyond the guidelines This isn’t the place to wade out into the intellectual depths of Aristotelian ethics.

Suffice it to say that Dr Turner and Dr Jameel believe that the framework for decisionmaking – and indeed medical education – is based on too narrow a definition of knowledge.

Dr Turner and Dr Jameel repeatedly underline that scientific knowledge (episteme) and technical expertise (techne) are important – but not the complete answer to the competing priorities of modern medicine.

They’re frustrated by the system’s stubborn focus on guidelines, principles and SOPs (standard operating procedures) that dictate ‘this is how it should be done’. More space should be made for phronesis or ethics in action.

Dr Jameel explains: ‘Let’s say, I have a patient who’s 72 with a new diagnosis of severe hypertension. I know the guidelines. But I also know the randomised controlled trials and the evidence base never studied people of 72 with renal malfunction, like my patient. I also know their spouse had a bleed on the brain because of hypertension and my patient’s petrified they’ll follow the same path.

The guidelines are important but these contextual things absolutely matter too. So it might mean putting them on a different medication from the one the guidelines suggest – and giving them a lot of reassurance.’

Dr Turner, now a consultant in emergency medicine in Coventry, believes there are exceptions to every rule, and medicine needs to be more honest about this. He cites the example of a policy of zero tolerance to abuse. ‘Many of us will have been hit by a confused elderly patient or by a patient who is postictal,’ he says. ‘We don’t apply zero-tolerance: instead, we understand the behaviour contextually and make accommodations.

‘Rigid rules and policies provide a degree of comfort, but the situations people find themselves in are complex and nuanced, and there is no policy that fits everything. We ask doctors to try to tread a wise path. If we simply asked people to just follow the rules, then we could have an app.

But we know that app-based medicine does not appear to be wise medicine.’

Prized characteristics Dr Jameel and Dr Turner have tried separately to break wisdom down into its component parts. For both, this has involved interviewing medical professionals about what they consider to be the characteristics of wise doctors.

Then, each has devised a framework and a language intended as a practical tool to help clinicians recognise wisdom and reconstruct it in their own practice. ‘A big part of wisdom is being able to articulate how you got there,’ says Dr Turner.

Dr Turner and his academic colleagues, led by Dr Mervyn Conroy, have devised what they call a ‘starter set’ of 15 characteristics – from

being courageous to resilient to reflective. Each is presented as a midpoint between two extremes – akin to Aristotle’s Golden Mean. So, the midpoint between ‘doctor decides’ and ‘patient decides’ is ‘negotiate with patients/carers’, and the ideal between being ‘too involved’ and ‘aloof’ is ‘being emotionally intelligent’.

Phronesis lies in establishing where that sweet spot lies. ‘In a consultation, we’re like graphic equalisers, deciding where to act between the two extremes,’ says Dr Jameel. ‘If somebody is misusing controlled drugs, I can’t be overly compassionate and dish drugs out to them, because I'm feeding their addiction. So, I might push the dial more towards being stern. You do what you think is necessary in that context.’

The key to this contextualised, more nuanced decision-making is discussion, debate and drawing in as many different perspectives as possible, from different roles and ranks, believes Dr Turner.

To this end, the research project he was involved with produced a series of films presenting health and social care dilemmas in the fictional town of Stilwell. They’re intended as ‘a moral-debating resource’ for medical schools and staffrooms.

It’s a practice embedded in the department where Dr Turner works. ‘For example, at the moment, ambulances are queuing up outside because hospitals are full,’ he says. ‘So we had a conversation about whether we in the emergency department should be providing care in the back of ambulances.

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‘The first senior clinician spoke beautifully about why we should; a second spoke beautifully about why we shouldn’t. The harder the question, the more that time, effort and hunting for other perspectives become key components of trying to make the best decision.’

Time constraints and system pressures are obstacles to debate. Dr Turner regrets the demise of places such as the senior staffroom which, ‘though perceived as elitist’, were safe spaces where juniors learnt from consultants, trading experience and ideas about complex cases.

Case discussion forums focusing on practitioners’ emotions, such as Balint groups, are important, says Dr Jameel. If time and space are not made for these constructive, contextual conversations, doctors are left feeling isolated and vulnerable in their decision-making.

Living with uncertainty For Dr Jameel and Dr Turner the pursuit of wisdom is ‘the ultimate continuing professional development’.

Dr Jameel’s PhD research established a set of character vignettes and a conceptual framework for how wise doctors think, based on the biographies of GPs who scored highly in a wisdom questionnaire. She hopes they might act as ‘role models’ and learning tools for others.

However, her focus is wider. Her teaching prioritises self-awareness as a key component of wisdom, giving credence to values, feelings and opinions. Though her research found wisdom bma.org.uk/thedoctor

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correlated with age, older doctors were not necessarily wiser; Dr Turner’s research concluded the same.

Some of Dr Jameel’s ‘wise doctors’ were trainees who had turned tough life challenges to good.

One of Dr Jameel’s key findings was that wise doctors all had ‘the ability to live with a high degree of uncertainty’.

She also found that wise doctors’ ability to chart a course through uncertainty was linked to a strong sense of motivation, the desire to see the patient flourish.

The quest for good, the ‘purposeful journey’ at the heart of phronesis means justice and compassion are highly prized. Restored to their rightful place, maybe.

‘We can get so tied up in micromanagement, bureaucracy, audits, that we don’t have time to hold a patient’s hand,’ says Dr Jameel.

‘People are scared to use words like this in medicine, but I think it’s about love for humanity.

For me, excellence lies in the humanity of the situation, that connection between human beings.’

She and Dr Turner have

found that studying phronesis has changed their practice: they now prescribe less medicine. ‘Less intervention, more connection,’ as they put it. One important expression of this is the ReSPECT form (Recommended Summary Plan for Emergency Care and Treatment).

Wisdom can look very different from different perspectives and value sets, Dr Turner acknowledges.

A junior doctor may focus on getting the right diagnosis and treatment, while a senior doctor may also have to consider bed shortages; a manager may introduce questions of cost and rationing.

‘But we must always remember that at the core generally are two human beings: a doctor and a patient.

It’s about you and me working together towards what’s right and best for you.’

TURNER: There are exceptions to every rule

‘For me, excellence lies in the humanity of the situation, that connection between human beings’

thedoctor | January 2022 13

17/01/2022 09:27

MATT SAYWELL

JAMEEL: ‘There is a profession on its knees and ready to fight for its existence’

Farah Jameel is the first woman to chair the BMA England GPs committee. She tells Peter Blackburn about leading the profession through one of its most difficult periods

A p rofe s s i o n i n n e e d ‘I

t’s a huge privilege. But it is also a huge responsibility – and there is a great weight on your shoulders.’

Farah Jameel is under no illusions about the scale of the task ahead, nor the importance of the moment.

The new chair of the BMA England GPs committee has been met with a to-do list of some length – an in tray with a seemingly endless list of items marked urgent. Another wave of the COVID-19 pandemic means GPs have been asked to step up again to lead the vaccine programme: the dwindling workforce and soaring workload has left doctors exhausted and the Government has failed to provide the meaningful support which could transform services and patient care.

Perhaps most pressingly of all GPs across the country feel burned out – having given so much to patient care and the vaccination programme during the pandemic only to find themselves victims of

smear campaigns from the media and tone-deaf communications and policy from Government and national NHS leaders.

‘We are angry, disappointed and upset,’ Dr Jameel says. ‘Despite pouring their hearts and souls into looking after patients – and make no mistake it is heart and soul – it feels we have had no recognition from the Government.’

Extreme pressure Dr Jameel, who has worked in practices across the country from Surrey to Filey, and Brighton to London, has felt the strain personally, as so many others have.

‘As someone who, like most of my colleagues, came into this profession to care for our communities and advocate for our patients, I have found recent months and years increasingly difficult,’ she says.

‘A decade of austerity combined with the incredible challenges of this pandemic have left us

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17/01/2022 09:26

with our hands tied and our options diminished. Like ensure a focus on new priorities, the results of the so many of my colleagues I face regular dilemmas ballot have further crystallised Dr Jameel’s instincts over how much time to give to patients who need to look to the future and, crucially, to find solutions to mental health support, social care or the dedicated the problems the profession faces. expertise of public health services but can only Dr Jameel says rebuilding the workforce and make an appointment with their GP. Often it feels placing well-being at the heart of everything are like we are the only people, the only professionals, central to the work she wants to do. And alongside on hand to lend an ear, to have a conversation or to those priorities she intends to focus on giving GPs try to help. The pressure of feeling so needed but ‘time to see the patients who need them the most, having countless consultations every day – each a time to lead their teams and time to keep up to date human being with their own unique story – can be with progress in healthcare and to innovate’. genuinely crushing.’

Dr Jameel follows Leeds GP Richard Vautrey in Urgent action needed the role. Dr Vautrey stepped down in November Dr Jameel also intends to use data to explain having been chair for four years and part of the more powerfully the work GPs are doing in their GPC negotiating and executive teams since 2004. communities in a bid to alter negative narratives from Paying tribute to his work, Dr Jameel says: ‘Richard media and Government. sacrificed his entire life in the dedication to improving All of these priorities come together around one the working lives of GPs and, through that, improving primary focus. Dr Jameel says: ‘What really matters in the services for patients general practice is how we ‘The pressure of feeling so across the country. He is can be empowered to look an extremely hard-working after our communities, really needed but having countless individual, a thoroughly make a lasting difference to conversations every day ... can decent human being, outcomes – improving their be genuinely crushing’ who has continually and lives and lifting them up. robustly made the case for GPs, practices, services We have such a significant role to play in shaping the and patients.’ health of our nation, but for this to happen we need to Dr Jameel’s arrival in the role coincided with a embed the right culture, commit appropriate support, decision having been made to survey the profession provide the right infrastructure and create the right environment that will allow general practice to thrive in the face of the extreme difficulty GPs were facing. and grow.’

The indicative ballot gave one vote to each practice In that LMCs conference speech, Dr Jameel with a GP partner who is a BMA member. The window said ‘the profession has had enough’ and that for this process gave practices just two weeks to ‘relationships are broken and trust has been lost’, respond, yet returned a turnout of 35 per cent. before telling colleagues The ballot revealed the that ‘enough is enough’. frustration and difficulties ‘It is time for ministers to demonstrate Years of under-investment, staff face. Eighty-four per a lack of care and the brutal cent of respondents said the sort of care and compassion we do’ experiences of the pandemic they would welcome nonhave left general practice compliance with COVID on its knees. And, for Dr Jameel, urgent action is exemption certificate requests, 80 per cent said they required immediately. would change the way they reported appointment Addressing the Government, Dr Jameel says: data, 58 per cent said they would support withdrawal ‘It is time for ministers to demonstrate the sort of from the PCN (primary care network) DES (direct care and compassion we do – and are expected to enhanced service) at the next opt-out period and do – on a daily basis by listening to the profession, 39 per cent said they would be willing to disengage understanding our struggles and showing from the PCN DES before the next opt-out period. appreciation for everything we have done. I want to In a speech to the profession at the English local offer the Government the chance to work together to medical committees conference last November, build general practice back better.’

Dr Jameel, who came to the UK from the UAE in 2007 Speaking to the profession, Dr Jameel says: ‘I will ‘in search of a genuinely equitable health service’, make the case for general practice and I will do that said: ‘Make no mistake. This is a profession on its in a way that carries our patients at the heart of knees, and ready to fight for its existence.’ everything we do.’

If election as new GPC leader was not enough to bma.org.uk/thedoctor

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thedoctor | January 2022 15

17/01/2022 09:26

REPORT IT, IMPROVE IT

Exception reporting enables junior doctors in England to raise concerns and help improve working conditions and patient safety. Jennifer Trueland reports on a campaign to increase awareness which highlights successes

I

t started with an exception report…

When Eva Wooding was concerned that junior doctors in her department weren’t being allocated the time due for administrative tasks, she knew she needed to take action – but what?

‘It was affecting quite a few trainees and I’d already raised it locally with the appropriate people,’ she says.

‘It was proving really difficult to incorporate it in the rota, alongside both [rota] gaps and service provision challenges.

So I spoke to a BMA rep and they suggested exception reporting, which I did. It proved a really effective way of opening a dialogue quickly with the people who have the power to make change.’

Exception reporting was introduced as part of the junior doctor contract in 2016 in England. Essentially it’s a way of providing juniors with a means of raising concerns in real time about deviations to their work schedule, which is an agreement setting out working hours, training and education. The aim is to allow trainees to raise specific issues affecting them as individuals, but also to help departments identify and address systemic problems, for example with understaffing, or poorly drawn up rotas.

Safety guardians The junior doctor contract requires guardians of safe working to present exception

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SARAH TURTON

WOODING: Talks about improvements started ‘within days’

‘I’ve been reassured by a number of people that it was the right way to go about it’

reporting data to the boards of the employing organisation, and also to local negotiating committees. This is to ensure that the information can be publicly scrutinised.

Consultant anaesthetist Pardeep Gill is guardian of safe working at Ashford & St Peter’s Hospitals. He says his trust has almost managed to eradicate missed educational opportunities for trainees – and that the exception reporting process is critical.

‘You need a strong exception reporting culture in your organisation,’ he says. ‘Doctors need to feel empowered to exception report. At induction, I talk to all new junior doctors, and I emphasise that to exception report is not just a personal responsibility but also a professional responsibility.

It will improve their working conditions, but also improve patient safety.’

Immediate effect

‘It proved a really effective way of opening a dialogue quickly’

Dr Wooding and Dr Gill feature in a BMA campaign to raise awareness of the value of exception reporting.

It shares positive messages about the change that has been achieved when junior

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doctors have taken the exception reporting route (see ‘Exceptional success’).

In the issue highlighted by Dr Wooding, who is a specialty trainee 2 in paediatrics in Exeter, she reports being initially unsure about raising her concerns via an exception report, but that a conversation about making improvements started ‘within days’. ‘This led to changes being made not just for trainees in my specialty, but for all trainees working on those rotas going forward, to make sure that time was appropriately ringfenced and allocated,’ she says. ‘I felt a bit nervous about using exception reporting in that way, but I’ve since been reassured by a number of people that it was the right way to go about it, and it certainly was very effective in my case.’

When the issue of missed educational opportunities

was raised via exception reporting, Dr Gill reports, it was addressed by good collaborative working between junior doctors, rota coordinators and clinical leads.

‘They did a number of things. They redesigned the rotas so there was a better spread of junior doctors through the week. They simply changed the teaching day – and that seemed to suit more doctors. They also reduced some remote learning and all these changes culminated in a significant reduction [of missed educational opportunities].’

As guardian, his role is to act as a facilitator, he adds.

‘I do not write rotas. My job is to identify a problem and get the right people in the room to discuss it. I hope I’ve given you some useful ideas to address issues you’ve come across in your own trust.’

Exceptional success

Junior doctors who have benefitted from making reports ‘I was unable to take breaks on a long day. There’s now been rota changes’ – junior doctor in Leeds ‘We now have more support on wards when SHOs are on nightshifts’ – junior doctor at Royal Surrey County Hospital ‘Urology weekends used to be 8am to 4pm but now are 8am to 8pm as people never finished at 4pm’ – junior doctor at Portsmouth Hospital University NHS Trust ‘We miss far fewer educational opportunities now that juniors, rota coordinators and clinical directors collaborate’ – junior doctor at Ashford & St Peter’s Hospitals NHS Foundation Trust

thedoctor | January 2022 17

17/01/2022 09:26

The unequal burden

GETTY IMAGES

STANLEY: Need to capture hearts and minds of the public

18

BRADLEY: Do more to help people overcome barriers they face

PATEL: Seeks ‘new political vision’

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SARAH TURTON

The chasm between the life chances of rich and poor is a huge determinant of health in Britain. Frustrated by feeling they were ‘tinkering around the edges’, a group of doctors is determined to address inequalities head on – with a focus on presenting solutions.

Peter Blackburn reports

T

he striking moment of realisation for Tom Gardiner came when he scanned the beds in the respiratory high-dependency unit of the London hospital where he was working: in every single one was a patient from an ethnic minority background working in an occupation where protection from COVID-19 was minimal.

Dr Gardiner, only recently graduated from medical school, saw no white patients, and none who had been able to work from home, protected by the privilege of more ‘professional jobs’. These people were bus drivers and security guards continuing to do their jobs as society desperately needed them to, but left vulnerable and at risk.

‘Sometimes you can feel a sense of helplessness,’ Dr Gardiner, who is taking a year out following his second foundation year to work in healthcare policy, says. He explains the overwhelming sense doctors sometimes feel, which is that while they are often treating symptoms, they are unable to do much about the causes of illness – in this case the socioeconomic and health inequalities in society.

He adds: ‘So much has happened before that patient comes into your clinic or your hospital ward. That is difficult. It can be quite morally distressing.’

Alarming co-morbidities Steve Bradley looks back on a similar moment where everything just clicked. Driving to work at a GP surgery in a deprived part of suburban Leeds one day, he heard Sir Michael Marmot discussing bma.org.uk/thedoctor

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one of his landmark reports on BBC Radio 4’s Today programme. ‘The way he expressed things so clearly was revelatory to me,’ Dr Bradley says.

It wasn’t that Dr Bradley, who now works in a Leeds GP practice predominantly providing care for asylum seekers, recent migrants and homeless people, was unaware of the stark health inequalities Sir Michael was discussing, but rather that someone was describing what he saw in his day-to-day work with such clarity, ‘so bluntly’.

‘I remember regularly having the experience of looking at the screen, pulling up someone’s notes, as you do in general practice when calling a patient in. I was often struck by how much older people looked and how unwell they looked for their age. And then you looked at the summaries and the list of co-morbidities which was alarming.

It was all quite jarring.’

It is these experiences – and the exacerbating and illuminating effect COVID-19 has had on health inequalities – which have led Dr Gardiner and Dr Bradley to organise a collection of essays from leading experts across health, care and related fields, with the stated aim of discussing and presenting policy solutions to health inequalities, rather than simply describing the problem.

‘Our role as doctors is often mitigating against much of these health inequalities but it can be frustrating when it feels you are just tinkering around the edges while there are much bigger causative elements here that can be tackled and can be improved,’ Dr Bradley says.

Junior doctor Parth Patel is one of the

GARDINER: ‘Morally distressing’ to be unable to address the root causes of illness

‘I was often struck by how much older people looked and how unwell they looked for their age’

thedoctor | January 2022

19

17/01/2022 09:25

EMMA BROWN

RAO: Contributor to policy solutions

‘We need to move away from a false sense of an even playing field’

‘Health inequalities exist, are unfair and need to be addressed’

contributors to the collection of essays, which also includes pieces from the health foundation’s director of research and economics Anita Charlesworth, former NHS England chief executive and independent member of the House of Lords Nigel Crisp, professor of operational research at University College London Christina Pagel and senior clinical fellow at the department of primary care and public health at Imperial College London, Mala Rao (an interview with whom will appear in a future issue). The essays covered a vast array of topics and how they interact with health inequalities, from climate change to early years support for children and the workplace to science and innovation.

Dr Patel is a research fellow at the IPPR think tank, works at the UCL Institute of Health Informatics on COVID, and locums in emergency departments. His essay argues that the same policies are required to dismantle structural racism and to reduce economic and health inequalities. Speaking to The Doctor, he says seeing the unfairness of the tragedies of the pandemic had led him to begin working in this area of health inequalities and moving to UCL to work on national COVID research studies. He says: ‘It was one thing reading the numbers in the papers but another doing the academic research yourself and seeing in the day-to-day work how different people’s outcomes were based on quite arbitrary demographic features.’

Dr Patel adds: ‘The problem with health inequalities is some people get to live longer and lead healthier lives than others and the problem with structural racism is some people are more likely to have a particular job, for example. When you follow these things to the core they come down to the distribution of economic resource and the ability to have a healthy life, a good and meaningful job.’

Dr Patel argues that while society has mostly, at least in a shallow sense, accepted that these inequalities are not caused by people’s individual choices, rather the circumstances in which they live, that understanding isn’t echoed in policy decisions. ‘Whether it’s anti-racism training or educating people or weight loss classes and calorie counting. These are policies that rely on

individuals changing behaviour even though we agree these problems are bigger than the individual,’ he says.

Personal Everests These are some of the themes Dr Bradley sees in his daily working life. One patient’s reduction in alcohol consumption or progress with a drug replacement programme should be considered an incredible success. When that is taken alongside their amassed trauma and ongoing circumstances, that is even more significant.

For that patient, with so much stacked against them, those victories are like scaling Everest.

‘We need to move away from a false sense of an even playing field when there isn’t one,’ he says.

‘We need to do more for some people because of the barriers they face.’

Also in the collection of essays, executive director of not-for-profit organisation FrameWorks Institute Kate Stanley says doctors and health organisations need to tell the story of health inequalities in a way which captures the hearts and minds of the public in order to drive improvements. She adds: ‘We found the most effective way to explain that to some people around health inequalities is that, ultimately, some people are dying earlier than others based on where they live. That really increased their support for action to address inequalities.’

The BMA has long campaigned on issues around health inequalities. Immediate past president and former chief medical officer for Scotland, Professor Sir Harry Burns, recently led the association’s production of a health inequalities toolkit. It supports doctors and medical students across the UK to get involved in reducing health inequalities in their local area, using case studies of initiatives all over the country which have helped communities and disadvantaged groups of people.

Where the BMA and Dr Gardiner and Dr Bradley are concerned it is clear the time for action on health inequalities is overdue. As Dr Bradley says: ‘We wanted to put together a project where we would take the problem as read – that health inequalities exist, are unfair and need to be addressed, and wanted to challenge people to think about the potential policy solutions that could make a real difference. We see this as a starting point.’

Read the essays at https://fabians.org.uk/ wp-content/uploads/2021/09/Prescriptionfor-fairness-web-file.pdf

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on the ground

GETTY IMAGES

Highlighting practical help given to BMA members in difficulty

A doctor’s post-operative recovery and return to work was blighted by a manager’s insensitive approach

A consultant felt stressed and threatened when she was recovering from an operation, because of the intrusive and insensitive approach adopted by her manager.

The doctor needed an extended period of time off work for an operation and her subsequent postoperative recovery. The trust’s guidance for managers is to be ‘sensitive and supportive’ when contacting staff who are taking sickness absence.

However, this was not our member’s experience. Instead, the manager contacted her to arrange hour-long Teams meetings, which she found unnecessary.

The doctor had an extended phased return, which was helpful. However, upon her return to work, the manager informed her that her ‘Bradford Score’ was too high.

This is a tool commonly used by HR departments to monitor absence. It is geared so that several, shorter absences generate a much higher score than a single, longer one of the same overall duration. It has been called a ‘blunt instrument’ (and worse) by employees. While it was designed to highlight

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regular callers-in-sick, it can penalise those with disabilities or who need long recovery periods, particularly if used by managers who fail to take any other factors into account.

In this case, the consultant was advised by the manager that he would continue to monitor her with regular fortnightly meetings until her score dropped below 100, and that one more absence would trigger a formal process. This was never put into a written warning, however.

There was further confusion in that the manager’s version of the return-to-work form included her Bradford Score on it while the one available to staff through the intranet, did not.

When the doctor contacted the BMA for advice, she indicated that she felt completely unsupported upon her return to work and that she was anxious and uncertain as to what, if any, policy the manager was following.

As a consequence of this contact, the BMA adviser and IRO (industrial relations officer) met with the HR department, and the response from them was reassuring.

There was recognition that the policy needed to be reviewed.

It was agreed that more training for managers was required. Specifically, it was accepted the Bradford Score was only one of a number of indicators, which was not appropriate to use in all cases, and should not have been used in this one.

Following the meeting with HR, the IRO, who leads on policy negotiations and takes on collective cases, is working with the local negotiating committee at the hospital to ensure the necessary changes take place. It means the case is not just being dealt with as a one-off, but steps are being taken to ensure other doctors are not treated in the same way in future.

For the adviser and IRO, this was also about giving the doctor confidence to speak up in future. She had not felt able to question or challenge her manager until she had met with the BMA, and had affirmation from them that his approach was unacceptable.

She received friendly, expert support at the time she needed it most.

To talk to an adviser about work-related issues, call 0300 123 1233 or email support@bma.org.uk thedoctor | January 2022 21

17/01/2022 09:25

Your BMA Only if we look after ourselves can we do the same for patients It’s that time of year again. The new year is stretching out ahead of us and you may be reflecting on the year that has passed and the things you might like to change in the coming months.

For 2022 I have decided to make a resolution that I will try to stick to, and I would like to encourage healthcare staff and their leaders and organisations who hold sway over their lives to do the same. My new year’s resolution is to focus on well-being. To really, and seriously, look after myself.

It is nearly two years since the onset of this pandemic and I don’t think any new year’s resolution could be any more important.

A BMA survey at the end of November revealed the extent of the daily pressure staff in the NHS are under. Three quarters of hospital doctors said they had experienced increased delays to discharge and more than 80 per cent said they had seen more delays to admission.

Eighty per cent said they were more concerned patients may suffer avoidable harm owing to delays.

Forty per cent of doctors asked how confident they were about their department or practice’s ability to manage demand during winter said they were not at all confident and a further 38 per cent said they were not very confident.

Our surveys are backed up by the anecdotes we are hearing at the BMA. From the doctors who feel the risk they are managing is overwhelming, to the staff being told to work despite testing positive for COVID on lateral flows. Our members’ experiences tell the story of a profession that is burned out – a workforce that is stressed and broken.

The workload and the day-to-day struggles in our hospital wards, community services and GP practices would be difficult enough, but we’ve all had to deal with this pandemic on a personal level, as well.

I, personally, have found these 22 or so months tough. During the pandemic I found out I was pregnant,

@drlatifapatel and I was instructed to work from home. I felt isolated and locked in just like many of our clinically vulnerable patients and their families that I was looking after while working as a paediatric respiratory junior doctor.

As a pregnant woman I shared their fears of going outside, of catching COVID, I worried about my baby and I being more vulnerable owing to my minority ethnic background and then there were months of uncertainty and confusion around whether it was safe, or encouraged, for people in my situation to have the vaccine.

Quite soon after beginning maternity leave, I also unexpectedly had to step up to become a chief officer at the BMA. I have tried to do the best by our baby and family all while grappling with being a new mum during a pandemic, during lockdown and balancing this against ensuring we represent our members. It’s been quite a challenge.

Only if we look after ourselves – if we are looked after – can we do the same for our patients. Only if we lead nourishing lives, if we can find a work/life balance and have the time and health to connect with the things we love, can we provide the sort of care and compassion that drove us into this vocation.

If you are struggling, please reach out. I’m personally contactable by email – rbchair@bma.org.uk – and Twitter and the BMA has wonderful support to offer.

You can call our First Point of Contact teams and we have free and confidential 24/7 counselling and peer support services open to all doctors and medical students regardless of BMA membership and their dependants. Your well-being is so important to us.

Please do not suffer in silence and please look after yourself. And if there is anything your BMA can do to help – tell us.

Dr Latifa Patel is interim chair of the BMA representative body bma.org.uk/yourwellbeing

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viewpoint thedoctor

Absenceminded COVID staff shortages have left hospitals on their knees – but years of under-investment have made it harder for them to cope with such crises You might remember a scene from The Lord of the Rings: The Fellowship of the Ring in which our heroes are inside a mountain fortress.

The previous occupants, long dead, have left behind a journal, in which an increasingly frantic series of entries relate the incursion of the attacking Orcs, getting ever closer. It ends with the scrawled words ‘They are coming…’

At that moment, it becomes clear that the enemy are very much still there.

I thought of that journal this morning as I read the handover notes. Outside the sanctity of the partitioned space we laughably call an office, there is not an army of orcs; they are people, in need, and most of them are perfectly pleasant and extremely patient.

But there are lots of them – people with COVID, people in some ways affected by COVID without having it, and that small group of others who we sometimes forget, the ones who have all the other diseases and conditions known to mankind.

And there are very few of us. Our senior house officer is isolating. Her replacement, a locum, was unable to start work yesterday because her mother is unwell with COVID. And her replacement has gone to the wrong hospital because of an error by HR and the wrong hospital now very much wants to

The Doctor

keep him. We have just over a half of the usual number of nurses, even fewer porters, and no one is sure if we have any radiographers at all.

I spent Christmas avoiding every party and almost all family gatherings because I was afraid of catching COVID, not for myself as a vaccinated and healthy 30-something, but for its effect on my hospital.

A lot of my colleagues did the same. I also did it because, when I tested positive in September, I was told rather tartly by a manager that it was the ‘worst possible time’ for me to be off.

The manager might consider this to be a worse-than-worst possible time. But he’s off with COVID so we don’t know.

It tends to be the weaker and more vulnerable patients who suffer the worst effects of COVID – and it’s the weaker and more vulnerable healthcare systems that suffer the most too.

The NHS was exhausted before the pandemic – understaffed, under-resourced and undervalued by its political masters. It has performed heroically.

But this feels a cruel, if inevitable, outcome – the NHS has gone and caught the virus it has been so heroically battling, and it has caught it good and proper.

We’ll get through it. There’ll be no Gandalf appearing for us on the horizon, just an everlonger queue of ambulances. But in my hospital at least, there’s understanding and gratitude from patients, and quite a few even offer to help us out.

I just ask this of the politicians – the next time you send us out to battle please do not, like some terrible anxiety dream, send us out with nothing to wear, no way to protect ourselves. I’m not saying we will win every battle, but give us a chance, at least.

Matthew O’Neill is a junior doctor in the north of England. He writes under a pseudonym

Editor: Neil Hallows (020) 7383 6321

BMA House, Tavistock Square, London, WC1H 9JP. Tel: (020) 7387 4499

Chief sub-editor: Chris Patterson

Email thedoctor@bma.org.uk Call a BMA adviser 0300 123 1233

Senior staff writer: Peter Blackburn (020) 7874 7398

@TheDrMagazine @theBMA The Doctor is published by the British Medical Association. The views expressed in it are not necessarily those of the BMA. It is available on subscription at £160 (UK) or £225 (non-UK) a year from the subscriptions department. All rights reserved. Except as permitted under current legislation, no part of this work July be photocopied, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical or otherwise without the written permission of the editor. Printed by YM Chantry. A copy July be obtained from the publishers on written request.

The Doctor is a supplement of The BMJ. Vol: 376 issue no: 8322 ISSN 2631-6412

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Staff writer: Tim Tonkin (020) 7383 6753 Scotland correspondent: Jennifer Trueland Feature writer: Seren Boyd Senior production editor: Lisa Bott-Hansson Design: BMA creative services Cover photograph: Simon Bolton Read more from The Doctor online at bma.org.uk/thedoctor

17/01/2022 10:35

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The fund itself meets annual charges of 2.5%.

Your investment return is purely in the form of holidays and, as with most investments, your capital is at risk.

You can surrender your investment to the company after two years or more (subject to deferral in exceptional circumstances) but you will get back less than you invested because of the charges referred to above, as well as other overheads and changes in the value of the fund’s properties and securities.

This advertisement is issued

by HPB Management Limited (HPBM) registered at HPB House, Newmarket, Suffolk, CB8 8EH. HPBM is authorised and regulated by the Financial Conduct Authority and is the main UK agent and the property manager for HPB, issued by HPB Assurance Limited (HPBA) registered in the Isle of Man and authorised by the Financial Services Authority there. The Trustee of HPB is Equiom (Isle of Man) Limited, registered at Jubilee Buildings, Victoria Street, Douglas, Isle of Man, IM1 2SH. The Securities Manager is Stanhope Capital LLP of 35 Portman Square, London, W1H 6LR. No medical examination required. HPB is available exclusively through HPBM. HPBM promotes only HPB and is not independent of HPBA. Holders of policies issued by HPBA will not be protected by the Financial Services Compensation Scheme if the company becomes unable to meet its liabilities to them but Isle of Man compensation arrangements apply to new policies.

17/01/2022 09:23