The Doctor – issue 45, July 2022

The magazine for BMA members

thedoctor

Issue 45

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July 2022

Against all odds A story of determination to become a doctor

Cradle to grave GPs on achieving continuity of care

Patient safety fears Doctors warn over new triage system

A grisly trade

The legacy of Burke and Hare

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MATT SAYWELL

In this issue 3-5 At a glance: ARM2022 News from the BMA annual representative meeting

6-9 Cradle to grave The benefits to patients and the profession of continuity of care

10-11 Dignity at work The push for better provision of sanitary care at work

12-13 The body of knowledge When the demand for cadavers was insatiable

14-17 Against all odds Medical student Alexandra Adams’ struggle against adversity

18-19 A trusted voice How the BMA board of science helps make Britain safer and healthier

20-21 Triage system in question New referrals process may risk patient safety, doctors warn

22 Your BMA The next steps after the ARM

23 On the ground Pay docked over an employer’s mistake

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Welcome Phil Banfield, BMA council chair Dear members, colleagues and friends. I am humbled to be elected BMA council chair – and to be taking up this monthly column from my predecessor, Chaand Nagpaul, in our award-winning magazine, The Doctor.

It’s a real honour to be the next person to take on this privileged position.

I am an obstetrician in north Wales, an academic and a trade unionist.

My promise upon taking this position is simple – I will be honest and straightforward with you because I detest hypocrisy and double standards.

I am here to serve you, the members.

This is an incredibly difficult time for those of us working in the health service. The system itself and the staff working in the NHS have been seriously undervalued. This failure of Government and of our national leaders is having a direct effect on the wellbeing of doctors and patient outcomes.

My priority in this role will be to stand up for doctors. In doing so we stand up for our patients and the NHS. I will endeavour to make sure the public understands why so many are leaving the profession and why you are angry and frustrated.

Pay and working conditions have been eroded too far; it is time that we make our demands clear and act decisively. Our strength is as a united profession.

Under my leadership the BMA will be a powerful voice for doctors as a trade union and a professional association. It is time to act, and we will deliver.

In this issue of the magazine we look at many crucial issues facing the NHS and our profession.

Among other pieces, we have an exclusive feature with GPs warning about patient safety owing to a new triage system for referrals, an analysis of continuity of care and an interview with a doctor who is wrestling with physical challenges many of us couldn’t even imagine.

Also in this edition of the magazine we bring you some of the moments from the BMA annual representative meeting 2022.

Let us be clear on what we want to achieve and join together to make it happen.

Keep in touch with the BMA online at twitter.com/TheBMA

instagram.com/thebma

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AT A GLANCE

ARM2022

News from the BMA annual representative meeting EMMA BROWN

Doctors are walking away, outgoing BMA chair warns

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he Government is ‘exploiting a well of goodwill which has totally run dry’, former BMA council chair Chaand Nagpaul has told doctors.

Giving his final keynote speech at the BMA annual representative meeting, days before his five-year term came to a close, Dr Nagpaul warned that doctors were exhausted, with thousands of vacancies, and many more planning to retire early.

With 6.5 million patients on the waiting list, the Government should not be risking losing even more doctors from the workforce with derisory pay awards, long and unpaid overtime and no hot food or free parking.

‘Doctors will, and are, walking away,’ he told the meeting in Brighton.

Two and a half years into the COVID pandemic, with more than 190,000 deaths in the UK, Dr Nagpaul said lessons needed to be learned now, rather than having to wait years for a public inquiry to report.

He said: ‘We took matters into our own hands with our lessons-learnt review.

We’ve published the most comprehensive account of the lived experience and testimonies of tens of thousands of doctors.

It unequivocally concludes that the UK Government failed in its duty to protect its workforce. The lessons from our review demand action today – not sometime in the future – given that a new surge, variant or virus could strike at any moment.’

Dr Nagpaul said there should be guarantees that the ‘brutal’ pre-pandemic cuts to public health would be reversed, that there would be no repeat of the failed, private, test-and-trace service and bed numbers would be brought up to the level of European neighbours.

And he called for ‘fairness for the front line’, as junior doctors struggled to pay basic living and accommodation expenses while being saddled with tens of thousands of bma.org.uk/thedoctor

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NAGPAUL: Learn lessons now

pounds of debt, while others were falling into a pensions ‘tax trap’ which forced them to leave their jobs.

‘It’s the height of irresponsibility that the Government is wilfully shrinking the workforce and harming patient care, when we’ve given them solutions on a plate that will result in an overall positive balance for the Treasury, while retaining doctors at a time when the NHS desperately needs each of us.’

Reflecting on his 30 years representing his fellow doctors, he said it was painful

that the founding principle of the NHS, to treat people equally whoever they were, was not being applied to the NHS workforce.

He said: ‘We simply must not accept a health service where a black doctor is six times less likely than a white colleague to be offered a job in London. Where bullying, harassment and disciplinary referrals continue at twice the rate for doctors from ethnic minorities, with differential attainment of postgraduate exams, poorer career progression and an ethnicity pay gap.’ thedoctor | July 2022

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AT A GLANCE

ARM2022

EMMA BROWN

Doctors seek right to respite

News from the BMA annual representative meeting

KENNEDY: Change culture from top to bottom

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octors cannot continue to be treated like robots and must be allowed to switch off amid a growing tide of moral injury facing the medical profession, doctors have said.

The association must lobby for doctors to have the right to have some time away from work pressures if there is to be any possibility of the medical profession recuperating and recovering from the effect of the past two years, the BMA annual representative meeting heard last month.

Addressing his colleagues, Derbyshire GP Peter Holden called for doctors to be given a right to switch off from work, warning that not a single doctor could have emerged from the past 28 months without having incurred some adverse consequences.

He further warned that the rise in digital technology during the pandemic had ushered in a 24/7 approach to work for many doctors and an ‘Amazon Prime’ level of expectation of what health services could provide by some patients.

He added that this situation was being further compounded by the unrealistic expectations being fostered by politicians as EMMA BROWN

RENNISON: Feeling burnout at early stage of career

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to what an understaffed and traumatised health service could achieve, all of which having had a tremendous human cost.

He said: ‘All sentient human beings have been impacted by the pandemic, but as clinicians we’ve witnessed terrible events which we never thought we’d see and of which the public cannot possibly conceive.’

Backing Dr Holden’s call, junior doctor Hannah Kennedy demanded a full culture change from top to bottom in which having the right to switch off from work was not only permissible but embraced by the medical profession.

Dr Kennedy said that the idea of going ‘above and beyond’ as a doctor was instilled as early as medical school but said that there was a time and place for this sentiment and that it could not come at the cost of individuals’ wellbeing.

She said: ‘We shouldn’t be made to feel like looking after our mental health is shameful, we should be empowered to

switch off, switch on the “out of office” and relax, recuperate and heal after what has been an extremely challenging two years.’

London foundation year 1 Catriona Rennison told the ARM that, despite being at a very early stage in her medical career, she felt that she was already starting to experience the symptoms of burnout.

Explaining how a recent cycling accident had kept her off work and struggling with her mobility for several weeks, she said that she had at no stage felt properly supported in her recovery, and in fact often felt pressurised about returning to work.

She said: ‘I received almost daily WhatsApp messages telling me how overstretched the ward was and how understaffed they were and asking me when I would be coming back to work. That made me feel undervalued as a junior doctor and that enquiries about how I was were only ever really a leader to asking when I would be coming back.’

thedoctor | July 2022

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AT A GLANCE

ARM2022

News from the BMA annual representative meeting EMMA BROWN

Demand for pay restoration applauded

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anaesthetist, said he supported fair pay and called for it to be restored quickly but warned losses had been ‘exaggerated’ in the motion which ‘undermines the argument’.

Dr Runswick responded: ‘If your issue with this motion is that it’s going to take too long, you should have been with us two years ago, one year ago.

Catch up, sort your act out, make a plan.’

RUNSWICK: Pay restoration is the moral thing to do

ARM2022 news Find more news from ARM2022 online at bma.org.uk/news

MATT SAYWELL

o not be tempted to accept a pathetic future for our profession. You are worth more.’

Junior doctor Emma Runswick received the loudest cheer of the first morning of the BMA annual representative meeting last month when she tabled the motion calling for pay restoration to 2008 value within five years.

The debate that followed was not centred around whether the BMA should or shouldn’t be calling for better pay for doctors, but how soon it should be demanded.

‘We should not wait for things to get worse,’ argued Greater Manchester-based Dr Runswick.

‘Pay restoration is the right, just and moral thing to do. But it is a significant demand and won’t be easy to win.’

She believes industrial action is ‘likely’ as the fight intensifies and insists ‘all of us need to take action’.

‘A union that could win a 30 per cent pay award is a union that can win anything. If we do nothing we will see pay halved, doctors in financial difficulty, demoralised and leaving.’

Those who spoke against the motion wanted to see pay restored sooner.

Anna Athow, a retired surgeon in Enfield and Haringey, urged ARM delegates against ‘sitting on our hands’ and ‘begging the Government for the next five years’.

‘This pay rise is needed now,’ she said as she backed other industries taking or threatening strikes. ‘Now is the time to fight. This is the time for doctors to ballot alongside our junior doctors and other sections of organised workers.

Doctors are leaving in droves. It’s not just about burnout… but because they can’t afford to pay the bills and maintain their living standards.’

Brighton-based gynaecologist Aizemea Okojie said: ‘I’m moving against this motion not because of the content but because of the fiveyear timeframe. I would prefer it to be shorter. I get anxiety attacks looking at my bank balance every month.’

Stephen Millar, a retired consultant

OKOJIE: ‘I get anxiety attacks looking at my bank balance’

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ED MOSS

SHIELDS: ‘Absolute trust’

‘It’s important to be involved in people’s care right the way through their lives’

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Continuity of care has been shown to benefit patients, doctors and the NHS. Peter Blackburn speaks to GPs about how best to achieve it

Cradle to grave

‘I

t’s absolute trust. If you have continuity of care you have trust that you will see patients not just for the big complex issues, but the smaller issues – you will see them for the urine infections, the ear infections, the contraceptive advice and things like baby checks and post-natal checks which are really important.

‘It’s important to be involved in people’s care right the way through their lives.’

Gavin Shields has first-hand experience of the benefits of a strong, stable and enduring relationship between patients and doctors. When Dr Shields finished his specialty training, some 28 years ago, he was approached to become a partner at the GP surgery in Coventry where his mother worked and had done through his upbringing.

Dr Shields and his mother have seen several generations of the same family come to them during the most vulnerable moments of their lives. The result? A trusting relationship – and a decreased reliance on other services.

‘If they know you can give them sensible advice across a range of health issues they will believe and trust what you say. I think that’s absolutely vital for keeping people out of A&E and away from stretched out-of-hours services.

‘They know they can trust the advice you’ve given. On a Friday if I’ve seen their child they know I’ve seen that child 10 times over the year and they trust the management plan I’ve given over the weekend and they will trust and believe in what I say. That continuity is what we want.’

‘In decline’ Continuity was a hot topic at the UK conference of LMCs in May, with representatives calling on the BMA GPs committee to negotiate a GP contract that incentivises continuity of care.

GPC chair Farah Jameel said the evidence of the benefits of continuity was mounting but that ‘high-quality, cost-effective and timely care is under-estimated and poorly valued by policymakers’ and was ‘in decline’ in this country.

Speaking at the event she said: ‘If continuity of care is to be rewarded and preserved, it will need to be measured and monitored and it will need new payment mechanisms. So we’ll need to spend some time thinking about these matters. bma.org.uk/thedoctor

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‘I have a strong idea on what is happening with my patients’ medical story and I know what has happened in the past’

JAMEEL: New payment mechanisms will be needed

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‘We must reward continuity of care and it is right that we ask for it. We’ll need courage – from policymakers, from us [and] from parliamentarians.’

A 2018 report by the Nuffield Trust found ‘there is a large body of evidence to demonstrate that continuity of care delivers significant benefits to patients and staff’ – citing better clinical outcomes for an array of conditions; reduced mortality; better uptake of preventive services; better adherence to medication; reduced avoidable hospital admissions; and better overall experience of care among patients who prefer continuity and are able to obtain it. Ultimately, all of these things mean better outcomes and reduced costs.

The Parliamentary health and social care committee recently heard evidence about the benefits of continuity of care from several experts. Among them, Steinar Hunskår, a professor in the University of Bergen’s global health and primary care department, said a major study in Norway found a 25 to 30 per cent reduction in mortality for patients with the longest observed relationship with their regular GP. These are the experiences of Pauline Grant, a GP who still works with a personal patient list – around 2,000 patients – in Southampton.

Dr Grant says: ‘It’s the social side but it’s also a medical safety issue. All my results come to me. All the documents and letters come to me. I have a strong idea on what is happening with my patients’ medical story and I know what has happened in the past. I know when a course of medical action might be dangerous.

‘I pretty much know which patients are allergic to penicillin, for example. I still ask, but I do know.’

Dr Grant adds: ‘If I’m treating somebody, for example in palliative care, if I’ve looked after them when they’re alive I know what their attitudes are, I know quite a lot about them and I can look after them much better when they are dying – I know how far they might want to go with

treatment and whether they believe in the medical model for example.’

New incentives needed According to Kate Sidaway-Lee, a research fellow from the St Leonard’s medical practice in Exeter, fewer than 10 per cent of practices operate on a personal list basis. Speaking to the health and social care committee, Dr Sidaway-Lee said the first step to increasing that number was to begin measuring continuity of care.

And London GP Rebecca Rosen, who is also a health policy analyst at the Nuffield Trust, attributed the low numbers, at least in part, to there being too many funding ‘micro-incentives’ attached to existing priorities in general practice. She calls for new models of primary care to prioritise access and continuity, rather than continuity simply being added to existing funding streams.

Proposing the local medical committees conference motion – a motion which called for a move away from target-based contracts to rewards for continuity – Bristol GP Sam Creavin said continuity would provide an ‘incentive to sort out the problem properly first time’.

He added: ‘Continuity can be measured – there might need to be some debate about how, but it can be done. Placing a modest financial value on continuity would change our behaviour in a way that would improve outcomes for patients and our own job satisfaction.

‘Ultimately, if we don’t have continuity with our patients, then we are just a less well equipped, less well staffed and more easily accessible version of A&E.’ In May, GPC England passed policy reaffirming commitment to the GP independent contractor model, which chair Dr Jameel linked to continuity of care. Dr Jameel said: ‘We know that patients appear to benefit from continuity of care, with the quality, strength and consistency of their relationship with their family doctor having a significant impact on their health outcomes. All of this and more is possible through the independent contractor model.’

Dr Shields agrees. ‘Ultimately I think there needs to be a recognition that the partnership model helps keep stable practice teams, helps maintain core practices and I think there needs to be a recognition of the model which I feel has been increasingly undermined. I think there needs to be work to protect the core funding into our contract to allow stabilisation of practices as

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Reducing duplication For Dr Grant there may be a degree of ‘learned helplessness’ about that sort of thinking, perhaps resulting from so many years of being continuously up against dwindling funding and rocketing demand.

‘We are all so busy that we haven’t got time to step back, we don’t have the capacity to take time off and look at the whole thing,’ Dr Grant says.

Dr Grant adds that she is able to manage her patient list better and build a relationship where people will trust her decisions about how urgent an appointment is. On top of that there may well be a reduction in work due to being able to oversee everything that happens in each patient journey – with far less duplication and the potential to spot incoming problems more quickly.

For many lay people and for some doctors the responsibility of that relationship might seem like a burden. Dr Grant says: ‘When you first start with your personal list the first 18 months are very scary… But you can quickly learn. And you can quickly see the effect your actions have.’

NEIL HODGE

the building blocks of local stable teams.’

Some doctors, however, think that continuity of care is a good aspiration but not necessarily one that is realistic to achieve.

Speaking at the LMCs conference Bedfordshire GP Christiane Harris suggested that a continuity-based contract may be impossible for GPs to deliver.

She said: ‘Sadly, given a declining workforce and the fact that as most of us are ageing we are finding it more difficult to work as many sessions as we did when we were younger – the one thing even the most dedicated advocate of the partnership model quickly realises is that we cannot offer the continuity of care that we would love to do.’ Dr Harris added: ‘The use of members of the MDT to fill the workforce gap makes continuity even more difficult.

‘The danger of passing this motion is we may end up voting for something we’re even less able to fulfil. By all means vote to end the tyranny of the quality and outcomes framework, but not to replace it with something we don’t have the means or the workforce to provide.’

These are concerns echoed by many doctors.

Is it possible to innovate and improve continuity of care – even if that innovation is, to some extent, a return to past principles – in an NHS starved of resource and staff?

Among Dr Grant’s suggestions for making a new system work would be for the Government to fund the equivalent of a salaried full-time equivalent GP for every practice to be a continuity champion for their patient list – with built-in time away from clinical work to help practices implement continuity. It would be a ‘significant investment’ which would make ‘practices think seriously’ about the move.

There are efforts continuing in parts of the country to make similar steps. In one part of south-west England, GPs have set up a programme where administrative staff are supplied to practices to help them organise and implement systems led by continuity of care.

For Dr Shields it all, ultimately, comes down to what is the ‘right thing to do’. As he says: ‘Continuity of care can be measured – there are ways of measuring it. But if you look at the evidence of continuity of care reducing admission, reducing investigations and reducing health anxiety I think sometimes we need to put our tape measures away and say this is just the right thing to do. Any future decisions or funding arrangements, I think, should be ensured that they are not destabilising continuity and are helping to protect continuity of care because I don’t want my colleagues to be working in a hot-desking, never-know-your-patients service. I think that would be demoralising for them and for us as patients – because we’re all patients in the NHS.’ Data and analysis of the pressures on GPs can be found on the BMA website

GRANT: Personal lists can be ‘scary’ but you learn quickly

‘I pretty much know which patients are allergic to penicillin, for example.

I still ask, but I do know’

‘We need to put our tape measures away and say this is just the right thing to do’

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D I G N I T Y AT W O R K

The growing provision of sanitary products at work following successful doctor-led campaigns is helping to promote wellbeing and tackle ignorance.

Jennifer Trueland reports

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‘I’ve been working for the NHS for 20 years and I’ve senior registrar in obstetrics and gynaecology had a lot of near misses and full-on hits of being caught is assisting with a long operation when she short, bleeding through clothes because there’s been suddenly is conscious of menstrual flooding. nowhere to get period products,’ says Rosie Baruah, a With nowhere in the theatre suite to store her bag, consultant anaesthetist in she had left it in the doctors’ Edinburgh, who spearheaded room near the ward – a long ‘Why was it that the NHS was the campaign. ‘You wouldn’t walk away – so she hadn’t had not geared up in any way to provide expect not to be able to use the time to change her tampon for periods?’ toilet because there’s no toilet before scrubbing for the paper, so why was it that with case. She is embarrassed, a 70 per cent female workforce, the NHS was not geared uncomfortable – and keeps her surgical gown on to hide her stained scrubs until she gets a chance to change. up in any way to provide for periods?’

It’s not about affordability, nor is it a question of This was one of the stories shared with BMA Scotland women and people who menstruate coming to work when it launched its #BMAPeriods campaign, which unprepared, she adds. Rather, it’s about dignity and aimed to get period products placed in all staff toilets workforce wellbeing. across all NHS sites. And it was successful. In March ‘This is part and parcel of the acknowledgment that of this year, it was announced that all health boards we have needs as human beings. Doctors in particular in Scotland would provide free period products for have sometimes seen it as a badge of honour to neglect healthcare workers.

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BMA

TONY MARSH

BARUAH: Spearheaded the campaign for free period products

CHEETHAM: ‘SOS box’ scheme expanding

your needs – like “I can stand up for 12 hours without needing to pee, without needing to drink because I’m so awesome”. But we need to move away from the sort of approach that breaks people to one that’s about wellbeing, that recognises that people have needs, and that their employers are going to meet them.’

Lack of understanding

Reaction to the initiative has been largely positive, she says, including from some ‘amazing male advocates’ although she has had negative comments from a number of men on Twitter, including doctors.

Again, she blames a lack of understanding of the real issues. ‘I think it possibly goes back to medical school where we were almost taught that people who menstruate have regular monthly cycles and that should be a standard 28 to 31 days between them. But anything can set it off or disrupt it – it can be stress, or changing shift patterns, or lots of different reasons.’

Part of the problem, she adds, is that there is a lack of understanding about periods, and that discourse on the topic needs to be expanded to recognise that menstruation is a part of life.

Josie Cheetham, joint deputy chair of the BMA Welsh Gaps in provision junior doctors committee, has been campaigning for Labour MSP Monica Lennon, convenor of the Scottish the NHS to provide sanitary products for staff for the last Parliament’s cross-party group on women’s health, worked four years – and her campaign has come a long way. She with BMA Scotland on the #BMAPeriods campaign. initially set up a small pilot in one hospital, where she She had submitted freedom of information requests to provided what she calls an SOS (sanitary products on Scottish health boards to find out which had policies or site) box. This quickly expanded to three hospitals in the plans on period products, which showed that provision Aneurin Bevan Health Board, was far from universal. where she was based.

She said the Period ‘This is part and parcel of the The initiative proved popular Products (Free Provision) Bill, acknowledgment that we have needs with staff and has expanded which she introduced, and as human beings’ significantly. Her own which parliament backed, gave health board has been very women and people who need supportive, she says, and SOS boxes are now available in period products the right to access them without any clinical areas in many parts of Wales. questions. But while it resulted in widespread provision Although she initially met the costs herself, with through schools, universities and local authorities, there sponsorship from organisations such as Bloody Good were still gaps.

Period she has been able to send out launch kits to ‘The legislation we have in Scotland is a strong anywhere in the UK – essentially a box of products foundation and a major achievement but it was never alongside lobbying resources and tips on how to expand about getting a bill passed and then moving away from it. She has also continued to press politicians and medical the topic. It’s about how we embed it in our culture, how organisations to provide support for the initiative. we improve access to products in workplaces.’ thedoctor | July 2022

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The body of knowledge There was a time when ‘human resources’ meant something even grimmer than it does now.

Jennifer Trueland reports

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life-size papier mâché model of a man stands at the doorway. Dating back to the 19th century, and constructed in the Auzoux workshops in France, it’s an anatomical model designed to be taken apart or dissected repeatedly. This one (pictured left), bought by the University of Aberdeen in 1879, separates into 92 pieces.

As teaching tools, such models were popular and practical – but they were no substitute for the real thing, for the experience of dissecting an actual human body.

It’s a fitting start to Anatomy: A Matter of Life and Death, which opened at the National Museum of Scotland on 2 July.

The presence of this early experiment in clinical simulation points up the enormous challenge in acquiring sufficient cadavers for teaching and research. This very real problem of ‘human resources’ was to culminate in one of the most horrific episodes in Edinburgh’s medical history; that is, the scandal of those who sought to feed demand by robbing graves, or even murdering people to meet the need. Although it contains such highlights as the skeleton of William Burke, who was sentenced to hanging and dissection for murder, the exhibition is far from a chamber of horrors. Rather, it takes a new and very contemporary view of the history of anatomy, which also casts an interesting light on how medicine has changed – and where, arguably, it hasn’t.

Da Vinci and dissection The importance of dissection to learning about anatomy is threaded throughout the exhibition. For example, there are some rarely seen drawings by Leonardo Da Vinci (lent by the Queen). Da Vinci who dissected more than 30 human bodies.

His unpublished notes contained information about the heart’s movement and structure that was only ‘discovered’ centuries later (an important lesson on making sure you publish your research findings, says the museum’s senior curator for biomedical science, Sophie Goggins as an aside).

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Coming bang up to date, there is also video testimony of the continuing value that dissection brings to today’s medical students. Beth Fitt, a medical student at the University of Dundee, talks about how dissection really helps doctors to understand the whole person, while Joyce Faulkner describes the process of donation of the body of her late husband (in accordance with his wishes), and explains why she has also decided to leave her body to the University of Edinburgh.

Donated cadavers today – described as ‘silent teachers’ – were from people who were willing and actively wanted to help. They could also be sure that their bodies would be treated with respect. This, however, was not always the case for those ending up on the dissection table. The exhibition does not shy away from the fact that it was those from the poorest backgrounds whose bodies would help feed the insatiable demand as Edinburgh became a world leader in medical education.

Guarded graves While the wealthy could afford to hire ‘mortsafes’ – heavy equipment designed to keep robbers away from corpses until they were too decayed to be of value to anatomists – the poor did not have the same luxury. Indeed, the exhibition reveals that graveyards could be lively places: some families employed people to protect their loved ones’ graves, but these could be decoyed or bribed into dereliction of duty. The local guards were often on the scene too. They wouldn’t intervene to protect the graves, but rather to break up fights between would-be robbers and angry families.

The story of Burke and Hare illustrates the difference that income and status makes to life and death in early 19th century Edinburgh. This exhibition does its best to foreground the victims of these two serial killers with a moving wall of posters giving the names and any biographical details there might be of their 16 victims (some were never even named). It also gives due prominence to the roles of Hare’s wife, Margaret,

who was certainly involved in facilitating the murders, and to Burke’s partner, Helen McDougal (who was charged with murder but the case was ANOTHER AGE: found unproven).

Miniature set of And what of the role of the doctors wooden coffins in this?

Were they innocent recipients (above left) and a mortsafe (right) of bodies they thought were obtained legitimately, or were they more complicit? The anatomist Robert Knox, who had paid Hare a substantial sum for the body of a lodger who had died, was exonerated by ‘a panel of other doctors’, the exhibition notes say. Although ‘Were doctors shunned by many for his involvement, he nevertheless remained free to develop innocent recipients of his career (which took the unsavoury direction of scientific racism). bodies they The West Port murders, as they thought were became known, did however pave obtained legitimately?’’ the way to the Anatomy Act of 1832, incidentally four years after a petition from medical students asking for a better supply of cadavers – an early example of student activism. They also continue to contribute to popular culture and legend. Just a few feet from Burke’s skeleton sits a set of miniature wooden coffins, each containing a miniature wooden body.

‘The These were found on Edinburgh’s anatomist ancient volcano, Arthur’s Seat, in June was 1836. The fact that there were 16 of exonerated them led to speculation that they by a panel represented the victims of Burke and of other Hare. Whether or not that is the case doctors’ (and there’s really no evidence that it is) they make a touching end to what is an excellent exhibition.

Anatomy: A Matter of Life and Death runs at the National Museum of Scotland in Edinburgh until 30 October. thedoctor | July 2022

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ADAMS: ‘There are times you feel like giving up. But then you remind yourself of the goal and keep going.’

Few who have trained to become a doctor have had to struggle like Alexandra Adams. She tells Seren Boyd that despite – or perhaps because of – her disability and serious illness, her determination just gets all the greater

AGAINST ALL ODDS

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eing deafblind would be more than enough to contend with as a trainee doctor, let alone all the doubters and discrimination.

Yet, Alexandra Adams wrestles with other physical challenges too. During the pandemic, these conspired to put her in hospital for 17 months and brought her studies to a screeching halt.

Now, after a two-year interruption, she is back at medical school in Cardiff, doing clinical placements at a hospital where she was a long-term patient, fighting off the flashbacks.

Even now that her health has stabilised, she is on 24-hour oxygen, has a gastrostomy tube and drain, and is sick many times a day. She is also highly prone to joint dislocation and has had sepsis seven times in one year.

‘My life is definitely not boring,’ she says.

In it all, Alexandra is determined to stay positive.

Unexpectedly, she found herself thrust back into the role of diversity advocate recently after she introduced herself to TikTok as a deafblind medical student and went viral.

But she is still coming to terms with what’s happened in the past two years.

The truth is that the 17 months she spent in three different hospitals, during the COVID pandemic, left her traumatised – and doubting her choice of career.

‘It is something that I thought about every day as a patient,’ she says. ‘At one minute, I’d be feeling I’m learning so much about medicine and how to treat my future patients. But the next, I wanted to run as far away from medicine as possible.’

The respiratory and digestive issues she has had since her mid-teens had been growing progressively worse. Respiratory muscle weakness has landed her in ICU 23 times.

During the first lockdown and her fourth year at medical school, her condition had deteriorated so far that she was admitted to ICU three times. On the day of her first discharge, her rental agreement was terminated with immediate effect on the grounds that her health and hospital visits were ‘putting other tenants at risk’.

When Alexandra was admitted in July 2020, just after her parents had managed to find her new accommodation, she was severely malnourished, fitting and fighting to breathe. This time she stayed in.

23 ICU visits

It took three months in hospital for her to be diagnosed with Ehlers-Danlos syndrome, a rare genetic condition resulting in faulty connective tissue. In Alexandra’s case, this has affected her immune, cardiovascular, respiratory and gastrointestinal systems, causing,

Alexandra would like to be able to trot out unreserved truisms about her experiences as a patient preparing her to be a better doctor. They have, of course, but it is not quite as straightforward as that.

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‘My fault’

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PHOTOGRAPHS © ALEXANDRA ADAMS

‘I’m just trying to focus on the good stuff’ bma.org.uk/thedoctor

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But some experiences she found deeply distressing. What she saw on the COVID ward was ‘horrific’, though beyond anyone’s control.

But she has found it harder to come to terms with what she feels was unkindness and neglect from some.

Alexandra knows staff everywhere were – and remain – under extreme pressure. But she felt some expected her to ‘just get on with it’ and deal with things better because she among other things, intestinal failure and was a medical student. gastroparesis (delayed gastric emptying and Before she was diagnosed stomach paralysis). She also has extreme with the rare condition Ehlersjoint hypermobility.

Danlos syndrome, she felt Then, on Boxing Day, she tested positive for medical staff believed her COVID. ‘The hospital was drowning in COVID by then: condition was ‘all in her head’. Frequently afterwards, pretty much every ward became a red ward. I was in she was made to feel a nuisance – even when she was in gastroenterology when I caught COVID. The patient next excruciating pain or genuine distress. At one point, when to me basically said it was my fault and “now you’re going she had a painfully infected central line site, which turned to spread it to the rest of us”.’ out to be severe sepsis, she was told: ‘Your neck’s not In fact, the three other patients on her bay all caught fractured! Move it!’

COVID: Alexandra was the only one who survived, after And when she asked about the long-term prognosis a month in the red zone. ‘I knew it wasn’t my fault, but for people with Ehlers-Danlos, scared for her future, a I felt really guilty that the three others didn’t make it. It doctor replied, ‘You’re a medical student: surely you’re destroyed me.’ competent enough to work it In early March 2021, she ‘What kept me going was a voice reminding out for yourself.’ was transferred to a hospital in ‘The doctors were in a very me: “This is one hell of a journey but it’s all London for six months, then difficult position because I was lived experience you’re going to learn from”’ after a brief respite at home in a complex case and nothing Kent, she was back in hospital seemed to be working but I did in Wales. For much of the time, Alexandra was very get a lot of sarcastic comments,’ she says. unwell, strongly medicated, bedbound, unable even to Months after requesting mental health support, she lift her head. COVID meant she couldn’t have visitors for saw a psychologist who offered only dietary advice and many months; playing the piano in the hospital chapel, suggested she try kefir. And the promised discharge when she grew stronger, was her only respite. letter to her GP and referral to a specialist hospital never ‘There were nights when I was bawling my eyes out materialised. She now has a drainage tube in the wrong and thinking: I don’t have a future, I don’t have a purpose. place and no overseeing consultant. ‘As a patient I feel I’ve I didn’t want to be here any more. slipped through the net – but as a medical student I still ‘What kept me going was a voice reminding me: “This love the NHS and couldn’t think of a better place to work.’ is one hell of a journey but it’s all lived experience you’re Financial pressures going to learn from. It’s going to be valuable, whether it’s Towards the end of last year, Alexandra decided to ignore through being able to help people, making you resilient, her health challenges and resume her studies. She says or making you more grateful for the little things”.’ she had ‘reached a point where I felt nobody cared for Contrasting care experiences me’ so she stopped caring for herself.

Some of the care she received, especially from nurses She was passed fit to return in January and began at St George’s Hospital in London, was first-rate. Nurses catch-up placements in June, with a view to restarting her in Wales brought her ICU bed outside so she could meet fourth year in September. Her previous year group has Winnie, the new family Cavapoo puppy. since graduated.

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one eye and only 5 per cent in the other.

She started making videos addressing these questions, explaining, for example, how her stethoscope links by Bluetooth to her hearing aids, how she accesses veins by touch or uses magnification to read scans. The first TikTok went viral, with 2.4 million views and counting.

‘I do believe you don’t need the best vision or hearing to be a good doctor: having insight and empathy is the most important thing. But wait till I tell TikTok I stick needles into people as a phlebotomist. That’ll really tee some people off!’

Diversity advocate This major setback is not Alexandra’s first.

There are other pressures. She’s not sure how she In her early teens she was part of the GB paralympic can fully fund her accommodation. Her requirements swimming team, training for the London 2012 games. are specific: her blindness and chronic fatigue mean that But complications following stomach surgery left her in she can’t live too far from the university, so rooms tend hospital for a year and ended her swimming career. to be more expensive. The extra equipment and tech she From promoting disability inclusion in sport needs are costly too. Her parents can’t afford to help: the alongside the likes of Baroness Tanni Grey-Thompson whole family have been hit hard emotionally, physically as a teenager, she is now an advocate for diversity in the and financially by events of the past two years.

NHS. Sadly, she has faced discrimination from the public, In 2020, Alexandra took the ‘uncomfortable’ step peers and doctors alike. of crowdfunding for her Her Faces of the NHS ‘I do believe you don’t need the accommodation and was campaign and photo exhibition able to fund a two-year rental celebrating diversity in 2019 best vision or hearing to be a good doctor: contract. Unfortunately, she led to a TEDx talk, and she’s having insight and empathy is the most was in hospital for much of given regular media interviews. important thing’ that time.

Consistently, it’s To help with her finances, she’s taken on bank work as a phlebotomist at the same hospital where she was her ability to turn admitted as a patient in July 2020. tough circumstances ‘I took a little detour after my shift the other day and to good that has went into the chapel to play the piano again. I cried propelled her forward. because I saw the old me in the distance, a patient in a The year she spent in gown and a wheelchair. But I just have to get over that.’ hospital at 16 inspired Alexandra has set herself an 870-mile sponsored her to become walking challenge to raise money on GoFundMe for a doctor. pianos in NHS hospitals.

This new chapter, marked by chronic Social media star illness, has proved far In public and on social media Alexandra is more challenging than resolutely cheerful. her deafblindness.

Unexpectedly, she has attracted the attention of a But, if anything, it has new audience by posting a short video on TikTok about made her more determined. returning to medical school as a ‘deafblind medic’. It ‘I’m not going to lie: there are times when I think: “Oh, triggered a familiar storm of disbelief and trolling: some stuff it, I hate this,” and you do feel like giving up. But then impressed by her resolve, others ridiculing her ambition. you remind yourself of the goal and keep going. I’m just ‘It was proof that ableism is very much still out trying to focus on the good stuff.’ there,’ she says. ‘But people were asking some genuine questions too, such as: How would you take blood if You can donate to Alexandra’s initiative to buy pianos you can’t see or how would you hear someone’s heart?’ for hospitals at www.gofundme.com/f/pandemicAlexandra has been deaf from birth; she has no sight in pianos-music-medicine-for-nhs-hospitals thedoctor | July 2022

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A trusted voice For decades, it has helped make Britain a safer, healthier place. The BMA board of science’s two leaders tell Seren Boyd about how they plan to use doctors’ influence to bring about positive change

H

ealthy societies are everyone’s goal but influencing the bigger picture is hard when you’re grappling with the urgent and immediate in silos and specialties.

Yet, COVID has created an appetite and momentum for tackling some of the big ‘We need public health issues – and it is something the BMA board of to make science is keen to leverage. sure that a It is the board’s role to supportive environment inform and shape government and public opinion on these is there overarching public health to enable concerns, and champion the people to science and research around be healthy’ them, whether through policy briefings or symposiums, lectures or webinars.

So, its new chair David Strain and deputy chair

REDMAN: Doctors want to tackle wider issues in society

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Melody Redman are excited to be taking on their roles at a time when these issues are gaining traction.

We’re entering a new era in medicine,’ says Dr Strain, a clinical academic with interests in issues such as diabetes, older adults and obesity.

‘Everyone is more informed now: people crave information.

They want to understand why, for example, somebody living with obesity is more at risk of a cancer.

‘And there’s a shift in the mindset of the medical profession towards coproduction, involving service users when designing a service. I don’t deliver care to a person with diabetes: I may suggest some tablets, lifestyle management, incentives,

but ultimately they deliver their own care. We need to make sure that a supportive environment is there to enable people to be healthy.’

The board’s priorities are wide-ranging: oral health and its association with other health conditions; obesity; suicide prevention; and addressing poor health outcomes stemming from economic inequality. Work is ongoing on other issues such as smoking, climate change and long COVID. And at last month’s BMA annual representative meeting members voted on a motion, developed by both board and BMA public health medicine committee representatives, to explore ways of addressing gambling addiction.

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MATTHEW SAYWELL

SARAH TURTON

It is keen that its work, in close collaboration with other BMA committees, BMA staff and the patient liaison group, has ‘measurable outcomes’ in areas where there is a ‘clear deficit’.

Campaign wins

‘We should be using our voice to speak out for the most vulnerable in our society’

This professional arm of the BMA is not at odds with its work as a trade union.

In fact, the board bolsters and gives credibility to its lobbying and campaign work, Dr Redman argues.

‘We strongly believe, and we see, that our work as a board improves our ability to negotiate from a trade union perspective, because we have a reputable and respected voice in other areas,’ she says.

Dr Strain cites several examples of BMA campaign wins on the back of work by the BMA board of science.

Its papers helped usher in laws requiring helmets for motorcyclists and seatbelts for drivers; its scientific updates on tobacco contributed towards smokefree public places.

‘And our symposium on AMR (anti-microbial resistance), which is still very much a live issue, helped shape the Government’s own AMR strategy, and many of the recommendations from our event were incorporated into its five-year action plan,’ says Dr Strain.

‘We capitalise in our advocacy on brand recognition of the BMA as a professional body and a trusted source of information.’

bma.org.uk/thedoctor

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And doctors’ interests are directly served by moves to improve patients’ health and wellbeing, as Dr Redman points out. ‘When we see wider issues in society that cause people harm and that we can’t directly address within our medical role, it affects us strongly too, in terms of moral injury and frustration.’

Positive influence There are other important reasons why they believe the BMA should continue to contribute to the debate on public health. Chief among them is the fact that the BMA has a unique voice.

The cross-specialty perspective offered by the diverse group of clinicians sitting on the BMA board of science makes its contribution to the debate important.

The fact that the vast majority of board members are still practising medicine and regularly seeing patients also differentiates them from many other representative medical bodies.

‘The BMA is one of the very few trusted voices out there representing the overall healthcare setting,’ says Dr Strain.

Both Dr Redman and Dr Strain are keen to stress the board is accessible to all

STRAIN: ‘Entering a new era of medicine’

BMA members. Any member can influence what the board works on by proposing a motion through the ARM – an opportunity not generally afforded in other professional bodies. And any member can stand for election to the board.

For Dr Redman, being on the board is an opportunity to pursue in practical ways one of the reasons she came into medicine: influencing the big picture for the sake of those who can’t.

‘As a medical profession, we have a powerful and respected voice, and I believe we should be using that to speak out for the most vulnerable in our society. I love being able to work with the board on wider issues I couldn’t address in my dayto-day role.’

To learn more about the BMA board of science, or any other BMA committee, arrange a visit through the committee visitors scheme at bma.org.uk/committeevisitors-scheme thedoctor | July 2022

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Patients are getting stuck in an ‘incredibly frustrating’ referrals process, creating more work for GPs, who fear it is more about controlling numbers than addressing clinical need. Peter Blackburn reports

New triage system could risk patient safety, GPs warn ‘In some of my clinics more than half of the people are waiting for something to be done in hospital and are stuck’

NORTHCLIFFE MEDIA LTD

Queen’s Medical Centre, Nottingham

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Ps have raised concerns about patient safety, a growing workload burden and the emergence of a two-tier healthcare system after the introduction of a new ‘virtual triage’ system, which has dramatically cut the number of patients able to access specialist neurology services.

The Doctor has obtained figures which show that the number of patients not being seen in secondary care in Nottingham has rocketed, with rejection of referrals or advice and guidance being issued in 40 per cent of cases in 2022 – a massive rise from just 7 per cent of cases in the 12 months leading up to the pandemic.

NUH (Nottingham University Hospitals) NHS Trust, which runs the two biggest hospitals in the city, says it had introduced the new system owing to ‘greatly’ increased referrals and a lack of staff.

But the trust’s own figures show the total number of referrals has previously been significantly higher than they are now.

During the last six months of recorded data – covering November 2021 to April 2022 – there were, on average, 428 referrals a month.

In the six months leading up to March 2020 that number was 611.

‘A battle and a struggle’ Doctors have raised concerns that the situation is being driven by stretched NHS funding, limited workforce and the mounting backlog rather than in the pursuit of improved patient care.

Irfan Malik, a GP in Sherwood in north Nottingham, says he fears for patient safety – and is having to advise people to consider private healthcare because accessing services is becoming so difficult.

Dr Malik says: ‘Neurology is a difficult subject and it is hard to diagnose properly from our end in general practice. We get a wide range of patients, and we are not always qualified to make the diagnosis or carry out the specialist tests.

‘We only refer when we absolutely have to, but more and more referrals are being rejected with advice and patients not seen. Every referral is becoming a battle and a struggle – they send a letter back with lots of advice and things to do and other referrals to make. The patients are getting stuck and they still have the problems they initially had.’

Dr Malik adds: ‘It is incredibly frustrating. In some of my clinics more than half of the people are waiting for something to be done in hospital and are stuck. What can we do? It feels like people will get more and more poorly and some will have bad consequences.’

Increased GP workload BMA East Midlands co-vice chair and Nottingham GP Kalindi Tumurugoti says the problems are causing significant issues around workload too.

He says: ‘Any referral that is rejected or returned generates a huge amount of work in general practice. It is a case of seeing what to do next, looking at further investigations, considering pain relief and medicine

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MALIK: ‘We only refer when we absolutely have to’

management and trying to access MRIs or other steps that may be required. We are already a stretched and demoralised workforce and this is effectively going to give patients secondclass treatment.’

NHS leaders in Nottingham say they introduced the ‘virtual triage system’ for outpatient referrals ‘in line with national guidance’ and ‘co-designed with primary care partners’ to address the challenges raised during the pandemic in July 2020.

The number of rejected referrals or referrals responded to with advice and guidance increased significantly in the following months to a high of 78 per cent in November 2020. The numbers have not returned to anything like pre-pandemic levels.

The Doctor has seen a briefing document from NUH which discusses the issue. It says a ‘conscious decision’ had been made to ‘carefully vet all referrals from primary and secondary care’. It says even without this ‘enhanced vetting system’ neurology waits are three to four months and would likely be more than six months if it was removed.

The document adds: ‘Please be assured the sole driver for this is patient care and safety.’

It says the move was driven by a combination of ‘greatly increased referrals to neurology’ and loss of outpatient capacity ‘due to recent consultant shortages and a COVID-19-related redirection of neurology services to urgent care’.

Long waits The figures released to The Doctor by NUH do not show a significant increase of referrals. In fact, the two highest amounts of monthly referrals, during the period covered by the released bma.org.uk/thedoctor

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figures, were in July and October of 2019 with a combined total of just 114 rejections from 1,462 referrals.

Michael Wright, chief executive of Nottinghamshire local medical committee, says local GPs have raised concerns that the increased use of advice and guidance is ‘effectively a way to control workload rather than address genuine clinical need’.

He says: ‘This also causes practices extra work and GPs would feel that they’ve discharged their contractual duties responsibly by referring the patient and would prefer to use advice and guidance when looking for pre-referral help as the name suggests – advice and guidance.’

Mr Wright says the LMC was aware of situations where patients were facing long waits and GPs felt they had to suggest they consider private treatment – which ‘feels very alien for many doctors’. He says: ‘This may be the reality of the situation, some patients are also opting for private GP care. The system is clearly in the early days of “recovery” mode [as] regards returning to “normal” levels of activity.’

GPs have raised concerns that significantly increased use of advice and guidance could become normal and end up being dictated to other areas as NHS policy.

Mr Wright says local GPs want to work ‘collaboratively with the trust to make the best of a difficult situation and try different approaches’.

NUH told The Doctor that a local audit of the new ‘virtual triage’ service shows that ‘the majority of referrals were seen virtually or physically but a significant proportion were returned, often with either a request for additional information or a management plan’.

It says around 15 per cent of patients were re-referred to the service after six to 12 months, adding that the trust welcomes feedback which ‘helps us best advise, support and action the care of every referred individual’.

‘Any referral that is rejected or returned generates a huge amount of work in general practice’

TUMURUGOTI: Rejected referrals generate a huge amount of work

A longer version of this story can be found at bma.org.uk/new-gp-triage-system thedoctor | July 2022

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Your BMA

The hybrid ARM was a huge success – let us now implement our policies with vigour

It was my honour to chair the BMA’s first ever hybrid annual representative meeting – and the feedback I have received since has really vindicated all the hard work that so many people, elected members and staff, have put in over the last nine months in making this event happen.

I am so proud to have seen members and staff attending virtually and physically being able to participate more accessibly than ever – whether through debating, voting, commenting on proceedings or supporting the meeting.

While the virtual aspects of this year’s hybrid ARM were great, it was also brilliant to be back in person.

We have all been through an incredibly tough period of time – it has been difficult for members and for colleagues and staff at the BMA – and it was brilliant to be able to meet people, say thank you, and to listen to what members and representatives have to say. For me, that is what my role is all about. And that interaction is what so many of us have missed.

We were finally able to hand out awards and honours to members and staff who have served the association and our profession. We were able to remember those we have lost in these last years, together.

I have now been elected chair of the representative body for the next three years and will do everything in my power to take all the achievements of this year’s ARM and build on those successes – making our ARM the most inclusive, accessible and efficient policyforming event it can be.

During the three days of the event in Brighton your elected representatives voted on policy democratically.

And now elected members and BMA staff will get on with delivering on those motions – whether actions are required around terms and conditions of service, pay restoration, patient care, considering industrial action, or public health, among so many other areas.

All that work will be driven by the BMA in the coming 12 months. Where policy is not completed it will remain in the policy book – and thus remain a BMA priority – until it is completed. That is democracy in action. You will be able to assess progress when, at the next ARM, our document of policies is released.

While this year’s ARM is only just behind us, my 22

@drlatifapatel thoughts have already turned to my role for the coming months and, ultimately, to next year’s event which will be held in Liverpool from 3 to 5 July.

While the deadline for next year’s motions will be in April 2023 – and that might seem like a long way away – there has never been a better time for you to get involved, to have your say and to consider stepping up to be a representative of the profession.

If you are already considering writing motions for next year’s ARM then you can receive support by emailing armmotions@bma.org.uk In the coming months there will be elections for positions at local and national levels, with the elections for regional branch of practice committees all taking place in the near future. And there will also be opportunities to get involved in divisions and regional councils.

I am keen to see more elected members from groups we under-represent: women, members with disabilities and long-term conditions, ethnic minority colleagues and colleagues who identify as LGBTQ+.

If you don’t want to stand for an elected role there are other ways to have an influence, too. As always, social media is a great tool for sharing your thoughts and you can receive newsletters relating to all of the activities of your relevant committee/s, including how policy from the 2022 ARM is being actioned simply by signing into your account on the BMA website and setting your preferences.

Our BMA can only be the best voice for members – medical students and doctors working on the front line – if we hear from as many people as possible. Whatever your reflections, your experiences or your ideas I want you to know that your voice matters.

As always, you can contact me directly via Twitter @drlatifapatel or email me at RBChair@bma.org.uk PS – and I encourage you to hold me to account!

Dr Latifa Patel is chair of the BMA representative body

thedoctor | July 2022

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on the ground thedoctor

Highlighting practical help given to BMA members in difficulty

Pay docked for an employer’s error When a junior doctor rotates during training to a new trust, there is often a wearying ritual they must go through.

It is not uncommon for something to be wrong. It could be with work schedules, rotas, pay, the contract, where they are supposed to be working or regarding pre-employment checks, which every new employing trust has to ensure are completed before a doctor can be cleared to work in a clinical environment.

No one expects employers to be perfect, but there are far, far too many errors, which can sometimes take years of unpicking. What is particularly disappointing about this case is that the doctor was expected to pay for the employer’s mistake.

The doctor was two weeks into a new rotation when he was told that he had missed having an occupational health clearance. This was the employer’s fault. The member was not informed he could not start his new rotation, nor was his department advised of the same. Furthermore, the employer added a huge insult to injury by telling the doctor that he would not be paid for the two weeks he had already worked.

The doctor contacted the BMA. The employment adviser allocated to support the member wrote to the head of medical staffing at the hospital, explaining that the member had worked in good faith, carrying out all his duties and the failure in completing the checks was their error, not the doctor’s, so it would be unreasonable of the employer to penalise this doctor by not paying him his wages.

The adviser had radio silence from the employer so patiently chased it up and tried to arrange a telephone meeting. She then advised the member to instigate early conciliation with ACAS to protect his claim in this case as it was deemed to be an unlawful deduction from

The Doctor

wages claim, if the employer persisted in not paying him. ACAS can talk to the claimant and respondent about a dispute at work, giving the chance for agreement without having to go to an employment tribunal. Soon after ACAS got involved and likely the employer realised they could not ignore this situation any longer, the employer started engaging with the BMA adviser and conceded to pay the doctor his full two weeks of salary. The occupational health clearance was completed within days of the trust realising the error.

One way to lessen, if not entirely eliminate, the bureaucracy as well as the chance of errors that junior doctors go through with each new job would be to have a single lead employer for the whole of the programme, as per BMA policy.

The BMA believes it would have a number of benefits, such as eliminating the need for repeated DBS checks.

While employers messing up the practicalities of junior doctor employment is all too common, the BMA adviser said a case where an employer has made a mistake then subsequently docked pay without the agreement of the doctor was, thankfully, very rare in her experience of more than 15 years with the BMA. Through the persistence and dedication of the BMA adviser, this matter was resolved to the member’s satisfaction and he commented to say he was pleased to have it resolved without it becoming burdensome on him as he left the matter to be managed by the employment adviser. This case was resolved over a period of four weeks following the dispute arising, and our member is happy for it to be used as an example to warn others of what can go wrong and the benefit of contacting the BMA at the first sniff of a problem at work to get informed advice and support with a view to reaching an early resolution.

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 may 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 William Gibbons. A copy may be obtained from the publishers on written request.

The Doctor is a supplement of The BMJ. Vol: 378 issue no: 8345 ISSN 2631-6412

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

11/07/2022 10:54

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