The Doctor – issue 12, August 2019

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The magazine for BMA members

Issue 12 | August 2019

Going viral

Fake news costs lives – the rise of anti-vaxxers

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thedoctor

The Doctor BMA House Tavistock Square London WC1H 9JP Tel: (020) 7387 4499

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0300 123 1233 @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 YM Chantry. A copy may be obtained from the publishers on written request.

Senior staff writers Peter Blackburn (020) 7874 7398 Keith Cooper (020) 7383 6390 Staff writer Tim Tonkin (020) 7383 6753 Scotland correspondent Jennifer Trueland 07775 803 795 Senior production editor Lisa Bott-Hansson Design BMA creative services

The Doctor is a supplement of BMJ vol: 366 no: 8210 ISSN 2631-6412

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In this issue 4-5

Briefing Thousands of doctors are cutting their hours due to the pensions tax crisis, a BMA survey finds

Welcome Chaand Nagpaul, BMA council chair The NHS has long taken hard-working doctors for granted: the compassion and care that drive us into our professions often mean we stay late to make time for another consultation or to ensure patients can be discharged back to their homes – making sacrifices that affect our work-life balance and can lead to stress and burnout. And now the pensions crisis means the same doctors, who regularly go above and beyond, are punished for working planned extra hours. This is the sorry situation we find ourselves in thanks to the Government’s punitive pensions tax rules. In this issue of The Doctor, we tell the stories of three doctors whose experiences demand change. These stories include one consultant whose clinical excellence award will cost him many times its value, and another who has been pursued by bailiffs. Pressed by the BMA, the Government has now announced a consultation on proposals for reformation of pension taxation. But simply promising a rethink is not enough – we will be demanding tangible reform to end this crisis. Hospital employers are already seeing reduced hours affecting patient care, with patients waiting longer for treatment – increasing the risk of harm. This cannot go on. The August issue of The Doctor also contains a stark warning about the dangers of fake news – with ‘anti-vaxxers’ becoming a louder voice in society thanks to social media and a growing number of conspiracy theorists. As our feature says, 40 years on from the global eradication of polio this should be an era remembered for successfully tackling terrible diseases – not one of needless setbacks. In this edition we also look at the investment in general practice, secured by the BMA during contract talks with the Government, and assess how primary care networks in England could tackle the systemic issues in general practice while also improving care for patients. Given genuine clinical engagement and the time to innovate these new networks potentially allow doctors working in primary care to design the services their patients need and through collaboration to start to tackle the workload and workforce issues which have long crippled general practice.

6-9

Primary goals Can the new primary care networks help tackle GPs’ unsustainable workload?

10-15

Tackling anti-vaxxers Lies spread on social media undermine confidence in one of the safest and most effective interventions in medical history

16-19

Paying to work Doctors describe how they were rewarded for their contribution to the NHS with huge tax bills

20-21

The pressure to cope How a harmful NHS culture means doctors attempt to soldier on in all circumstances

22-25

Unwanted attention Overseas and BAME doctors are referred to the GMC disproportionately often. How can the system be made fairer?

26-30

Life experience Working while sick, memory aids, and the corrupting power of a free pen

31

What’s on Keep on top of events

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Current issues facing doctors

Thousands revealed to be cutting hours over pensions crisis It’s not always pleasant to be proved right. For months, doctors have been warning of the dire consequences of the changes to pensions tax, which have left many with huge bills and no choice but to reduce their working hours. Now, the stark findings of a BMA survey show the full extent of the crisis. 30 per cent of consultants and 42 per cent of GPs surveyed have already reduced their hours. 40 per cent of consultants and 34 per cent of GPs plan to do so. More than 6,000 doctors from England, Wales and Northern Ireland responded. ‘The BMA has repeatedly warned the Government that this would happen,’ said BMA consultants committee chair Rob Harwood. ‘These results show that we were right. We don’t want to be. ‘What we want are the annual allowances and tapering annual allowances scrapped so we can get on with caring for patients. High interest rates on loan schemes lead many doctors to consider the possibility of re-mortgaging or selling our homes.’ For BMA GPs committee chair Richard Vautrey, it’s a ‘shambolic situation’ when primary care is already under unprecedented pressure. ‘These results show the extent to which GPs are being forced to reduce their hours or indeed leave the profession altogether because of pension taxes,’ he said. ‘With patient lists growing and the numbers of GPs falling, swift and decisive action is needed from the Government to end this shambolic situation and to limit the damage that a punitive pensions taxation system is inflicting on doctors, their patients and across the NHS as a whole.’ The overall numbers show just how unsustainable the situation is, but the issue becomes even more vividly real when you hear about the problems that individual doctors have faced. In this issue of The Doctor we tell the story of three of them. One has had bailiffs at the door, another is strongly committed to working extra hours to bring down waiting lists but is being financially punished for doing so. It has to change.

Not a job for the GMC While far older in its origins, the aphorism concerning the road to hell being paved with good intentions, is often an all too apt analogy for politicians’ approach to NHS policy. Last month saw the Department of Health and Social Care announce that it was handing regulation of PAs (physician associates) and anaesthesia associates to the GMC. While they, like any other healthcare professionals, need regulating, the risk is that making them the GMC’s responsibility will actually exacerbate GMC

briefing

HARWOOD: The survey results ‘show we were right. We don’t want to be’

another problem – the blurring in the public’s mind over doctors and PAs’ roles and responsibilities. The introduction of PAs into the health service could certainly be described as a good intention; one designed to complement rather than compete or conflict with existing workforce structures. While not possessing a medical degree, the majority of PAs are biomedical science graduates while

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some are drawn from allied health roles such as nursing. As such they perform a number of supporting roles within clinical settings, from taking medical histories and performing examinations to analysing test results and assisting with diagnoses. With the ever-increasing demand facing the NHS coupled with the shortage of staff, PAs can play a welcome and vital role in lightening the day-to-day workloads of doctors. With safety and the confidence of patients in the health service paramount, a long-standing concern around the PA role was that it was not subject to statutory regulation, clinical governance or supervision. The Government has tried to solve this problem, but why does it have to be the GMC who regulates them? The GMC itself has tried to be reassuring – insisting that doctors should not pay for the extra cost, and that medical education will not be compromised. But it seems to needlessly institutionalise the existing misapprehension that doctors and PAs are of the same profession. Placing PAs under the same regulator as doctors does little to provide such clarity. BMA council chair Chaand Nagpaul said that, while the association had long called for the regulation of PAs, it was ‘fundamentally opposed’ to the GMC carrying it out. ‘Given the significant scope of work the GMC currently undertakes in overseeing doctors’ medical education and training, setting professional standards, and acting on concerns, it is vital it should not be diverted from its efforts in this regard. ‘We remain steadfast in our belief that public interest is best served by the continued regulation of doctors through a separate medical regulator.’

Keep in touch with the BMA online at

High-tech rhetoric can’t mask the cuts ‘Artificial intelligence’ is key to publichealth prevention going boldly into the 2020s. So says the Department of Health bumf for Advancing our health: prevention in the 2020s – its green paper on prevention. ‘New technologies such as genomics and artificial intelligence will help us create a new prevention model that means the NHS will be there for people even before they are born,’ it says. Our tech-savvy health secretary Matt Hancock envisages an NHS of ‘smart devices’ and a ‘new wave of intelligent public health’ when ‘many more health interventions are personalised’. Some sort of intelligence in the national public health policy of Government is much needed. It has dwindled, recently, as has the budget, with councils responding by closing basic, effective services, such as smoking cessation. There’s never been much political capital in local government to help the poorest escape the addiction of Britain’s biggest killers. Pledges to fill potholes and collect bins are better at winning councillors seats, so they say. It’s why national policy is important, of course. Sadly, the intelligence in the prevention green paper is more rhetoric than reality in many parts. For instance, its apparently bold (though old) pledge that smokers in hospital are ‘offered support to stop smoking’ without extra funding to re-open support services whose doors have been closed by budget cuts. Offering advice at a time when people are more likely to accept it is, of course, pretty smart, if basic medicine. Offering it to people when services are closed and budgets fall? Not so much.

instagram.com/thebma

KUMAR: ‘The Government must reverse cuts and invest in services’

BMA board of science chair Professor Dame Parveen Kumar welcomed the long-awaited green paper and its commitment to ‘work to reduce childhood obesity’. ‘The green paper has been introduced at the same time as public health funding is being repeatedly cut. In order to truly prioritise prevention, the Government must reverse these cuts and invest in services,’ she said.

Read more online Break-time victory for junior doctors Consultant’s bid for compensation continues Doctors’ hard work ‘not recognised nor rewarded’ BMA launches pensions modeller Doctors urged to lead change Read all the latest stories online at bma.org.uk/news

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FACE TO FACE: Dr Spencer in his consultation room

Primary goals For GPs facing a spiralling workload, it is hoped primary care networks in England will help tackle long-standing, systemic problems. Peter Blackburn meets early adopters of the principles behind them

‘I

t’s the end of the working day and my brain was absolutely frazzled,’ GP Mark Spencer recalls, reflecting on his working life before he and colleagues took matters into their own hands. ‘Many clinicians will look back on their 30, 40 or 50 patient contacts and wonder: have I made a difference – a real difference – to any of these people? How can I make a difference in 10 minutes when their needs are so complex? It feels like I might have just as well not been here – I’ve done nothing for nobody.’

Those questions, asked after another 10- or 11-hour shift, will be grimly familiar to many across the profession. A spiralling workload, with increasingly complex patients in a resource-poor environment is an equation that is only likely to lead to dissatisfaction and burnout. There have been efforts to rebalance this equation before. But most have been clumsily forced from the top down and without the resource or clinical engagement to make them worth more than just the latest empty words in another NHS plan for the future destined for the shredder. It is into this thorny world that PCNs (primary care networks) arrive in England, with remarkably lofty aims: to put doctors in charge of the local design of care, kick-start population health in local areas, and tackle the longstanding systemic problems crippling primary care. PCNs are groups of GP practices, usually covering between 30,000 and

50,000 patients, which will collaborate to deliver services in a more integrated way, while also allowing GPs to retain independent contractor status. GP practices will hold the PCN contract and be the ‘core members’ of the network but may ultimately invite other organisations to join, in a bid to bring local mental health, community and social services together. Each network will be given extra funding for this, as well as money to extend access hours for patients. The deal includes PCNs being reimbursed for hiring a clinical pharmacist and social prescriber – and will next year pay for the additional roles of first contact physiotherapists, physician associates, and primary care paramedics, with PCNs deciding which roles to recruit based on their population needs.

GPs centre stage Fundamentally, the ideas behind the move seem sound: GPs know their

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ACOUSTIC CLUB: Marine Hall in Fleetwood where the community meets to sing

localities and patients best – so why not put them at the heart of planning the care they need, while also working at a scale where they may be better able to afford and accommodate staff and services for their population. And while the networks aspire to improve care for patients, they are also intended, first and foremost, as at least part of a solution to the continuing systemic problems in primary care. Recruitment and retention difficulties largely stem from unsustainable workload and inflexible working arrangements – PCNs, which are promised cash for multidisciplinary teams who can take unnecessary workload from GPs, and may be able to offer more flexible working arrangements across a wider area – could be an answer to some of those issues. Perhaps most crucially of all, these changes aren’t being forced upon GPs. The BMA has been at the table, as part of negotiations around

the NHS Long-Term Plan and new GP contract, and is helping to drive the process. ‘We are leading this change,’ BMA GPs committee executive member Krishna Kasaraneni says. ‘This is not something that has been done to us, it’s something collaborative to try and support general practice. ‘The way we look at PCNs is as an umbrella and support for practices so they can ‘It’s work together on things something they need to do together collaborative while maintaining their independence. We have to to try and start looking at things where support we can say what is right for general the patient, how can we practice’ support GPs to deliver that seamless patient journey while also managing workload issues.’ Dr Kasaraneni adds: ‘It’s a five- to 10-year plan with fixed investment for five years. It will rely on many things working in our favour – recruiting the workforce, people getting behind the ethos, and taking small steps rather than giant leaps so the

whole thing doesn’t fall over.’ So where have PCNs come from? Schemes with similar aims have been running around the country for some years as pilots, and, anecdotally, have helped tackle some of the issues GPs face. These are models which seek to link staff from general practice, other NHS services, and the social and voluntary sectors. One was set up in Durham Dales, Easington and Sedgefield. Rajiv Mansingh, GP at the Marlborough Surgery in Durham, says community services contracts have been reprocured to be aligned to the geography of each scheme and community nursing had returned to GP practices. Dr Mansingh says: ‘Many key long-term-plan initiatives are already under way, including a proactive population health management approach, rapid community response teams to keep people out of hospital, expanded neighbourhood multidisciplinary teams, social thedoctor  |  August 2019  07

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Beach huts in Fleetwood

prescribing and joint working with community pharmacy.’ The models became PCNs and now employ social prescribing link workers, an enhanced clinical pharmacist service and a ‘first contact’ physiotherapy role commissioned by the local acute trust and placed within the networks. In Fleetwood, Lancashire, Dr Spencer and colleagues have also been on their journey to integration for several years, having been an early adopter of the PCN idea. The seaside town, once famed for its fishing industry, now has significant health inequalities, poor health outcomes and a much higher than average prevalence of all major long-term conditions, with high rates of mental health issues like depression and anxiety. With workload, and complexity, spiralling, general practice also faced a

workload crisis. Just five years ago, only eight GPs were doing the work of 16 in the town and collaboration between the three GP practices seemed the only option to stave off the ‘genuine risk’ of collapse of services in the area. ‘We really did have that burning platform people talk about,’ Dr Spencer says. ‘And despite the best efforts of the NHS, the health of the town by any measure was getting worse and the patient ‘The system need becoming ever more itself won’t complex.’ Dr Spencer adds: ‘It make PCNs required us to think differently work – it and we chose voluntarily has to be the guys on to work in a very integrated the ground way, not only across three practices but also with all the doing it’ other healthcare providers in the town – community nursing, therapy, mental health services and drugs and alcohol providers.’ The PCN, called Healthier Fleetwood, has since become something of a model for others to follow. Here, doctors decided to address the systemic issues WELLBEING WORKOUT: in general practice and the Fleetwood health of their population residents at the same time – looking perform at their singing club to make general practice

a feasible workplace as well as developing a ‘social movement around building hope’ in the town, a place where ‘there has been a lack of hope and optimism for decades’. The GP practices employed multidisciplinary teams including paramedics, clinical pharmacists and mental health nurses, all of whom were integrated not just into services but also into the KASARANENI: ‘PCNs are an umbrella and a support for practices’

physical buildings housing general practice. The PCN also adopted a medicine management hub. On top of that local residents were assembled to form a committee with access to funding for patients to set up groups, run activities and pilot schemes which could benefit the area – tackling problems such as isolation and obesity. The projects are created by the community, sanctioned by the community and provided by the community. A team of staff are on hand to help set up table tennis and singing clubs. The good news? Anecdotally, many patients are getting better. They are more connected, happier and healthier.

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Culture change While the intentions – and possible results – seem positive, there will clearly be difficulties and obstacles along the way, particularly for practices not used to working together. ‘It’s a big culture change and there will be times when practices fall out with PCNs,’ says Nottinghamshire local medical committee chief executive Michael Wright. ‘The biggest thing during these early days has been the expectation of 100 per cent of patients having extended access. ‘That’s been a big difficulty for us – some practices have not done that for years so need their PCN to have a way of delivering it in their name. It’s the first of many tests.’ Mr Wright also says PCNs attract a whole new wave of

MATTHEW WRIGHT

The bad news? The unmet need in the community – an area which has suffered deeply from underfunding and the collapse of industry – swallows up much of the time and breathing space generated by the proactive work of the PCN. More innovation, and more resource, will be needed. Dr Spencer says: ‘I am optimistic about the future of general practice – I firmly believe that if a PCN is set up in the right way and it does involve every single health and social care professional in that community and neighbourhood, and residents are equal partners and do have control, I am really hopeful that this model is heaps better than the model that we’ve had which is no longer fit for purpose.’

younger GP leaders and that those staff would need access to continuing leadership and organisational development, as well as suggesting LMCs around the country would have to be on hand to ‘broker’ things wherever surgeries, which have not traditionally been part of local alliances or collaborative work, feel isolated. Despite the obstacles, Mr Wright, whose LMC has been encouraging collaboration through a project called Phoenix in the East Midlands for some time, is optimistic about the future. ‘I can see where this could go,’ he says. ‘The system itself won’t make PCNs work ‘I am really – it has to be the guys on the hopeful that ground doing it – but the LMC this model is feels this is the way forward.’ Speaking at a King’s Fund heaps better conference on PCNs in July, than the model that NHS England’s acting director for primary care provider we’ve had’ transformation Ned Naylor was coy about whether the funding would be forthcoming, despite hailing PCNs as a ‘bold vision’. He said: ‘It’s a bit of a case of wait and see… watch this space.’ The issue – unanimously, it seems, agreed upon – is that HARMONIOUS: Mr Wright (above). Dr Spencer (right) takes part in the local choir group

PCNs are given time. Time to make mistakes, time to build relationships and time to grow. These changes cannot be forced through in a year and then ripped up if they don’t bring instant results. GP leaders are committed to making PCNs work and want feedback. Dr Kasaraneni says: ‘This level of investment and commitment from NHS England has been very welcome – it won’t solve all the problems but it’s a muchneeded investment and a real commitment to support general practice. ‘We will try our best to make it work but we need the profession to tell us when it’s not working so we can fix things and try and make it work better.’ Ultimately, the ambition has to be that when GPs such as Dr Spencer reflect at the end of the day, the question is, ‘how many people have I helped?’ As Dr Spencer says: ‘In this new world we have the ability to actually make a difference. And general practice can become an attractive place to work again.’  bma.org.uk/pcns thedoctor  |  August 2019  09

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Need ess waste of life Lies spread through social media have helped demonise one of the safest and most effective interventions in the history of medicine. So how can we vaccinate against the disease of conspiracy theories and fake news? Tim Tonkin reports

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‘T

he world and its peoples have won freedom from smallpox… collective actions have freed mankind of this ancient scourge and, in so doing, have demonstrated how nations working together in a common cause may further human progress.’ These triumphant words formed the WHO’s (World Health Organisation) 1980 declaration proclaiming the eradication of smallpox – a virus responsible for the deaths of hundreds of millions of people throughout history, following a 20year global public-health campaign. During the last two centuries, vaccination has proved itself as one of the most cost-effective methods for disease prevention. According to WHO it now

helps to prevent up to three million deaths a year around the world. Yet, much like the fall of the Berlin Wall was once prematurely cited as the permanent triumph of liberal democracy over totalitarianism, the end of smallpox did not spell the end of scepticism and opposition to vaccination.

‘Vaccine hesitancy is one of the top 10 global health threats’ The phenomenon of ‘vaccine hesitancy’ is defined by WHO as the ‘delay in acceptance or refusal of vaccines’ despite the availability of such services. Those who stoke such sentiments are commonly described as ‘anti-vaxxers’. As such, WHO has listed

vaccine hesitancy alongside antimicrobial resistance and climate change as one of the top 10 global health threats of 2019, warning that such beliefs have contributed to a 30 per cent increase in measles cases globally. The Wellcome Trust’s Global Health Monitor for 2018 meanwhile found that while 79 per cent of people globally strongly or somewhat agreed that vaccines are safe, 7 per cent strongly or somewhat disagreed, with 11 per cent indifferent and 3 per cent unsure. The trust also identified that scepticism in vaccination has been creeping upwards in recent years in developed and developing countries. In France, for example, one in three people disagree that vaccines are safe. thedoctor |  August 2019  11

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MEASLES: Increases in cases linked to fall in confidence in vaccines

WAKEFIELD: Falsely linked MMR vaccine (left) to autism

PA

Not coincidentally perhaps, France has recently seen a 462 per cent increase in the number of measles cases, rising from 518 in 2017 to 2,913 last year.

‘I have called in the social media companies to require that they do more to take down lies’ Public misinformation It is not a new phenomenon. Discredited research by Andrew Wakefield, falsely linking the MMR vaccine to autism, was associated with a fall in take-up of that vaccine after its publication in 1998. But while the years that followed saw a gradual recovery in public trust, the huge proliferation of antivaxxer activity on social media in recent years has led to a renewed, sustained, and stronger threat to public health. Speaking at the Nuffield

Trust summit in March, NHS England chief executive Simon Stevens read out a message, apparently posted by another parent to a WhatsApp group for his children’s school, to illustrate the type of anti-vax rhetoric he himself had encountered. ‘My kids aren’t vulnerable, and I think loading up on vaccines blocks their system from fighting disease as it should do,’ he paraphrased. Mr Stevens went on to label anti-vaxxers as another part of the ‘fake news movement’ that appeared to be gaining traction. Figures published by NHS Digital on childhood vaccination rates in England for 2017-18 showed a decline in coverage for threequarters of the 12 vaccines routinely provided, compared to 2016-17. MMR vaccine coverage in children aged one stood at

91.2 per cent in 2017-18 – the lowest rate since 2011-12 and well below the 95 per cent recommended for conferring herd immunity. Health and social care secretary Matt Hancock has publicly stated his growing concern with the spread of anti-vaccination messages online, to the extent that he has more than once raised the idea of compulsory vaccination, while qualifying that such a move is not something he wants or feels is yet necessary. ‘I have called in the social media companies… to require that they do more to take down lies that are promoted on social media about the impact of vaccination,’ he said in April. ‘Vaccination is safe and is very, very important for everybody’s health.’ The significance of social media in amplifying false concerns has become

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MATTHEW SAYWELL

TURNER: ‘The anti-vax ideas are creeping up again’

PA

TRUMP: Backtracked on advising parents to avoid vaccines

‘If you just dismiss their beliefs out of hand then you’re not going to get very far in persuading them’

FERTILE GROUND: Anti-vaxxers have found social media useful to spread their beliefs

apparent to David Turner, a GP in Hertfordshire. While the number of patients expressing concerns seemed to have peaked following the Wakefield case, and then were falling away, he says they have been reignited in recent years. ‘I would say that [anti-vax ideas] are creeping up again. It had gone away but it’s come back again with people using things like Twitter and Facebook where damaging messages are being spread. ‘A lot of people ask for separate vaccines rather than the combined MMR, which is not something we do on the NHS. They might then decide to go via a private clinic, which can lead to a delay and put children at risk during the interim period.’ He says that, while there is no specific training on how to handle a discussion on vaccines with a hesitant patient, having good general communication skills and judgement often makes all the difference in addressing concerns. ‘I think it’s really first of all about finding out where a patient has been getting their information from and why they believe it,’ he says.

‘If you just dismiss their beliefs out of hand then you’re not going to get very far in persuading them. It’s about listening to them and then gently challenging those ideas by giving them the facts.’ Dr Turner says that explaining the importance of herd immunity and the fact that not being vaccinated could put others as well as oneself at risk, is also a persuasive approach. He adds, however, that trying to talk round those trenchantly opposed to vaccination is generally a pointless exercise. Certainly, a cursory glance at anti-vax online groups and message boards quickly reveals that there is no such thing as a casual or parttime anti-vaxxer. Discussion threads reveal that many contributors have invested considerable amounts of time in accumulating vast amounts of information to buttress their positions. This information ranges from genuine yet highly selective facts cherry-picked from scientific papers, to blatant pseudo-scientific falsehoods, around the science of vaccination and the supposed consequences.

Bizarre echo chamber Anecdotes shared by parents on one public group give some insight into the views and attitudes that can propagate within an online echo chamber. One contributor cites how their son was ‘vaccine injured and had autism’ adding that thanks to treatment he was ‘cured’ of the latter. Another said that the MMR vaccine had led to her son developing Type 1 diabetes, while another parent expressed concerns about the risk of her child being exposed to ‘viral shedding’ from vaccinated children. It also seems that if you believe one conspiracy theory, you may well believe them all. Many of the anti-vaxxers online also express views about the veracity of the moon landings, for example. US president Donald Trump, a proponent of the absurd and offensive notion that his predecessor Barack Obama had lied about his place of birth, was also once an anti-vaxxer. In March 2014, he tweeted: ‘Healthy young child goes to doctor, gets pumped with massive shot of many vaccines, doesn’t feel good thedoctor |  August 2019  13

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MATTHEW SAYWELL

LARSON: The internet has proved a game changer for vaccine sceptics

and changes – AUTISM. Many such cases!’ He has since, apparently, changed his view, urging parents to get their children vaccinated amid a serious measles outbreak. Heidi Larson is director of the Vaccine Confidence Project at the London School of Hygiene and Tropical Medicine, having previously headed up UNICEF’s global immunisation communication.

‘We need a more proactive effort to contain the negative information but also to be in the same social media space’ She says that while vaccine questioning and alternative beliefs are not in themselves new, the role of the internet has been a game changer. ‘In my view the waves of anti-vaccine sentiment have been a tipping-point phenomenon in the sense that we’ve primarily had a lot of these other infrastructure and access [to vaccination services] issues but this is on top of all those other issues,’ she says. ‘The questioning of vaccines is not new but in the context of social media it is

amplified quite a bit. ‘We do see from our 67-country study into vaccine hesitancy that Europe featured as the most sceptical region in the world [and] the countries that we picked up as being the most sceptical absolutely correlated with the worst measles outbreaks that were seen a couple of years after [the study]. ‘We can’t pretend that it’s not having an impact.’ Professor Larson is keen to stress that declining vaccination rates cannot solely be explained by online anti-vaccine material, pointing to other factors such as underfunding and lack of access to public health services. She adds that while efforts to do more to tackle false information online is important, the medical establishment also needs to up its own game in how it communicates with – and listens to – the public about vaccination. ‘The problem is the tendency that we push out, as a medical and public health community, the information that we think is important, but it’s not necessarily what

people are asking and that disconnect has really been a problem. ‘The reality is that some of the questions that the public are asking are not the sort of things that doctors and healthcare professionals will necessarily have at their fingertips. ‘I don’t say that with any criticism of the doctors. The public is coming up with questions that are well beyond any medical curriculum, really probing on things like ingredients in vaccines. ‘We do need a more proactive effort to contain the negative information but also to be in that same social media space with better and more accessible information that is responding to people’s questions.’

Public health cuts Other doctors agree that the proliferation of conspiracy theories about vaccines is not the only reason for falling take-up rates. BMA public health committee chair Peter English points to the ‘huge cutbacks’ in health-visitor services, meaning parents receive fewer reminders about vaccination and less follow-up when they miss appointments. A report published by the CD Howe Institute in Canada identifies factors such as parents who face difficulty in getting time off to enable their children to attend health centres and a general sense of complacency as being significant factors. Some would argue that you reach a point with public health arguments where you can have all the reasoned

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SOURCE: The Wellcome Trust’s Global Health Monitor

France has seen a 462 per cent increase in the number of measles cases, from 518 in 2017 to 2,913 last year

518 2017

2,913 2018

‘I hold Andrew Wakefield, and those anti-vaxxers who have turned him into some kind of tragic hero, personally responsible for harm to young people’

ACRES: Her mother questioned whether to get her vaccinated

discussions in the world but it’s still not enough, and that’s where the law comes in. The compulsory wearing of seatbelts is often cited. But there are two considerations as soon as something is legally mandated or banned – unintended consequences, and whether society is willing to follow through on enforcing the law. Dr English says: ‘The problem is, would it improve uptake or not? Are we seriously going to arrest people or force children to be vaccinated against their

parents’ wishes? I can’t see that being feasible. ‘There’s a serious concern that if you made it compulsory, people who would otherwise have had their children vaccinated won’t do so because they don’t like being told that they must.’ In the absence of compulsion, then, this is a battle of information. It’s a battle that doctors took to the high-tech giants at the BMA annual representative meeting in June. They urged the BMA to lobby the Government to compel social-media corporations to prevent the dispersal of false or misleading information on the effects of vaccination.

Needless setbacks Midlands foundation doctor 2 Rebecca Acres was one of those who spoke in favour of taking action. She said her own mother had struggled with whether to get her vaccinated because of the information she was hearing about the false links made between MMR and autism. ‘Since then, my extended family have experienced a diagnosis of autism in a relative vaccinated with separate measles, mumps

and rubella vaccinations at high profit to a private service,’ Dr Acres said. ‘That relative is a brilliant, bright person integral to our family lives and their autism is not worse than the risk of death from measles.’ She added: ‘I hold Andrew Wakefield, and those anti-vaxxers who have turned him into some kind of tragic hero, personally responsible for significant harm to young people like me, my family and the students and youth in my church community.’ Almost 40 years on from the global eradication of smallpox, the next big victory: the eradication of polio is tantalisingly close, with the virus now endemic to only three countries. And yet what should be remembered as an era of successfully tackling terrible diseases may be as much remembered for one of needless setbacks. Pseudo-science, fake news and conspiracy theories are diseases in themselves. If only there was a simple vaccination to prevent them. It will be a battle that every doctor will need to fight.  thedoctor |  August 2019  15

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Paying to work The NHS pensions crisis continues to affect doctors and health services across the UK, leading to rising waiting lists and hefty – unexpected – tax bills for individuals. Some doctors have had to essentially ‘borrow’ money back from their pensions through the ‘Scheme Pays’ system (which they have

to pay back with significant interest) Even doctors who have not been affected yet have been taking the difficult decision to cut their hours or refuse to do extra shifts or take on responsibilities such as national roles, in case it pushes them over the annual limit.

As the BMA continues to fight for a more just system, Jennifer Trueland hears from three doctors about what the pensions crisis has meant for them – including one consultant whose clinical excellence award will cost him many times its value, and another who has been pursued by bailiffs.

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BODY: CEA award will become a drain on his finances

Manchester University NHS Foundation Trust

JULIAN BROWN

Rewarded with a tax bill for his efforts

‘I knew there would be a tax cost but didn’t imagine that it would cost more than the actual value of the award’

Rick Body has won a CEA (clinical excellence award), in part for developing a decision-aid for diagnosing heart attacks that could save the NHS £100m a year. Unfortunately, he is now likely to be hit with a tax bill costing almost twice as much as the £36,000 salary boost from the CEA. What is more, if he uses Scheme Pays to pay the huge bill – which could be in the region of £60,000 to £70,000 – because he is relatively young at 41, he fears that paying it back with interest could cost him £250,000 over the course of his career. Professor Body, who is a consultant in emergency medicine at Manchester University NHS Foundation Trust, and professor of emergency medicine at the University of Manchester, applied for the award last year. ‘It was quite late in the tax year that I found out I’d got it, which meant I didn’t really have a lot of time to work out the tax implications,’ says Professor Body. ‘I knew there would be a tax cost but didn’t imagine that it would cost

more than the actual value of the award. ‘But when I saw an accountant she calculated that it could be as much as £68,000 – she just said it quickly then moved on. I said: “Hold on a minute, just explain that again,” and she told me not to worry, but frankly I am worried.’ The bill came at a particularly bad time for Professor Body, who is married with two young children, as – partly on the basis of the increased salary from the award – they had remortgaged to extend the family home. ‘I don’t mind paying tax. Consultants are paid well. But this is absolutely crazy. It’s not just this year either. Over the next few years the award will also mean a net drain on my finances, and I’ve worked out that with an interest rate of 4.8 per cent, that I’ll end up paying back £250,000 over a lifetime. It’s distasteful,’ he says. If he could go back in time, Professor Body would not have applied for the CEA which, as is the nature of these things, was granted for

‘performing over and above the standard expected’ of his role. The particularly compelling element in his application was his work in developing and implementing an algorithm to rule in or rule out acute myocardial infarction with a simple blood test, the results being available within an hour. ‘It means that nearly half of patients [with suspected heart attacks] can go back home after one blood test rather than being admitted to hospital,’ he says. This test has already been implemented in his own hospital and is being rolled out to others in the Manchester area. Economic modelling has suggested it could save the NHS £100m per year if implemented across England. As for Professor Body, his delight in receiving the award has been more than tempered by the likelihood of a large tax bill. ‘I asked if I could give it back, but once it’s there in your pensionable salary you can’t withdraw it,’ he says. thedoctor  |  August 2019  17

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HMRC building in London

KAR: ‘If this can happen to me it can happen to anybody’

RICHARD H SMITH

Bailiff threat to sell doctor’s belongings Portsmouth consultant Partha Kar, who is also associate national clinical director for diabetes with NHS England, has faced months of stress even after trying to pay an unexpected tax bill of almost £30,000 – including repeated visits to his home by bailiffs threatening to seize and auction his possessions.

‘I kept getting letters from the HMRC demanding payment’ ‘When a tax bill landed – for around £29,000 – I didn’t understand why it was so high, but my way of looking at these things is that whether it’s right or wrong, it is what it is and you deal with it. ‘Obviously, I didn’t have that sort of money sitting around so I arranged to take it out of my pension pot. I spoke to NHS Pensions and they assured me it was all done but I kept getting letters from HMRC demanding payment.

Every single letter I got, I contacted NHS Pensions and HMRC and they confirmed there wasn’t a problem. But the letters kept coming.’ Then one day came a knock at the door – it was a bailiff giving notice that his goods would be auctioned if he did not pay the bill. Again he contacted NHS Pensions, only to be told that his payment to HMRC was ‘in a queue’. He requested – and received – a letter from them confirming that the payment was in the system, but even that hasn’t stopped the continued harassment, including a further bailiff visit. The bill has risen with each letter (the last one added a £750 charge) and now he has been threatened with interest charges of 7.5 per cent. Asked how it felt to have the bailiffs visit his home (on one occasion the door was answered by his 17-year-old daughter, and he also has a

13-year-old son), Dr Kar is remarkably calm. ‘By nature, I’m quite relaxed,’ he says. ‘We joked about it a bit as a family – I said I would auction the kids but not the dogs. But seriously I’ve been a bit gobsmacked by everything that’s been happening. ‘There are two issues here – there’s the fairness of the tax changes but I don’t think that’s for me to judge. What really matters is what comes next after you’ve agreed to pay it.’ Although he has (yet again) been reassured that all is under control, he has no confidence that the issue has been solved and warns that he cannot be the only one stuck between HMRC and NHS Pensions. ‘I have a national profile – I have a big NHS England role. If this can happen to me it can happen to everybody. It’s the system that’s wrong – and it is starting to irk me a bit.’

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Penalised for tackling waiting lists ‘As someone who has worked and trained in the NHS since 1995 I feel completely torn’

HUGE DEMANDS: Doctors may be forced to reduce commitments in an already pressured specialty

Sarah Tennant admits that she has mixed feelings about her decision not to take on extra work to help cut waiting lists. As a consultant radiologist specialising in breast imaging, she is only too aware of the shortage of radiologists and of the importance of getting images ready in a timely manner. But the Nottinghambased specialist is already working a 48-hour week – 12 programmed activities – and in addition, she knows that working overtime could well lead to a tax bill far in excess of any extra money she would gain. She wouldn’t be working for nothing – she would be paying to work. ‘Our specialty is extremely busy and we see lots and lots of women every week. There’s a huge demand and units up and down the country have been running waiting-times initiatives to try to keep up.

‘As someone who has worked and trained in the NHS since 1995 I feel completely torn. People are obviously worried about it but you can’t do all the work yourself in any case – you can only do what you’re able to do safely.’ She first became aware of the issue in 2017 when she found out she had breached the annual allowance. This wasn’t a big problem because at that point she was able to take steps to mitigate it by carrying forward the allowance. She also educated herself about the implications – and decided, reluctantly, that she could no longer take on additional shifts. The complexity of the calculations and the general lack of awareness of the issue meant that she was the one who actually flagged it up to her accountant and independent financial adviser. She has also made it her mission to spread the word

with colleagues and on social media. She is, however, concerned that people might feel panicked into refusing extra work because they fear they will cross the taper threshold, or will leave the NHS scheme when it is not actually in their best interests to do so. Dr Tennant believes the solution is to scrap the taper, but adds that the situation has highlighted how short-staffed the NHS is. She is also aware of the risks of raising the issue, particularly in the public domain. ‘It’s difficult to express what the issue is without sounding greedy or entitled or spoilt,’ she says. ‘But I don’t think any of my colleagues mind paying tax. We work in the public sector and are very happy to pay our taxes and support our hospitals. But we can’t be held personally responsible for the state of the NHS when it’s costing us money to go to work.’

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TERRIBLE LOSS: Alastair Watt and his wife Ruth

I The pressure to cope Alastair Watt’s death raised serious questions about how the NHS looks after it doctors when they return to work after illness. Robert Wrate (pictured opposite) finds parallels with his own research into an NHS culture where doctors soldier on in all circumstances, even though the service is not resourced to meet demand

read with dismay the circumstances of Alastair Watt’s death, sharing the sadness that all must have felt who were familiar with his circumstances. Notwithstanding that in Dr Watt’s case, psychobiosocial factors were involved, the article in the May issue of The Doctor entitled The hard road back highlights a striking difference from acute medical care: the apparent absence of any sustained application of well-coordinated skills to drive through a resolution of his escalating difficulties. Anxiety was a prominent theme throughout descriptions of him; before his head injury, anxiety about his workload as a sole consultant in an under-staffed service and then on his return to work. Previously accustomed to managing clinical uncertainty, he became engulfed by uncertainty arising about his place at work; his anxiety became intolerable. Managing uncertainty is an important task within

many professions; for those in medical practice, frequent clinical uncertainty ‘comes with the territory’. Their training involves the progressive acquisition of clinical skills to explore complexity, where maintaining curiosity requires becoming unafraid of uncertainty.

Adverse culture Drawing on his war-time experience, the psychoanalyst Donald Winnicott likened this to developing the capacity to ‘think clearly under fire’, not rushing to judgement. His observation was intended to apply to complex clinical scenarios, not on how to manage when feeling under fire on return to work. Dr Watt’s first occupational health consultant appeared to recognise the distinction but this may become lost inside large employers, and clear sight of the needs of vulnerable employees lost. Accounts of unacceptably poor mental healthcare are sadly only too common, including the likely role of

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BMA wellbeing support services: 0330 123 1245

‘Accounts of unacceptably poor mental healthcare are sadly only too common’

stigma but, as Dr Watt’s wife Ruth highlighted, the culture of the NHS plays an important role, a culture which adversely affects vulnerable employees. It’s a culture of which we are all a part, and the lessons are for everyone. Almost from inception the NHS has accumulated idyllic myths, not just the principle of freely available healthcare for all but that clinical care depends on human contact, including that patients feel ‘cared for’ by staff who are appropriately skilled and well supported... and that all this is sustainable despite increasing evidence of inadequately staffed services. From Edinburgh, funded by the NHS Management Executive in London, a prospective national study of doctors was undertaken that seemed to indicate that doctors themselves, if not always buying into these myths, nonetheless place excessive reliance on being seen to ‘cope’ with such expectations. This is not just on return from sickness absence but as each young doctor sought a place in the NHS that personally fitted them, which later adverse life events and ill health episodes can disrupt. The health behaviours and wellbeing of this cohort, who were first recruited in 1986 on entry to a Scottish medical school, have been reported elsewhere. Since qualifying, the doctors responded to five further waves of assessment, by interview or post, most recently in 2002-03. To explore what may underlie the cohort’s selfreported health behaviours,

which had been observed to be excessively stoical in 1993 and were still marked in 200203, 38 subjects were selected, by stratified random sampling, for further interview from those still working in the NHS. Analysis of the 38 interview transcripts, by grounded theory, identified eight common themes. These were: professional learning; coping; health; personal learning; relationships with consultants; research; work-life balance; and gender. We then proposed two constructs that underpinned these themes. All the main findings from the 38 interviews, including these two propositions, were then validated through responses to an open-ended questionnaire posted to the full cohort. The first of the two constructs had concerned ‘fit’, the rather hit-and-miss process by which most respondents found their place in medicine, and the place of medicine in their lives. The second concerned ‘language’ – how individuals articulated their experience of their workplaces, which was related to participants’ concerns with coping, and fears of being regarded as acopic. Irrespective of whether or not they had experienced ill health, or were vulnerable to it, or were particularly resilient across the decades since medical school entry, we discovered that fears of being seen as acopic were widely held. Those with ill health maintained excessive stoicism (by reporting more days at work still unwell) but the

most resilient doctors had become less inappropriately stoical. Nevertheless, they were equally likely to fear being seen as acopic. Even the acquisition of a clinical skill set (the sample included some prodigiously successful academics) was clearly offering little protection. A crowded curriculum, competitive career environment, and cultural beliefs in medicine may all have added to the absence of effective training in managing workplace uncertainty.

Coping unwell As UK medicine is embedded in the NHS, doctors’ fears may be exacerbated by holding on to idyllic myths about the NHS – that irrespective of adversity, ‘doctors cope’, whatever their personal uncertainty in the workplace. In some the underlying anxiety might be debilitating, a few may feel catastrophically unsafe. More effective training in managing workplace uncertainty might be one lesson from Keith Cooper’s article, either universally provided or targeted to specific need, allowing vulnerable individuals to feel safe. From my own experience, it was never safe to be single-handed in an under-staffed service. Another lesson might be an examination between politicians, the public, and health professionals on the core values and idyllic myths of the NHS, taking the long, hard road to agree on what is practically possible.  Robert Wrate is a retired consultant psychiatrist from Edinburgh thedoctor |  August 2019  21

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Unwelcome attention Overseas and BAME doctors are referred to the GMC in disproportionately high numbers. How do you make the system fairer, and keep those doctors who shouldn’t be there out of an intensely stressful process? Keith Cooper reports

‘Are there ways we can stop people entering the process who shouldn’t be there?’ The latest scholarly exposé of this apparent injustice, by respected academics Doyin Atewologun and Roger Kline, aims to be different. Published last month, Fair to Refer hopes to stop doctors getting caught up in unnecessary probes in the first place. Its focus is on employers, not regulators or inspectors. Hundreds of doctors and managers have been quizzed. And in line with a general move in the NHS, it calls for investigations, if necessary, to look for

lessons to be learned not people to be pilloried. ‘The priority should be to keep people out of the disciplinary process – not just to improve it,’ Dr Kline told The Doctor. ‘This is not the only thing to be done – but it can make the biggest difference. Are there ways we can stop people entering the process who shouldn’t be there?’ This focus on employers, of course, means the GMC, which wrote the research remit, has itself escaped scrutiny. Its previous ‘audits’, a spokesperson says, found ‘no evidence of bias’. The last one, in 2014, was two years after Hadiza Bawa-Garba, the doctor whose case prompted the study, was referred to it by her employer, the University Hospitals of Leicester. Some doctors remain unconvinced by the limited scope of the research. ‘We welcome the recommendations but it is a little disappointing that it appears to absolve the GMC of all responsibility,’ says BAPIO (British Association of Physicians of Indian Origin) chair JS Bamrah.

Professional induction Newly arrived, overseastrained doctors in one organisation are given a short supernumerary period with intensive mentoring and support. Each new arrival is assigned a ‘buddy’ from their specialty. The supernumerary period helps it assess their clinical skills and acquaint them with local practices and procedures. ‘It is unreasonable to expect someone to travel halfway across the world, land in a different social and clinical environment, social mores and language and not expect there to be challenges,’ the organisation’s clinical director says.

GOOD PRACTICE – Identified by researchers

T

he pressure on doctors accused of making mistakes can be huge, especially when managers, regulators, inspectors, and NHS England all investigate. That some get more attention than others – those trained overseas or from BAME (black, Asian and minority ethnic) backgrounds – has been a trend itself investigated, again and again, down the years.

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‘If the GMC is to change its own process, it needs help to do that too.’

GMC ‘not complacent’ GMC chief executive Charlie Massey tells The Doctor a new audit is imminent following advice from its BAME forum. BAPIO and the BMA are members. ‘I am not in the least being complacent about our own processes,’ Mr Massey adds. The researchers themselves are confident their findings will make a difference to doctors, as long as employers and NHS officials agree to their suggestions. ‘In order for things to shift in a sustainable way all of the key stakeholders need to be involved and mindfully so,’ say Dr Atewologun. So, what did it find and what does it recommend? First, they examined the high-level numbers. BAME doctors are referred to the GMC by their employers at double the rate of white doctors. Those trained overseas are 2.5 times more likely to be referred than UK graduates. On digging deeper, they

‘Groups that are disproportionately affected in referrals to the GMC are commonly perceived as lower-status’

found reasons to explain these disproportionate referral rates. For instance, locums and staff, associate specialist and specialty doctors, which have high BAME representation, are described as a ‘potentially exploited workforce’ in the report. SAS doctors felt treated as ‘nameless and faceless’ and ‘workhorses’, locums seen as a ‘commodity… almost traded between trusts’. While full-time employees were helped with errors, locums would be referred to the GMC. ‘What else can you do?’ one doctor asked the researchers. Another reason for disproportionate rates among overseas-trained GPs and those from BAME backgrounds is their prevalence in small or single-handed practices in down-at-heel areas, such as the inner cities, ex-mining communities and seaside towns. One spoke of their struggle to join ‘larger, white practices’. GPs in such tough environments are also subject to NHS England’s inspection regime, which includes

MASSEY: NHS officials must ‘up their game’ on GMC referrals

Social support Another organisation reliant on overseas doctors appointed a member of staff part-time to improve support. They meet them on arrival, help with accommodation, bank accounts, and connections with communities from their home country. ‘Doctors were bringing to work a whole range of worries which could distract them from a focus on induction and their new job,’ its responsible officer said.

GOOD PRACTICE

ATEWOLOGUN: All decision makers need to play a role

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KLINE: ‘The priority should be to keep people out of the disciplinary process – not just to improve it’

BAMRAH: The GMC appears to be absolved of all responsibility

a network of PAGs (performance advisory groups) at local level. There is ‘significant variation’ in the approach of PAGs in England, the researchers found. The Doctor has focused on the conduct of some of these PAGs in previous issues. One ‘perfectly healthy and capable’ 70-year-old GP, who was trained overseas, was subject to an ‘interrogation which was bullying in tone’ in one PAG meeting, they heard. His records were reviewed, the Care Quality Commission arrived. He was locked out of his premises. The pressure forced him to resign yet no fitness-to-practise allegations were levelled. ‘The NHS lost a good GP,’ the researchers heard. In light of these concerns, the report calls for a ‘review and report’ on all ‘processes for responding to concerns about doctors’, including PAGs, across all UK administrations. NHS England has refused to release data to the BMA on its performance investigations, despite numerous requests since late last year. The circumstances and situations 24

which led to disproportionate referrals left some doctors isolated, distanced from colleagues, and ‘othered’, Dr Atewologun says. ‘The demographics for these groups can be different; the fault lines might be different, too. But while the specifics of what makes someone an insider or outsider are different, the implications can be similar.’

This organisation depended on SAS doctors but without appropriate support or opportunities. The medical director supported adoption of the BMA’s SAS charter to improve their opportunities for training. SAS staff here were found to be significantly more ‘upbeat’ than in other organisations.

GOOD PRACTICE

The SAS charter

Racial hierarchy The fault lines in medicine, the research found, divide the profession along multiple lines: where you went to medical school, which country, region, and which type of university. There are hierarchies of race: Asian above black. ‘Many of the groups that are disproportionately affected in referrals to the GMC are commonly perceived as lower-status outsiders. ‘An Indian medical qualification is viewed as inferior to a European medical qualification, which is viewed as inferior to a UK qualification,’ one clinical director said. Using their analysis, the

NAGPAUL: ‘We need better recognition of systemic pressures in investigations’

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‘We cannot allow doctors working hard in incredibly tough conditions to continue practising in fear’ ‘We deliberately looked at trusts that we thought might be better than average and we found stuff that looks like it works,’ Dr Kline says. The GMC’s Mr Massey admits that the problem of disproportionate referrals has long been the ‘elephant in the room’ of medical regulation. The senior NHS officials he speaks to agree they must ‘up their game’, he says. He hopes to establish a ‘project board’ of ‘NHS leaders’ to oversee this and other recommendations from

the reports and recommendations sparked by doctors’ anger about how Dr Bawa-Garba was treated. The final one, into workplace stresses on medical students and doctors, is due in late September. BMA council chair Chaand Nagpaul welcomes the report and backs its calls for a fairer approach to regulation, a point he and the association has long called for. Last month, he launched Equality Matters, a broad programme to ‘embed a culture in which every member can flourish and achieve their best’, he told the BMA annual representative meeting in Belfast. ‘We cannot allow doctors working hard in incredibly tough conditions to continue practising in fear,’ he says of the report. ‘We need better inductions, more inclusive leadership, a recognition of systemic pressures in investigations, a review of NHS England’s performance management processes, and wholescale improvement to the entire culture of the health service – leaving behind the toxic environment of blame and instead focusing on support and learning.’

‘We cannot allow doctors to continue practising in fear’

BAWA-GARBA: Referred to the GMC by her employer in 2012

Early intervention for struggling GPs One clinical commissioning group has an early warning system which flags GP practices likely to suffer above-average pressure. It regularly compares sizes of patient lists and demand related to their demographics to pinpoint where extra support is necessary. ‘It is better to fix the car when the brakes need checking than after it’s crashed,’ is its mantra.

GOOD PRACTICE

researchers arrive at a series of recommendations and examples of good practice (see ‘good practice’ boxes on all pages), drawn from the dozen or so trusts they examined. Bespoke inductions and personal support for overseas-trained doctors, an early-warning system for GPs under pressure, and a commitment to the BMA’s SAS charter are among them.

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on the ground Highlighting practical help given to BMA members in difficulty

DATA RULING: Justin Nowell outside St George’s Hospital in London

A consultant says his reputation suffered after his name was released to the media by his employer. A ruling found that he should have been informed first. With the BMA’s help, he continues to push his trust to ‘take responsibility’ A surgeon’s name was released to the media without advance warning in a breach of data-protection rules, unfairly linking him to a troubled department in his trust. St George’s University Hospitals NHS Foundation Trust in London had its trainees removed by HEE (Health Education England) last year after what was reported in the media as a

dispute between clinicians and management. The trust was cited in the piece naming two surgeons as those who led the trainees’ supervision. One of the two, consultant cardiac surgeon Justin Nowell, contacted the BMA for help. BMA senior employment adviser Mark Briggs said: ‘The information… did nothing to avoid readers drawing a negative inference about

the connection between the consultants named and the problems which have sadly plagued the unit. ‘I was immediately concerned that personal information had been shared in a potentially damaging way without consent and sought to establish whether it was a breach of data-protection law.’ While the trust was entitled to respond publicly to HEE’s actions, the BMA could not

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see any good reason why doctors’ names were released in this context.

Lack of fairness The BMA took legal advice from law firm Gateley and concluded that there was a possible breach of the GDPR (General Data Protection Regulation), an EU-wide set of rules which came into force last year. Mr Briggs advised that Mr Nowell take out a grievance. Neither found this to be a satisfactory process. While the trust acknowledged to Mr Nowell that, ‘you should have been informed in advance of the decision to disclose your name to the media’, and apologised for that, it did not accept there

had been any breach of GDPR. Mr Nowell reported his concerns to the ICO (Information Commissioner’s Office). The ICO said St George’s had not complied with its data-protection obligations ‘because of a lack of fairness and transparency’. People have the right to know how their personal data is going to be used, said the ICO. While releasing the name and job title of a doctor was not an infringement in itself – the information already most likely being in the public domain – the trust should have given Mr Nowell a ‘privacy notice’ to tell him what it was going to do with his data. The ICO also said that the trust’s data protection and confidentiality policy had not been updated in the light of new legislation, and that there were gaps in policy documents. Mr Nowell said: ‘The original disclosure [by the trust] caused much distress to me and my family. My reputation has suffered.’ He said he has yet to receive a satisfactory explanation as to why it happened. ‘At the very least, the trust should apologise to me. The fact they have not apologised suggests to me that either they do not accept the ICO ruling, or that they do not treat employees respectfully, which is supposed to be one of the trust’s core values.

‘I found the employment grievance to be long and arduous, but Mark was very supportive and helped me navigate the entire process.’

Taking responsibility The Doctor contacted the trust. A spokesperson said that, while it considered it reasonable to have said in answer to a media enquiry that Mr Nowell was one of the named supervisors of cardiac trainees, and the ICO supported the view that this was not a data protection infringement, it accepted that it should have informed him at the time. The trust had ‘apologised to him for not doing so’. The spokesperson added: ‘We fully accept the ICO’s ruling on this specific point and have amended our internal procedures accordingly.’ Mr Nowell said he thought the trust was yet to acknowledge explicitly that it had infringed rules on data protection, or make an apology on that basis. He said: ‘When I took out a grievance against the trust, it was adamant that it had not broken data-protection rules. When the ICO ruled otherwise, and Mark asked, on my behalf, for an apology from the trust, I was told that it was a matter between me and the ICO. I don’t get a sense of the trust taking responsibility.’ He is now considering further legal action. thedoctor |  August 2019  27

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it happened to me Doctors’ experiences in their working lives

Let your illness be your teacher It’s 9.45am and there’s already a packed waiting room in the paediatric outpatient department. I can hear children enjoying the array of toys in the play area while their parents sit patiently waiting to be called. Nurses trundle through with bundles of notes and there is a background hubbub of ringing phones and chatter. I’m in the only available toilet in the department, my face unnervingly close to the toilet seat while I eject this morning’s breakfast and multivitamins into the toilet. ‘It’s only morning sickness,’ I tell myself and wipe my eyes and nose. I peevishly emerge to a collection of sympathetic faces and make my way to my clinic room. I have to run hurriedly out of several consultations mid-sentence throughout the day to return to my familiar spot hunched over the toilet trying to evacuate my already emptied stomach again. I have hyperemesis gravidarum and I’m too unwell to work. If ketones weren’t swilling around my pre-frontal cortex I’m sure this would be blindingly obvious, and I would arrange to meet the consultant and rota coordinator, who know of my pregnancy, and explain the situation with clarity; but I don’t. I’ve been getting gradually

more unwell for weeks, my weight has dropped, my mood’s deteriorated. I’ve become irritable with colleagues, I frequently disappear in the middle of ward rounds and I am struggling to get into the hospital on time. When I collapse and I am shipped off to the maternity ward, the inevitable comment from my seniors is, ‘you should have said something!’ From angina to malignancy we often marvel at how severe patients have allowed their symptoms to get before presenting to us. But the truth is it’s hard to sense small changes in our bodies from day to day. What’s more, sickness makes us universally poorer communicators. Who hasn’t been frustrated by the incoherent mumbling of a patient trying to explain their inner sensorium when you have very clearly asked whether what they are feeling is ‘burning, aching or stabbing’? What we must remember is that those who are unwell are often trying to reach through

the fog of a disordered symptom-riddled cognitive state, to us, a comfortable clear-headed professional, for help. They may not realise the severity of their symptoms, they may not be able to explain them to you, and they may not be able to make logical decisions such as whether to take the day off or seek medical advice. When we ourselves are affected by illness we too have to accept our limitations and ask for help, even if the request comes a little late or less coherently than others would like. And above all we must remember to look out for one another. Be considerate of colleagues who seem a bit off, be prepared to offer them an ear or even a shoulder, and perhaps be prepared to act on their behalf if it looks like they need it. Maybe one day they’ll be able to do the same for you. Maria Kiesler is a junior doctor in Manchester. She writes under a pseudonym

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the secret doctor

ISTOCK

OK doctors, which part of the body looks most like a seagull?

It’s ’’s funny, the things you remember from medical school. Were The Doctor not a family-friendly magazine I would mention the useful mnemonic which helped me learn the cranial nerves, or the equally colourful one for the carpal bones. Both are firmly fixed in my memory – and, I suspect, yours too. Unfortunately, there are plenty of other things I’ve forgotten. Some were irrelevant to my specialty, and some were probably irrelevant to any specialty (anyone found a use for the Henderson-Hasselbalch equation lately?), but plenty would have been really useful if I could only remember them. Before I went to medical school, someone told me that you don’t have to be particularly clever to be a doctor. It sounded like heresy at the time, but they were absolutely right: a pretty modest intellect will see you

through, given diligence, decent interpersonal skills and – importantly – a retentive memory. So I’m grateful to those teachers, at all levels, who found effective methods to help me remember. Special credit goes to the lecturer at medical school who designed a whole series of little dances to demonstrate cardiac arrhythmias, in which his legs were the ventricles and his arms the atria. Nothing fixes the nature of ventricular fibrillation in your mind like seeing an otherwise sedate professor jitterbugging around the lecture theatre like an overcaffeinated bumblebee. Now, as well as being the student, I sometimes get to be the teacher, so it’s my turn to help other people find ways to remember. I once found myself teaching a bunch of more junior doctors how to perform neonatal cranial ultrasound. The combination of grainy black-and-white images, a wriggly baby, and everyone’s fear of neuroanatomy meant this was seen as a tricky job, but it turns out to be

easier if you treat anatomical landmarks as a series of animal pictures. The supraorbital margins look just like a seagull if you get them at the right angle, and I like to think that there’s a little cohort of trainees out there who will never be able to help thinking of the Sylvian fissure as the mouth of a smiley whale. Will medical memory become less essential, now that we have access to so much information at the touch of a button? I’m not sure it will: we’ll always need the vocabulary – equivalent, some say, to a whole extra language – to discuss medical issues accurately, and a quick Google is no substitute for understanding how anatomy, physiology and biochemistry fit together. There will always be a need for young medics to acquire a vast array of factual knowledge, and tricks – and teachers – that can help them do it are well worth remembering. By the Secret Doctor bma.org.uk/secretdoctor @TheSecretDr thedoctor | August 2019

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and finally...

A bad rep One of the few advantages of no longer being on the medical register is the comforting knowledge that despite the gravity of one’s misbehaviour, either currently or in the past, one can no longer be struck off. But the nuns once taught me that confession was good for the soul, so on the assumption that I may one day face an even higher authority, it’s time to set my conscience straight. I confess that over a period of more than 40 years, as a junior doctor and later as a consultant, I was willingly bribed, bought and corrupted. There, I’ve said it. Like so many other criminals before me, I started small. My villainous peers, once reformed, and usually prior to launching a book, are sometimes asked what single factor started their life of crime. A broken home, extreme poverty or drug abuse are regularly cited. For me, there’s one simple answer: Biros. I had a need; a young family to feed. Children at home who were as carefree in their scribbling as they were careless

in their ownership of pens. And there were those queueing up to meet that need. They were willing, they were pleasant (not necessarily good or kind, but always ‘pleasant’) and they had bags and bags of pens. The trouble is, a good medical rep will never stop there. They would unfurl the jotters, unhinge the miniature penknives, and clank an always slightly too large mug down on the desk. Things we never knew we needed, but that we craved nonetheless. That was how I came to find myself on a golf course one afternoon, a course I had previously spurned because of its eye-watering fees. We knew the routine. A short presentation on whichever product was being hawked, followed by the run of the course, unencumbered by guilt or further spiel. I know – or at least I think, or perhaps I hope – that I am referring to a bygone age. The greatly increased number of clinical guidelines means doctors have less individual power when it comes to prescribing, so there is less scope to corrupt the corruptible. The GMC’s

rules on gifts and hospitality appear to have become more rigidly enforced. But we didn’t always get away with it, even back then. As we trotted across the manicured fairway, we suddenly heard a sharp, challenging voice behind us. ‘Just who is paying for you?’ he asked. That was all; we ignored him, but it was enough to hamper the swing and trouble the conscience. Later, I thought I’d see what the rep thought. He seemed decent enough, he had his own code of standards, presumably, and he may not have worked in the health service but he was a patient, like everyone else, and he had an interest in it running fairly. I found him in the bar and, like a particularly clumsy ethics presentation, I stumbled my way through my observations, reflections, concerns and dilemma. His smile remained perfectly fixed. ‘Don’t worry,’ he said. ‘It’s all tax deductible.’ Peter Docherty is a retired consultant ophthalmologist from Derby

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what’s on

August 20 Pensions taxation and retirement planning – delivered by Chase de Vere Medical, Glasgow, 7pm to 8.30pm 22 Pensions taxation and retirement planning – delivered by Chase de Vere Medical, Aberdeen, 7pm to 8.30pm

September 19 Practical skills... for effective communication, London, 8.45am to 4.45pm 20 Planning for retirement – delivered by the BMA, Bristol, 9am to 4pm

21 BMA Scottish conference, Glasgow, 9.30am to 5pm

05 Neurology masterclass, London

27 Planning for retirement – delivered by the BMA, Leeds, 9am to 4pm

05 Care of an older person masterclass, London, 8am to 5pm

October

11 Planning for retirement – delivered by the BMA, London, 9am to 4pm

02 Critical appraisal workshop – Part 1, London, 9am to 4pm 04 Clinical pharmacists in general practice masterclass, London 04 Dermatology masterclass, London, 8am to 5pm 04-05 BMJ Live, London

14 CESR seminars for SAS doctors, Manchester, 9am to 12.15pm 16 Practical skills... time management and taking control, Manchester, 9am to 5pm 22 Critical appraisal workshop – part 2, London, 9am to 4pm

Visit bma.org.uk/events for full details Download the BMA events app at bma.org.uk/eventsapp

Foundation doctors retrace BMA history The BMA’s membership drive took it back to its roots last month. During the junior doctors’ induction at the Worcestershire Royal Hospital on 31 July, four foundation doctor 1s (pictured) signed up to the association. A total of 14 joined throughout the day. Founder of the BMA Charles Hastings – his bust pictured second from left – practised as a surgeon at this hospital. What better blessing is there for those starting out in their careers in medicine? bma.org.uk/membership thedoctor  |  August 2019  31

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