The Doctor – issue 14, October, 2019

The magazine for BMA members

thedoctor

Issue 14 | October 2019

Belittling

Be listening

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What kind of culture do you work in?

07/10/2019 11:14

thedoctor

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

Email thedoctor@bma.org.uk

Editor Neil Hallows (020) 7383 6321

Call a BMA adviser

Chief sub-editor Chris Patterson (020) 7383 6978

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 Cover RANK/All Star Picture Library and Ed Moss

The Doctor is a supplement of BMJ vol: 367 no: 8217 ISSN 2631-6412

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In this issue 4-5 Briefing

The potential catastrophe of a no-deal Brexit, and the curious case of a government that buries good news

Welcome Chaand Nagpaul, BMA council chair We work in a health service which aspires to treat patients equally and fairly – to ensure patients are prioritised solely by need.

Yet the same health service is not equal, or fair, for the doctors working in it. Doctors face systematic inequalities in our profession.

Nearly half of all BAME (black, Asian and minority ethnic) doctors believe diversity isn’t valued and there isn’t an inclusive culture in their workplaces. It does not end there – the pass rate in postgraduate exams, according to the most recent figures, was 75 per cent among white students and 63 per cent among UK BAME students, male hospital doctors are paid on average 17 per cent more than their female counterparts and disabled doctors struggle to get the adjustments and support they need to make the valuable contribution they could make to the profession.

It is in the face of this inequality, this unfairness, that the BMA has launched Equality Matters – a programme to promote equality for all doctors working in our health service, and also for our elected members in the BMA. As part of the project the BMA will press for action in a wide range of areas. Creating equality is a responsibility for every one of us. You can find out much more about this work at bma.org.uk/equalitymatters Some of the features in this month’s The Doctor touch on these issues and highlight their importance.

One piece reveals that doctors’ mental health is under attack on multiple fronts from staff shortages, poor basic amenities, and the target-chasing and bullying cultures in the NHS. In response to the report’s alarming findings, the BMA has launched a mental wellbeing charter to help employers prevent further harm to the profession.

Another feature looks at the work of Bristol anaesthetic registrar Layth Tameem, who has taken some of the issues facing doctors on the frontline – from wellbeing to bullying – into his own hands, with the help of colleagues. His story is truly inspiring and shows what we can all do to address these problems in our daily working lives.

The BMA continues to fight for members and the NHS in a wide range of areas. Last month, we finally saw the results of a Public Health England review into prescription drug dependence – long called for by the association – and we chart the history of that fight, and what comes next, in another interesting feature this month.

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A sea of troubles

Patients dependent on prescription drugs are being offered help following years of campaigning

10-11

I was lucky

An overseas-trained doctor says more support is needed with the transition to UK medical practice

12-15

Sir Lancelot Spratt RIP?

The NHS has a ‘diva subculture’ of powerful and unaccountable individuals, says a new report commissioned by the GMC

16-19

Not just a name on a rota

A junior doctor’s determination to help his colleagues struggling to cope

20-23

Pressure points

The five areas taking their toll on doctors’ mental health

24-25

Follow the evidence

Tested methods are better than vague promises when it comes to improving public health

26-30

Life experience

Can you be candid in personal reflections?

Plus, a GP saves thousands on her maternity pay

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What’s on Keep on top of events

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Current issues facing doctors

Into the unknown

An end to automatic tendering?

The Conservatives, famously, promised ‘no top-down reorganisation’ of the NHS and then in power did exactly that.

The Health and Social Care Act 2012 has caused those who commission care to put services in England out to tender, even when it undermines their plans to integrate services. Money that could have been spent on patient care has been wasted on expensive tendering processes.

A BMA survey a year after its implementation found only 5 per cent of doctors thought it had improved the quality of services.

Almost three quarters thought it had created greater fragmentation.

The BMA has been campaigning for years for the repeal of the act. While it remains on the statute books, there has at least been a promising development. NHS England, following years of pressure from the BMA and other campaigning organisations, is proposing to scrap section 75 of the act, which requires NHS organisations to put healthcare contracts out for competitive bidding automatically.

It plans to remove the role of the Competition and Markets Authority in NHS mergers and pricing, allowing all NHS organisations to work together by delegating decisions and budgets to joint committees, which could carry out their work across ‘place-based’ ICSs (integrated care systems).

Most of the proposals had already been outlined by NHS leaders but amendments, following a long period of consultation, include no longer allowing central NHS leaders to force foundation trusts to merge as well as outlining the importance of the role of local government and ‘wellbeing’ to future NHS plans. Under the proposals, the Government will be asked to review national oversight and funding of education and training, and statutory guidance created to require ICSs to meet in public and hold annual general meetings.

The BMA has cautiously welcomed the plans but has called for additions including the guarantee that private companies will not be eligible to run whole health systems through new integrated care provider contracts, and the protection of GPs’ independent contractor status, which ensures doctors are in direct contact with, and accountable to, those who use the service. It’s a start – it needs the Government to table legislation before anything can happen, and more clarity and detail are needed. Then, perhaps, the harm wrought by this legislation can begin to be undone.

Days after MPs’ rumbustious return to Parliament, a weighty report by the NAO (National Audit Office) thudded out.

Exiting the EU: supplying the health and social care sectors spells out the problems and costs of keeping essential medical supplies crossing the Channel if we crash out without a deal.

Their transport to the UK already involves complex logistics including GMC

briefing

WASTED RESOURCES: Money that could have been spent on care went on the tendering process

IN FOR THE LONG HAUL: The Government’s ‘reasonable worst-case scenario’ predicts a 60 per cent fall in the flow of goods across the Channel

manufacturers, hauliers, wholesalers and public and private providers of health and social care. Some 7,000 medicines come to us from or through the EU. ‘There is no way of knowing exactly what may happen at the UK/EU border when the UK leaves the EU,’ the report states.

The Government’s own ‘reasonable worst-case’ scenario predicts a 60 per cent cut in the flow of goods across

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the Channel, it adds.

And while stockpiles of most medicines have been built up, the NAO reports, there’s ‘incomplete information’ about their current levels.

Parliamentary public accounts committee chair Meg Hillier described the report as ‘deeply concerning’. ‘I’ve seen countless examples of deadlines missed and government failing.

‘If government gets this wrong, it could have the gravest of consequences,’ she said.

The NAO report also points to the huge bill attached to official contingency plans.

This includes £50m on the department’s ‘continuity of supply programme’, a ‘contingency fund’ of £281m, a further £150m for extra ‘freight capacity’ and £10m for storage, which includes 5,000 refrigerated pallets.

The BMA has repeatedly warned about the ‘catastrophic consequences’ of a no-deal Brexit.

‘From our invaluable EU workforce to the supply of vital medicines, and collaboration on medical research to Irish cross-border health arrangements, there is practically no area of health that will be unaffected if we crash out without a deal,’ BMA council chair Chaand Nagpaul has said.

The Government must relearn a skill it seems to have forgotten – that of listening. When David Nicholl, a consultant who advised the Government on no-deal Brexit planning, raised concerns last month he was accused of fearmongering by Jacob Rees-Mogg, the leader of the Commons.

His warnings, and those of the NAO, are the product of evidence and expertise. It is complacency and arrogance in the face of such warnings that cause fear. bma.org.uk/brexit

Keep in touch with the BMA online at

Why bury the good news on sugar cuts?

Tens of thousands of tonnes of sugar have been sifted from children’s diets at a time when a third leave the primary school gates either overweight or obese. All thanks to a policy to reduce it in everyday foods.

Great news! Rush out a press release!

Call round the news desks!

Err, no. Not exactly. According to The Times, the PHE (Public Health England) report proving a ‘sugar tax’ on fizzy drinks to be highly effective was repeatedly put on the back-burner by Number 10.

This will come as no surprise to those keeping tabs on our new prime minister’s approach to public health.

Boris Johnson pledged to review ‘sin stealth taxes’ during his leadership campaign, demanding evidence it ‘actually stops people from being so fat’.

It doesn’t need a doctor to point out the link between excess sugar consumption and obesity. Or that 30,000 tonnes of it taken out of school children’s drinks might ease the obesity crisis.

But for the record, here’s what the PHE report said, on its hasty release, after papers caught wind of the hold up: a 28 per cent cut in average sugar contents of drinks between 2015 and 2018; and a ‘consumer shift’ towards zero or lower-sugar products.

They’re not bad stats for a sugar reduction policy, which doctors successfully pushed for in their work with the BMA. It’s what the evidence showed would work, as the PHE report has now proved.

Politics, as ever, may still stand in the way of progress, which the report shows is much needed. Despite good progress on some foodstuffs, sugar levels reduced across all by just 2.9 per cent, making the reduction target of

instagram.com/thebma

NOT SO SWEET: Taxation measures have reduced the sugar content of fizzy drinks

20 per cent look likely to be missed.

While health secretary Matt Hancock apparently declared the sugar tax a ‘total triumph’ at a Huffington Post fringe meeting at the Conservative Party conference, his boss is yet to retract his pledge to review it. Doctors, meanwhile, will rely on the research, as always.

‘The PHE report makes clear that moving towards mandatory rather than voluntary reformulation will be the most effective means of reducing the public’s sugar consumption,’ said BMA board of science chair Dame Parveen Kumar.

Read more online Pensions tax bill hits senior doctors Giving back to doctors No-deal Brexit: doctor defends right to speak out Consultant vacancy rate remains high Awards programme boost for juniors Read all the latest stories at bma.org.uk/news

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A sea of troubles Patients who become dependent on prescription drugs often lack the support and information they need.

Following years of work by the BMA and campaigners, they are being promised new services and clinical guidelines.

Peter Blackburn reports

MIKE LAWN

MONTAGU: Took sleeping pills for 20 years

A

long-awaited study into prescription drug dependence has revealed a host of fundamental problems in care and communication.

The Public Health England review into the experiences of patients prescribed, and becoming dependent on, benzodiazepines, z-drugs, opioids and antidepressants found ‘barriers to accessing and engaging in treatment services’, a ‘lack of information on the risks of medication’, a ‘lack of access to effective management and NHS support services’ and a

host of other problems in the area.

It follows years of pressure from the BMA and other campaigning groups.

The review says 11.5 million adults in England, 26 per cent of the adult population, received and had dispensed one or more prescriptions for the drugs considered.

While this does not itself give evidence of dependency, the conditions are there in which dependency might develop. There were almost a million patients receiving prescriptions for antidepressants, and more

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TIM GRANT

than half a million for opioid pain medicines, continuously between April 2015 and March 2018.

‘After it happened to me it took me three or four years before I could function’

Lack of support Luke Montagu spent 20 years taking sleeping pills and antidepressants he says he did not need, before finally ‘entering hell’ while attempting to stop taking them.

After turning to the internet for help, he found scores of people who had also struggled with a lack of support, or the offer of alternative therapeutic approaches, and decided to

campaign for change.

‘After it happened to me it took me three or four years before I could function and leave the house. But I realised I was in a very good position to try to help and try to do something about it,’ Mr Montagu, the son of the 11th Earl of Sandwich and a campaigner at the Council for Evidence-based Psychiatry, says.

‘It was a moment in one’s life where you stumble across an injustice and you have a choice as to whether to help out. I feel very lucky that I was in that position.’

Mr Montagu’s experiences kick-started the campaign for change. He describes how he made contact with the former BMA president and board of science chair Baroness Hollins, who spoke on the issue in Parliament before helping to set up an APPG (all-party parliamentary group) to look at prescription drug dependency and campaign for better care and support.

Safe prescribing Sir Oliver Letwin, the West Dorset MP who later chaired the group, says he was convinced by Mr Montagu’s thedoctor | October 2019 07

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HOLLINS: Campaigned for better support for people dependent on prescription drugs

‘The BMA has been working for some years to understand the causes behind high prescription rates’

‘remarkable story’, combined with a natural interest in mental health provision.

The BMA’s voice was to be an important partner in the process.

In 2016 the BMA board of science, having gathered evidence on improving the prevention and management of prescribed drug dependence, recommended: – a national helpline for prescribed drug dependence – an increase in provision of specialist services – revised guidance for doctors on safe prescribing, management and withdrawal of prescription drugs.

The pressure for change began to grow.

‘We felt that the first step to tackle the problem would be a national NHS-funded helpline and website,’ says Mr Montagu. ‘We asked for support from the BMA and the [medical] royal colleges to sign up to that and that was tremendously helpful.’

A systematic review was undertaken on behalf of the APPG and published last year.

It indicated that an average of 56 per cent of patients who stopped or reduced their antidepressants experienced withdrawal symptoms, with almost half of those reporting symptoms as severe. It was not uncommon for patients to experience symptoms for weeks, months or longer.

Public Health England’s report supports all three of the BMA’s recommendations from three years ago and urges more action including ramping up collection of, and use of, data in the area as well as a much-increased focus on research.

It is, doubtless, a win for campaigners and health leaders who have fought tirelessly on this issue.

GP support BMA GPs committee prescribing lead Andrew Green says: ‘The BMA has been working for some years with patients and health organisations to

GREEN: High prescription rates a long-term issue

understand and address the causes behind high prescription rates, and we were pleased to engage with this review and welcome its recommendations.’

Sir Oliver tells The Doctor: ‘It’s very good that there is now a properly established evidence base which had previously been lacking, so we are all now operating on a much better platform of understanding and information which is very constructive.

‘The report makes some very sensible reflections about how to proceed and improve this situation – we don’t just want to know how bad it is, we want to make it better. There is all the difference in the world between a good set of recommendations in a report, and actually making them happen.

‘The next stage is to make this happen in the

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‘If you’re a GP and you know the referral will not be immediate you could feel you are bound to do something for your patient’

LETWIN: Access to CBT is essential to GPs

PA

real world. I’m optimistic that given the high degree of consensus between the professional bodies and the report about the steps that are necessary that we can get them to happen.

That’s the work we are now engaged in and will have considerable conversations with all the interested parties and hopefully shortly with the health secretary to make sure the recommendations are implemented, and in particular that the quick wins are won.

‘The helpline and the support for GPs and the improvement in the ways that GPs are informed are the kinds of things we can do pretty much immediately if there is a will.’

For GPs, new clinical guidance and a strong evidence base should help – and data shows prescription rates for some drugs, including opioid painkillers, are already falling so doctors are taking action.

But, crucially, it’s important to understand the complex

causes of a problem if a solution is to be found.

Dr Green says: ‘While there isn’t a single cause for high prescription rates, social deprivation, an increased prevalence of mental health problems and poor access to mental healthcare, a rise in the demand for GP services and a growing, ageing population, are likely to be significant contributing factors.

‘It is positive that this report recognises that, to reduce prescription levels, we need significant investment in support services; this will enable patients and GPs to manage dependencies together in the community.

‘GPs will often be the sole clinicians who are managing a patient’s withdrawal, and there is a real need for better clinical guidance in this respect. We are glad that [the National Institute for Health and Care Excellence] is in the process of developing this.

‘And while there remains a place for prescribing the kinds of drugs this report covers – including, in some circumstances, for long-term use – we need many more alternatives to medication, such as pain clinics, improved access to mental health services, and physiotherapy – the universal provision of which are all lacking.’

Sir Oliver echoes the point that GPs having ready access to non-pharmaceutical alternatives, such as CBT (cognitive behavioural therapy), is essential.

‘CBT is entirely evidenced already, it is entirely accepted as a powerful tool for addressing anxiety and depression and there’s lots of it but not nearly as much as

there is demand for it and the result is that people have to wait.

‘GPs will often be the sole clinicians who are managing a patient’s withdrawal, and there is a real need for better clinical guidance in this respect’ ‘That’s often a very, very serious problem. First of all, if [patients] have to wait, things get worse, and secondly if you’re a GP and you know the referral will not be immediate you could feel you are bound to do something for your patient.’

Social prescribing The timing of this report could hardly be more prescient. The NHS is working to establish primary care networks across England. These new structures in primary care, negotiated by the BMA in the GP contract, will allow GPs to work at scale and provide access to increased funding for social prescribing and support services.

This could be a major opportunity in the area of prescribed drug dependence.

As Mr Montagu says: ‘Social prescribing plays a really important role in all of this. It is completely understandable and right that a doctor should be able to give their patients a way forward other than a traditional prescription.’

Clearly, there needs to be an effort across the health, social care sectors and beyond to tackle the problem. For some conditions, doctors are left wishing, ‘if only there was a pill for that’. Here they are wishing for readily accessible alternatives. thedoctor | October 2019 09

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MATTHEW SAYWELL

I was lucky Chuka Nwokolo came to the UK from Nigeria and has become a prominent consultant.

He tells Tim Tonkin greater support for overseas-trained doctors will help others share in his success

‘I

n a sense, I am the one that got away.’ Chuka Nwokolo, a consultant gastroenterologist and leading figure in the Royal College of Physicians, gives a wry reflection of the career outcomes of other doctors who, like him, are black and trained overseas.

‘I can’t claim to be typical of black doctors [in this country].

I was helped by a huge infusion of luck mostly by way of supportive idealistic NHS trainers that I encountered,’ he says.

When Professor Nwokolo came to the UK on an RCP training programme in 1985, he at least did not have the stark sense of unfamiliarity felt by many overseas doctors.

His father Chukwuedu was

an internationally recognised physician and had taken his family on visits to the UK from their home in Nigeria. The young Chuka had chosen to come to Cambridge for a medical elective – a neat reversal of the traditional practice of British students going to Africa.

He had not only got to know the UK’s hospitals, but a

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Equality matters

different section of society too.

He recalls a holiday job in the East End of London, in a factory making cigarette vending machines. He may be the only luminary of a medical royal college famous for publishing the link between smoking and lung cancer to have seen the opposition quite so up close.

Under-representation Working first in Epsom, he later took a research post at the Royal Free Hospital in London and decided to stay in the UK because of the growing political instability back in Nigeria. He is now a consultant gastroenterologist at the University Hospitals Coventry and Warwickshire NHS Trust, an honorary professor of gastroenterology at Warwick Medical School, the UK’s representative on the European Board of Gastroenterology and, since 2016, the treasurer of the RCP. Asked what he felt might be contributing to under-representation of black doctors in senior and leadership roles, he says that the differing priorities of overseas medical graduates could sometimes play a role.

‘Discrimination in its many forms is present in every facet of life but in fairness it is probably less in the NHS because of its long period of interaction with an overseas workforce.

‘I think that when [BAME (black, Asian and minority ethnic)] doctors come from abroad they are busy trying to settle, trying to understand the way the system works trying to look after their family – some of them may have family still at home to support financially.

They put their heads down and

concentrate on their day jobs.

‘They [therefore] perhaps do not have the time to pursue some of the other goals that UK-born doctors are able to, [such as] research, medical education and management and medical politics.’

‘Overseas doctors perhaps do not have the time to pursue some of the other goals UK-born doctors are able to’ Professor Nwokolo adds that overseas-trained doctors who come to the UK sometimes also have to deal with adapting to different workplace cultures and medical traditions, a transition which is not always easy.

‘I try to explain this to my NHS colleagues using the example of a UK-trained doctor arriving to work in a village in Nigeria prescribing Chloroquine tablets for non-falciparum malaria. His patients would rapidly lose trust since they believe that any treatment not delivered by injection is ineffective. The doctor of course would also lose a powerful placebo tool.’

He says it would potentially be useful to provide brief adaptation training for doctors newly arrived from abroad.

The curriculum would be difficult but not impossible to design to include the unwritten, cultural nuances in UK medical practice.

There are also initiatives to help newly arriving international medical graduates. The February issue of The Doctor profiled the Royal College of Psychiatrists’ mentoring scheme, offered to doctors coming to the UK through the medical training

initiative. One recipient said she particularly valued the impartial advice available from a doctor who was not her clinical or educational supervisor.

Call for support Professor Nwokolo says: ‘A number of foreign-trained doctors run into trouble because of difficulties making this transition, and I think more can be done.

‘It is fine for the GMC to test these skills in the context of the PLAB [Professional and Linguistic Assessments Board], and similar exams, but I hope that it should be possible for such transition courses underpinned by a well-designed curriculum to be available in future.

‘We have to support newly arrived overseas doctors if we genuinely want them to be able to overcome impediments to aspiration’ ‘We have to support newly arrived overseas doctors if we genuinely want them to be able to overcome impediments to aspiration to higher roles in medicine.’

Professor Nwokolo is no doubt an exceptional doctor – but there is no reason why overseas doctors, who are also successful, have to be ‘exceptions’. He hopes he can be an example.

‘Most doctors wherever they come from are ambitious and it helps if they can see that someone like them has reached a higher level.’ bma.org.uk/ equalitymatters www.blackhistory month.org.uk thedoctor | October 2019 11

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RANK/All Star Picture Library OMNIPOTENT: Authoritarian and irascible, the fictional surgeon Sir Lancelot Spratt represents an enduring stereotype. Do his traits live on in today’s doctors?

ED MOSS

A DIFFERENT WORLD: Emergency medicine consultant Shewli Rahman embodies a very different leadership style. She says: ‘Good leaders take the time to listen and know their teams.’

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Sir Lancelot Spratt RIP? Do powerful, unaccountable ‘diva doctors’ really still command the wards, as a report for the GMC suggests?

In the first of three articles in this issue on medical culture, including junior doctors’ wellbeing and factors influencing mental health, we find a profound shift in leadership style since the days of Sir Lancelot. Keith Cooper reports

W

hat type of doctor are you? When you’re in charge, under pressure, up against it.

You might not feel you’re a ‘type’ at all.

You might just feel that you’re doing your best under very difficult circumstances.

But according to a report commissioned by the GMC, there are ‘notable subcultures’.

They sound a little like the outline for a new medical drama on daytime TV. The subcultures might be: ‘factional’, riven by endemic disagreement; ‘embattled’, where they feel perennially unequal to demand; ‘insular’, isolated from the wider organisation; or based on patronage, where there is a leader who may inspire loyalty but be difficult to question.

It’s the fifth, though, which has attracted the most attention. The ‘diva’ subculture, ‘when powerful and successful professionals are not called to account for inappropriate behaviour, and colleagues modify their working practices to accommodate them’.

Inevitably this became ‘diva doctors’ (why not also diva managers or diva nurses?) in opinion pieces thundering that they were the ‘symptoms of a rotten culture’ – which seemed a bit harsh, as the report was talking about perceptions and working practices more than real individuals.

Not my type The report, by the medical ethics consultant Suzanne Shale, is not aiming to stereotype doctors and still less aiming to rubbish the profession. Instead, its title claims it sets out

to establish‘How doctors in senior leadership roles establish and maintain a positive patientcentred culture’.

But, it inevitably raises some interesting questions about whether there are types of doctors, whether it’s helpful to think in this way, and, of course, to go in search of a diva or two. Here, Hugh Montgomery can assist us.

‘These people were relatively prevalent in the 1980s,’ says the professor of intensive care medicine at University College London.

‘I worked with quite a lot of them.’

Still, he feels ambivalent towards them.

‘There were some absolutely superb surgeons and physicians. Really superb but fundamentally flawed. They would put their own social life and personal agendas ahead of their clinical practices. It was an odd thing to watch.’

As a junior doctor, Professor Montgomery aspired to match their ‘extraordinary clinical acumen and skill set’, tolerating the eccentricities in their behaviour. Now, instead of populating his ambitions, they populate his published fiction. His thriller, Control, features a ‘super brilliant but vain and arrogant’ surgeon.

‘He’s an amalgamation of some of the worst traits in people I’ve known, all mashed into one.’

Were you to amalgamate the behaviours described in Dr Shale’s study, it would make a pretty ghastly fictional character, too. It describes medical leaders who deny bad news – instead of questioning every patient death, shrugging it off (‘a recognised complication’) – or choose to embrace only the positive aspects of patient

‘There were some absolutely superb surgeons and physicians.

Really superb but fundamentally flawed’

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ED MOSS

TEAM PLAYERS: Shewli Rahman, above, and, below, Chris Turner who says a debate about leadership is needed

‘As a surgeon, I am used to being labelled as single-minded and not suffering fools gladly’

skill and an art to maintaining good relations with colleagues of all levels and creating a ‘positive working culture’ under pressure, says East Sussex consultant orthopaedic surgeon Scarlett McNally.

‘As a surgeon, I am used to being labelled as single-minded and not suffering fools gladly,’ says Mrs McNally. ‘We’re all getting labelled because of something we said or did without realising it. You get a reputation from what people think you’re like; not from what you meant.’

She found one misunderstanding, early on in her career, on a list of her operating requirements. It had: ‘Mrs McNally prefers to operate in complete silence,’ penned in.

‘I thought it was odd that people were being really quiet. It must have been something I said in one of my early operating lists there. I had a chat with the sister, we had a laugh, and we went back to normal.’

Mrs McNally now alerts colleagues to potentially stressful parts of operations in ‘pre-op team briefings’.

ED MOSS

‘I raised concerns and ended up in a meeting with him, listening for an hour and a half about the pressure he was under’

feedback. These characteristics have been observed in reports into massive NHS failings.

This doesn’t mean there is a tribe of doctors with diva-ish traits stalking the wards.

London medical oncology specialty trainee 6 Adam Januszewski says: ‘It is rare to see these “caricatures”, but you do see some traits in individuals.’

Dr Januszewski, who holds a position with the FMLM (Faculty of Medical Leadership and Management), also believes this is not just an issue for very senior doctors, the main focus of the GMC-commissioned report.

‘Doctors are naturally in leadership positions,’ he says. ‘We can evaluate complex situations and manage uncertainty, but people assume we are good leaders because we are doctors, which is a problematic assumption. Good leadership skills are not automatic, doctors need the right development and nurturing of these skills.’

In the hierarchy of the hospital, trainees also find themselves setting the tone in the workplace, he says.

‘I have underestimated how much of a role model I’ve been for medical students and more junior doctors,’ Dr Januszewski adds.

‘When you are on call, overworked and it’s the end of a shift, it can be stressful. People can be curt or discourteous. It’s probably because we have many competing priorities.

I’ve now learned to sense when I’m feeling anxious, to look after myself a bit more.

And when I’m gruff, I reflect on it.’

How reputations are formed All doctors must wrestle with the occasional brusqueness of colleagues. In a service where work pressures are high, rising and unpredictable, it’s inevitable. But there’s a

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Close to tears West Midlands emergency medicine consultant Shewli Rahman witnessed a group of consultants brought near to tears by a medical director’s berating about their inability to achieve the NHS four-hour target.

‘He told us what an unimpressive team we were,’ she says. ‘I raised my concerns to the chief executive through the trust’s whistleblowing process and ended up in a meeting with the MD, listening for an hour and a half about the huge pressure he was under.

It was eye-opening.’

Emergency medicine specialty trainee 3 Hannah Baird, who also occupies a position at the FMLM, recalls similar experiences after night shifts when senior managers question why patients are still in the department.

‘There is often quite a lot of negativity about waiting times. This is often to sleep-deprived teams after 10-hour shifts who are expected to come back that night. It makes me feel quite disappointed – where is the compassion?’

These experiences led these doctors into studying the qualities they need to lead, those that it can’t be assumed are imbued in medical school. Good leaders take the time to listen and know their team, says Dr Rahman.

‘I’ve known medical directors who nobody would recognise in a line up and others who knew everyone’s name. To show that you know and care for the people you work with seems an obvious thing to do in a system that is caring for people.’

Dr Baird gives an example of a ‘listening’ leader, who acted with compassion and what she calls the ‘no heroes’ approach. ‘This senior

CLAIRE MCNAMEE

‘I say, I’m a bit worried about this bit, please don’t go on break and I might swear. We talk about it. We have a laugh.’

As a council member of the Royal College of Surgeons of England, she has helped compile qualities of ‘good’ and ‘disruptive’ medical leaders for its report, Surgical Leadership: A Guide to Best Practice.

Dominance, arrogance, aggressiveness, and egocentricity are out. In are: integrity, honesty, and the ability to recognise stress in yourself and your effect on others.

Many doctors will know what negative leadership looks like in a service where targets must be met, whatever the weather. manager came down during one of the worst shifts I’ve ever worked. He asked, what do you need me to do? You look incredibly stretched.

They made tea for patients and dipped wees.

We didn’t need someone else telling us where to move beds.’

MONTGOMERY: Wants there still to be room for those with ‘rough edges’

Moulded in their image Coventry emergency medicine consultant Chris Turner has also experienced the effect of poor medical leadership on workplace culture. He was a witness at the public inquiry into failings at Mid Staffordshire NHS Foundation Trust.

Now a well-known campaigner and speaker against rudeness for Civility Saves Lives, a growing movement, he believes, like the GMC, that a debate about ‘leadership’ and its link to workplace culture is needed. ‘Cultural tides are very strong,’ he says. ‘You are far more likely to become like the people you work with, than make them the sort of person you are.’

If doctors are to make good leaders in an increasingly complex service, the profession must decide what good ones look like, Dr Turner says.

‘The starting point is caring for people in a team, calmness in the face of adversity and getting the most out of people. If we are all going to behave in a certain way then we all need to know what that looks like.’

If such a ‘model’ of the good medical leader exists, Dr Montgomery hopes there will be room left for those with ‘rough edges’.

‘There are some things that cannot or should not be tolerated, of course but people’s personalities do differ,’ he adds.

Villainous and fictional caricatures aside, of course.

‘The starting point is caring for people in a team, calmness in the face of adversity and getting the most out of people’

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EMMA BROWN

More than just a name on a rota Doctors don’t feel looked after by the health service to which they devote their lives. A junior doctor refused to watch his colleagues suffer in silence and is offering practical help.

Peter Blackburn reports

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TAMEEM: Believes the NHS must find the time to make things better

I

t was in a hospital corridor at 4am that anaesthetic registrar Layth Tameem first realised something was dreadfully wrong.

For Dr Tameem, a ST6 in a specialty he says allows time for thought and to ask questions, the NHS has always represented ‘brilliant opportunities’ – a ‘brilliant job’.

But the junior doctor he had just encountered looked dazed and broken.

Dr Tameem had initially walked past his younger colleague after a robotic, affirmative response of ‘yes, fine’ came to his ‘are you OK?’ But something wasn’t right, so he turned back and asked again.

‘She said, I’m really thirsty – I want a cup of tea but I don’t know where the mess is and it’s probably got a code and I don’t know what it is. She said she hadn’t seen another doctor on that shift, and she didn’t want to bleep or call someone as it might have seemed like she was weak or not coping.’

What sort of a health service arms the people entrusted with the care of the most vulnerable in society with thought processes like this? What sort of NHS leaves doctors in training scared to ask for help? What sort of employer – let alone an employer of care-givers and life-savers – leaves staff not knowing if they have a safe space for a cup of tea, or, indeed, the time to use it.

The truth, as hard as it is to admit when it comes to our national treasure, is that this is our NHS. Dr Tameem’s story elicits a sympathetic ear but it does not shock or stun.

‘Something just wasn’t right – I thought there was something fundamentally wrong with the culture and the way we were caring for ourselves and each other.’

He adds: ‘I feel very strongly when I see injustices like that where I want to make things better. I was lucky to be in a specialty where I have the time to stop and say, “how are you?” It was a real eye-opener seeing that.’

‘Vicious circle’ Dr Tameem’s experiences of a health service which can be a difficult place to live – after all, we always say this is a vocation, not just a job – run deeper than his interaction in a hospital corridor that night. Five years ago his best friend, a fellow junior doctor, took his own life.

‘We’ve just got this all wrong,’ he says. ‘It’s a vicious circle. We say we don’t have the time to make things better but then more people thedoctor | October 2019 17

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EMMA BROWN

TEAM PLAYERS: Dr Tameem (centre, right), with his colleagues who began to advise and support junior doctors

‘People leave and that just makes the place of work worse and the staffing more problematic. We need to break that cycle’

to keep doctors in the NHS. And Dr Tameem is positive about the future as he says Health Education England has been supportive of his work, particularly around education.

Earlier this year the NHS unveiled its interim people plan in a bid to address some of these issues – and to give the health service a workforce foundation strong enough to cope in the coming years.

It’s a bit hazy on the details. There are pledges to tackle the NHS culture of bullying and harassment, a major focus for the BMA, and improvements to the leadership culture.

The plan’s creator-in-chief, the NHS’s new chief people officer Prerana Issar, has arrived in the health service from the UN and speaks passionately about creating a more diverse workforce where people feel valued.

Speaking at the NHS’s flagship annual conference, NHS Expo, last month she outlined her thoughts on the issues facing the workforce.

She said: ‘There are 1.3 million stories in the NHS – each of them counts, each is unique, and each brings something to the NHS. The golden thread between them is serving the patients who come to the NHS. ‘We all go into work to make a difference every day but there are things that get in the way – from the laptop that takes 10 minutes to boot up, the line manager who excludes us from key discussions and a lack of flexibility about balancing family and commitments.’

These were warm words, as were NHS EMMA BROWN

leave and that just makes the place of work worse and the staffing more problematic.

We somehow need to break that cycle.’

Where these sorts of realisations have led many to leave the NHS for more comfortable lives elsewhere, Dr Tameem – who himself experienced life in an Australian emergency department where doctors are ‘more than a name on a rota’, with ideas that would seem radical over here such as allowing partners working in the same department to share working hours – has been inspired to take action.

Following his experiences and the death of another junior doctor in his hospital trust he divulged his ideas for change to a consultant colleague one evening, unaware she was a senior leader at the trust, in a position to enact genuine change.

An invitation to take action soon came, as well as an introduction to another junior doctor with similar ideas. Soon the early shoots of an organisation which was to become WARD (Well and Resilient Doctors) came to life.

Dr Tameem and a group of colleagues began creating seminars and educational sessions for junior doctors about what to expect in their jobs, how to ask for help and support and answering some of the questions they all had in their early days on the wards.

Doctors leading sessions, which take place during curriculum teaching time, stay behind after to answer more personal questions or signpost to services. The WARD programme covers Dr Tameem’s entire deanery and discussions with senior NHS leaders could lead to further growth, with ambitions of national coverage one day.

Bullying and harassment Dr Tameem’s work shows the obvious problems in the system: doctors feel isolated and alone, staff are at risk of burnout and support services, if there, are not always easy to access.

But his efforts also show that, with a bit of drive and energy, things can be changed for the better – every little improvement could help 18 thedoctor | October 2019

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chief executive Simon Stevens’s at the same conference when he said that addressing workforce issues was ‘mission critical’.

Under-staffed

‘We all go into work to make a difference every day but there are things that get in the way’

‘There are some trusts that get it and they understand staff are the backbone’

But what should the NHS actually be doing?

It may sound self-evident but any ‘people plan’ needs enough people to make it work.

The NHS is chronically under-staffed.

More than nine in 10 doctors surveyed for the BMA Caring, supportive, collaborative project said staffing levels were not adequate to deliver safe, high-quality patient care, and more than seven in 10 said this had worsened in their main place of work in the previous 12 months.

In Scotland, there has been legislation for safe staffing – a move welcomed by the BMA, although as BMA Scottish council chair Lewis Morrison says: ‘It will not create more doctors – or staff of any type – simply by becoming law. Instead, we need much more concerted and targeted action to recruit and retain doctors and make the profession an attractive career choice once again.’

In Wales, the BMA has called for statutory safe-staffing provisions in its response to the consultation on the Health and Social Care (Quality and Engagement) (Wales) Bill.

If the NHS is truly in listening mode, listening to Dr Tameem would be an excellent start.

He cites everything from compassionate rota planning and flexible working, to giving everyone the opportunity to take leadership roles and sharing best practice around the country.

He says: ‘This is not impossible stuff.

We have shown what can be done.

‘I’ve seen some wonderful practice in 10 years working in the NHS, but I’ve seen too many where staff simply aren’t people and are treated as names on a rota. There are some trusts that get it and they understand staff are the backbone.

‘But I’ve also been told that there is just no time in the foundation year curriculum for non-clinical work. This is a problem. You can’t achieve targets if you aren’t looking after people – by looking after wellbeing we can deliver better care for patients too.

‘There needs to be a reorientation of thinking – we need to challenge what is seen as the norm in the NHS.’

Fear, blame and isolation An adverse environment is holding back staff and affecting patients, says BMA council chair Chaand Nagpaul People become doctors because this career embodies their values. It’s a long and arduous journey and it is a commitment that extends beyond working days.

Yet many doctors find themselves in a working environment that, instead or recognising this commitment, perversely works against them. Our own survey shows that nine out of 10 doctors feel they can’t provide safe, high-quality care because of the stress and strain placed on themselves, colleagues and the wider system.

To add insult to injury, if things do go wrong, more than half of doctors fear they will be blamed for errors caused by system and capacity issues and only half of doctors would feel confident to raise concerns.

Not only does this adverse environment prevent doctors from achieving their best but it is also denying patients the full potential skills and capability of care from our medical workforce.

Given this tough – and often unfair – working environment, one would expect employers to support frontline staff and offer them gratitude, understanding and support – rather than a culture many doctors inhabit of fear, blame and isolation.

As part of our Caring, supportive, collaborative project, the BMA will continue to campaign for an NHS that has adequate resources so that doctors can do their best for patients, underpinned by a culture rooted in learning and improvement rather than blame, and which values its workforce as its strongest asset. thedoctor | October 2019 19

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ISTOCK – image posed by model

Pressure points A new study highlights the risk factors to doctors’ mental health, as the BMA introduces a charter to help employers ease pressure on the profession.

Keith Cooper reports

D

octors’ mental health is under attack on multiple fronts from staff shortages, poor basic amenities, and the targetchasing and bullying cultures in the NHS, a major new study reveals.

The report, Mental Health in the Medical Profession, the latest in a series of BMAcommissioned studies in 12 months, pinpoints the chief pressures from interviews with medical students and doctors.

In response to its alarming findings, the association has launched a mental wellbeing charter to help employers

prevent further harm to the profession.

The first study, released earlier this year, found eight out of 10 doctors are at substantial risk of burnout.

The studies are part of a larger project led by the association’s immediate past president and consultant psychiatrist Dinesh Bhugra.

‘If in the NHS, we can’t look after the staff, then we are in really serious trouble,’ he says. ‘This report is important.

It helps us to begin to understand what is going on.

Doctors are professional and for professional reasons they

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want to do their best: they agree to provide cover, which becomes unmanageable.

There are so many rota gaps and vacancies, and now uncertainty related to Brexit.’

This latest study pinpoints five groups of ‘risk factors’ flagged by doctors from interviews and focus groups: systemic; endemic; interpersonal; environmental; and socio-cultural (see pages 22 and 23).

It suggests that doctors often attempt to manage their mental health by requesting more flexible working arrangements. When

CONCERNS NOTED: Doctors feel guilty taking time off because others have to ‘pick up the slack’

denied they are left ‘feeling their proactive attempts to help themselves are futile’.

Lack of flexibility Doctors often feel unable to request time off or reduced hours for concern their posts won’t be filled.

‘Your colleagues have to pick up the slack and it just makes everyone else’s jobs even more difficult,’ one GP partner with a diagnosed mental illness told researchers. ‘People are just very busy. If you have to book a day off, who’s going to cover your work?’ a consultant said.

‘We are running from one thing to the other all the time, firefighting’

The report found that doctors returning to work after illness were frequently not offered ways to ease their transition, such as phased returns or reduced hours.

Even requests for flexible hours for childcare were ‘typically dismissed’, several female doctors told the researchers, ‘as though family life and caring for children are deemed less important than work’.

While many of the ‘risk factors’ isolated from the interviews are within the profession’s power to change, others are outside its control, such as ‘socio-cultural’ ones.

They include the increased tendency of patients to ‘self-diagnose’ or request treatments they find on the internet, and the feeling that ‘public sentiment’ is turning against them.

‘Quite rightly, now you have to explain things to your patients and you have to give people choices,’ one salaried GP with diagnosed mental ill health said. ‘But the idea that you can do that in the same amount of time as when you would… say, “just take the pink tablet”, it is peculiar.’

‘I got bullied by a registrar and there was some belittling going on and again just lack of support’ Professor Bhugra believes the new mental health charter will be a major step forward if employers sign up.

But more needs to be done to identify and ease pressure on stress points on the profession, he says. ‘We can do things differently.’ bma.org.uk/ wellbeingsupport thedoctor | October 2019 21

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Five areas taking the greatest toll on doctors

systemic endemic interpersonal sociocultural environmental

systemic

What comes from above This is the ‘backdrop’ to everything else in your working life – things coming down from above, such as restructures, changes to working practices, often as a result of cost cutting. They include: understaffing; rota gaps; consultation time slots of 10 minutes; and in general, less and less time to look after patients.

‘We are running from one thing to the other all the time, firefighting,’ said one consultant with symptoms of mental ill health but no formal diagnosis.

‘It just feels like we’re being stretched

thinner and thinner. Patients are getting more and more of a poor service,’ said a junior doctor.

Such factors leave many feeling overwhelmed, anxious, and unable to perform at their best.

Respondents called for greater flexible working arrangements for a better work/life balance, longer appointment slots, and the ability to work shorter hours. All could reap rewards longer term by reducing resignations and early retirement.

endemic

What comes with the job Most doctors by definition are exposed to trauma. Over the course of careers such experiences build up and up. Interviewees felt they had no one to offload to or ‘deconstruct’ them. The result can be anxiety, several doctors told researchers.

‘There was a child, a toddler who choked to death on his vomit in an afternoon nap and was found by a teenage sibling,’ said a consultant with symptoms of mental ill health but no formal diagnosis. ‘It was too overwhelming, too close to home.’

The pressure to keep up to date in

5

an increasingly complex profession are also risk factors for mental health, the research says. ‘Scientific improvement in the management of patients is mushrooming,’ said one salaried GP. ‘There is patient pressure, scientific pressure and employment pressure.’ The report calls for more peer support, especially for junior doctors. Each hospital could build a peer support network. ‘Having a named doctor would be good or perhaps just be paired with another medical student from a [later] year,’ one medical student said.

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sociocultural

5

While many doctors think stigma around mental health is decreasing, it lingers still.

Junior doctors worry about being seen as ‘weak’ by superiors. Some older, male doctors remain dismissive of mental ill health, the researcher said.

‘In my time, I don’t think it was the right thing to do to talk about mental health issues,’ one consultant said. ‘People immediately think “oh dear, the poor chap is incapable” whereas that isn’t necessarily so.’

While doctors say some element of hierarchy is necessary in hospital, trainees feel unable to

talk to senior colleagues for fear of a ‘judgement that they just aren’t up to the job’, researchers heard. In some cases, they felt ‘bullied’ and ‘belittled’ by seniors.

‘I got bullied by a registrar and there was some belittling going on and again just lack of support,’ said a salaried GP with a formal mental health diagnosis.

A more open attitude to mental ill health should be fostered at medical school, doctors told researchers. In the workplace, this could be done through inductions, workshops, and the appointment of a ‘mental health champion’.

What comes from the world These are significant stress points for doctors, albeit ones outside their sphere of influence. Patients arrive more informed (or misinformed) about their condition. More come armed to appointments with pages of downloads or ideas about what the ‘best possible treatment’ they found on the internet is. GPs must spend time in short appointment slots explaining why treatments are not there in the NHS. ‘Patients expect us to be there all the time and get back to them straight away,’ one salaried GP said. ‘So there’s definitely a lot of pressure in terms of patient expectation.’ Some doctors said they felt undervalued by the public, prompting questions about their career.

‘We need a sense of being appreciated by physicians, surgeons, and hospital specialists as well as by our patients.’

The BMA has a role to continue to act as a voice for the profession, the report indicates. The Government could be more honest with the public about what services resources allow.

What comes from your workplace Doctors’ jobs have got harder as facilities and resources, such as mess rooms, are closed – and many have been. All interviewees felt their workplaces lacked basic amenities. There is nowhere to cook or prepare food away from patients, no personal space, such as lockers. As a result, many are left feeling undervalued.

Lack of breaktime leaves little or no space for doctors to socialise and relax together, leading to feelings of loneliness and isolation. ‘Any break you get is the time to walk to the sandwich shop and back,’ one salaried GP said. ‘Some days you don’t even get that.’

Protected lunchtime and coffee breaks and dedicated socialising space could help reduce professional isolation, the report recommends.

Efforts to address poor facilities are already under way, of course, with the BMA Fatigue and Facilities Charter. Hospitals could also help by earmarking parking spaces close by and by providing showers.

environmental

interpersonal

What comes from your colleagues

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P

ublic health is an area where the need for action is huge, the stated ambitions can be dazzling, and the extent of efforts pitiful.

Pressure needs to be applied to governments to fulfil ideas and honour commitments, in this area more than most.

The Government published a consultation in July on a ‘new approach to public health’.

Its green paper Advancing our health: prevention in the 2020s promises to bring central and local government together with the NHS to provide a ‘personalised, prevention model’.

The BMA gathered 18 health bodies and medical royal colleges, as well as the

‘When we even start thinking about prevention, we really need to have the resources, and people, in place’

NICOLA FERRARI, GETTY IMAGES

Follow the evidence

TIRC83, GETTY IMAGES

The Government promises emerging technologies will help solve the public health crisis but, after years of cuts, doctors say it should focus on what is proven to work. Tim Tonkin reports

Department of Health and Social Care, for a meeting last month to discuss the merits and shortcomings of the plan – and, importantly, to discuss shared priorities among health and medical professionals for the Government’s approach to preventing ill health in the UK. The paper makes claims about how emerging technologies will reshape the way public health can be delivered in the next decade, from health data gathered from patients’ wearable devices to genomics being used to identify and treat genetic disorders in utero.

It emphasises how it will seek to address existing public health challenges such as tobacco, alcohol and

obesity through measures such as providing cessation support to smokers and increasing the number of alcohol care teams in hospitals and extending social prescribing to one million patients by 2023-24.

Last year, the BMA published its own analysis into the state of public health funding, the findings of which laid bare the extent of the challenges. It found that spending was cut across public health services in England, including drug and alcohol treatment and prevention, smoking cessation, sexual health and obesity services, all contracted between 2016-17 and 2018-19, with this trajectory set to continue

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ISTOCK

across 2019-20. This has happened at the same time as hospital admissions related to alcohol, smoking and obesity increasing.

In highlighting the ‘unacceptable variation’ in services in different parts of the country, the BMA has called for funding cuts to public health to be reversed, while any proposed changes to models of service provision be subject to an audit to determine effectiveness and cost-benefit.

Setting this scene at the meeting with health bodies and medical royal colleges, BMA head of science and public health Rob Wilson said taking a preventive approach was vital not just for patients’ health but for relieving pressure on the wider health service. He said an estimated 40 per cent of the uptake of health services may be preventable through action

FRIEDMAN: The proposals need to be treated with a healthy level of scepticism

RCP

GILMORE: The report is ‘long on jargon’

in areas such as smoking and alcohol misuse.

Faculty of Public Health treasurer Ellis Friedman told the meeting that, while his organisation ‘broadly welcomed’ the green paper’s proposals, its ambitions would need to be treated with a healthy level of scepticism, until the wider issue of underfunding was addressed.

‘I think the key question for us is why should we believe that this time the greater emphasis on prevention is going to work when we’ve had so many similar initiatives over many, many years,’ said Dr Friedman.

Royal College of Physicians of London special adviser on alcohol and past president Professor Sir Ian Gilmore added: ‘It seems to be long on jargon and on catchy things like measuring everybody’s genome. I think overall the emphasis [of the paper] has

been more about catching attention rather than where the evidence already exists.’

The Government has pledged to respond to the consultation and set out its proposals in more detail, by spring next year.

The discussion at BMA House broght to the fore some priorities for medical professionals.

Any response must deliver adequate funding – to reverse the damage done by repeated cuts to the public health grant and to ensure the NHS has the workforce and services in place to meet the population’s needs.

It must address ill health through the lens of a ‘healthin-all-policies approach’ and facilitate greater coordination across the NHS. And, crucially, it must follow the evidence and introduce effective regulation to underpin any action. thedoctor | October 2019 25

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on the ground

A GP saved thousands of pounds by coming to the BMA for advice about her maternity pay There is a huge difference between NHS occupational maternity pay and what you’d receive from the state if you were not eligible. The difference could be tens of thousands of pounds in some cases.

A salaried GP was told by her employer that she did not qualify. Although she had spent several years in the NHS, she appeared to fall foul of the rule which says there must be 12 months’ continuous service. In addition, the employer did not initially believe GPs were entitled to receive NHS OMP (occupational maternity pay).

Highlighting practical help given to BMA members in difficulty

She contacted the BMA for advice.

First, the BMA employment adviser needed to establish the member’s circumstances.

These were a little unusual as she worked not for a GP practice, but an organisation owned by an acute trust.

So, she was subject to NHS hospital terms and conditions, rather than the model salaried GP contract which was negotiated between the BMA and the NHS Confederation.

After training, the GP had a number of short-term periods of employment, which were broken by two very short stints as a self-

employed locum. All other service had been continuous for the purpose of calculating an entitlement to receive NHS OMP. The locum appointments had taken place recently enough to mean that the member did not have 12 months of continuous service leading up to her application.

Had she not contacted the BMA, she may have been left with only SMP (statutory maternity pay). This gives 90 per cent of earnings for the first six weeks, and then £148.68 or 90 per cent of earnings (whichever is lower) for the following 33 weeks.

It contrasts with the NHS scheme which offers eight weeks of full and 18 weeks of half pay (minus SMP), then 13 weeks of SMP and 13 weeks of unpaid leave.

However, her employment adviser pointed out a very significant clause in the regulations, which her employer appeared to have overlooked – that periods of less than three months away from NHS employment, although not counting as service, would be discounted, meaning they would not affect the calculation of continuous service.

The GP took the information to her employer, who agreed that she did in fact qualify for NHS OMP. She told the adviser that ‘it wouldn’t have happened without you and the BMA’.

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the secret doctor

BLOOD SAMPLE: ‘A second episode of venepuncture can be a very big deal indeed’

I always keep to the two-sample rule.

Just like I always eat my vegetables The GMC says that one of the primary duties of a doctor is to be ‘open, honest and [act] with integrity’. Whatever your reservations about the GMC, this is very hard to disagree with Naturally, everyone would wish doctors to be honest and truthful, and the damage that can result when they aren’t is potentially profound.

I’ve never met doctors who would deny it is their duty to be honest. Sure, we may all have slightly different thresholds concerning telling the whole truth – is our confident reassurance to a dangerously ill patient always strictly truthful? – but very few of us would be willing to tell an outright lie.

Or so you might think. Now, kindly turn to your hospital’s blood-transfusion policy.

Most hospitals require that, before blood can be issued for transfusion, two samples for crossmatching must be supplied, taken by different individuals on separate occasions.

This is national guidance and has been shown to improve transfusion practice.

(The direct evidence that it actually improves outcomes seems pretty limited – two singlecentre observational studies – but leave that to one side for now.)

In lots of cases, the two-samples rule works fine. It’s not a big deal to obtain a second blood sample from a reasonably healthy elective patient. But for people with learning disabilities, young children, needlephobic adults, or those unlucky enough to have difficult access, a second episode of venepuncture can be a very big deal indeed.

Where taking blood involves physical restraint or sedation – and when the patient doesn’t understand what’s being done to them it sometimes does, despite Ametop and distraction – repeating the process can seem like needless cruelty.

I value my GMC number and therefore, for the purposes of this article, have never taken two crossmatch samples simultaneously and podded them to the lab half an hour apart, with different signatures on the tubes. But I have certainly heard of it being done, by colleagues about whose integrity I otherwise do not have the slightest doubt.

Were they wrong? If they were, what should they have done instead? Strict honesty clearly requires they undertake venepuncture twice, but if that was your screaming two-year-old, or your terrified autistic sister being held down, what would you want them to do?

The result is that large numbers of doctors and nurses end up, essentially, lying. Most of them feel bad about it but they would feel even worse about the alternative.

Surely, any rule or system which forces people into either dishonesty or (as they see it) acting against a patient’s best interests can’t be right? We need to give senior clinicians the flexibility to make exceptions, even to the most well-intentioned rule.

By the Secret Doctor bma.org.uk/secretdoctor @TheSecretDr thedoctor | October 2019 27

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the consultation

STOKE SENTINEL/BPM MEDIA

The Doctor will see you now

Roger Bloor, a retired consultant psychiatrist from Staffordshire, served in the RAF and later established a drug and alcohol service. He won the 2019 Poetry London Clore Prize. He talks to Keith Cooper My poem’s about Molly Leigh.

Her grave is in a churchyard, in Burslem, four miles from where I live, a visible reminder of her. She was accused of being a witch hundreds of years ago. Small children danced around her grave. The poem gives her a chance to respond to her accusers.

He showed me the value of writing, as a way of expressing a previously unheard voice. Like a lot of people, I started writing at school, inspired by an extremely enthusiastic and talented English teacher. I’ve written a lot on and off, since then. Work, of course, gets in the way.

There are sections of society who don’t have a voice. People with drug and alcohol problems or mental health issues. They often don’t have an opportunity to have their voices heard.

Through literature, poetry and writing, you can do that. I write more about local history and historic characters.

Medicine is a hard taskmaster.

You need outlets to help manage its stresses and pressures. That’s what writing does for me. I can express feelings, distract myself. There’s lots of facets of creativity which are useful.

One of my patients was The Railway Man. Eric Lomax, a prisoner of war in the Far East, was one of hundreds I saw as an RAF psychiatrist. He handed me 50 type-written pages about his time in Siam and Malaya. His book later became a film with Colin Firth and Nicole Kidman.

RESTING PLACE: The grave of Molly Leigh in Burslem, Staffordshire

BLOOR: Writing can give a voice to the voiceless

I’ve helped edit an anthology for new medical students at Keele University. There are poems about being a doctor, a patient, and specific diseases. It’s a message for them, from day one. Yes, the formal curriculum is important, but so are lots of other things if you’re to survive as a good doctor.

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it happened to me Doctors’ experiences in their working lives

FRACTURED CONFIDENCE: A young girl’s slip in the playground led to a learning experience

Let us be entirely open. You first ...

‘Can I have a minute before you start?’

It was my consultant, and there was tension in her voice. My heart began to pound.

‘Do you remember a patient from Monday with a sore right ankle?’ I couldn’t. Not at first anyway, such is the numbing effect of having worked seven days straight in the emergency department.

My consultant loads up the X-ray images and I see it’s the ankle of a young girl who had slipped in the playground. I’m fairly sure I had sent her home with a diagnosis of a sprain to rest, elevate and use ice and painkillers.

‘Did you notice anything on her X-rays?’

I see nothing. Then she clicks to the lateral image. There, clear as day, is a severely broken and displaced fibula. The shaft of the bone is pointing awkwardly forward and the loose tip is ragged-edged and floating below. I’d missed the fracture.

‘You did miss the fracture. But the good news is you gave excellent safety-net advice and they came back the next day.’ She pauses and I relax a little. ‘The bad news is they’re making a complaint.’

We go on to talk through the details of the case and the learning points to take away.

She brings the discussion to a close and I get up to leave.

‘And don’t forget to write something in your portfolio!’ she says with a wink. At the end of my shift I sit down to do just that. But then I

pause and wonder, what exactly should I write?

Our portfolios are intended to facilitate our learning and be a record of our professional development. But the question remains: how do we, as professionals, manage the potential public consequences of those inevitable lapses and foibles in an increasingly litigious age?

Legal cases have highlighted that, while our portfolio entries may feel private, they are, in legal terms, written materials that are not protected by any special legal privilege.

We all make mistakes; we tend to feel awful about them but the fact is mistakes are an invaluable educational resource and keeping a record of this learning is undoubtedly important.

So, how do we balance sincerity and transparency with professionalism and career preservation? A worldly-wise colleague and friend once advised me to use the ‘front-of-thebus rule’ when it comes to our communications with others.

Consider yourself sitting at the front of a busy bus unsure of who is occupying the seats behind you. Would you loudly proclaim whatever it is you are about to write or say? If the answer is yes, go forth and hit send. If the answer is no, perhaps think twice.

Maria Kiesler is a junior doctor in Manchester. She writes under a pseudonym thedoctor | October 2019 29

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and finally...

Why Suez was no crisis for my medical career ‘You wouldn’t even get into the toilet of any selfrespecting medical school these days.’

Not long ago my best friend’s crude but probably accurate observation when we were discussing how we became doctors. So, I told him how I was accepted, all those years ago.

You might have heard there is a fine line between genius and insanity. Well, that’s not my story. But I mention it because, back in Ireland in the middle of the last century, there was thought to be a similarly fine line between dyslexia and stupidity. In fact, it was worse than that because dyslexia was not even recognised.

My years of schooling were unhappy and unrewarding, marked by amusement from my classmates and vicious reprisals from my teachers, who often were convinced that my malapropisms were contrived. At 16, my only ambition, when it came to education, was to leave it, and the only thing I wanted to learn was how to ride a motorbike so that I could become a dispatch rider.

My father had other ideas.

He wanted me to follow

my brothers and sister and become a doctor like himself.

But this was to be no dynastic shoo-in. He was going to put everything into my application. So, he used his experience as an ex-teacher to prepare me for the entrance exams.

The process was a little different from now and included questions on history, geography and English literature. My father

and my father had a hunch that the contemporary obsession with Nasser would have even permeated the hallowed walls of the Royal College of Surgeons in Ireland, and the heads of the examiners setting the papers.

So, my preparations for a life in medicine became centred almost entirely on the history and politics of the Suez Canal. My father’s judgement on the exam

PA

NASSER: An unlikely inspiration

was an exceptional teacher and it is he who will always have the main credit for me becoming a doctor. I say the main credit because an honourable mention needs to go to one other person. He was one Gamal Abdel Nasser, the president of Egypt.

Nasser nationalised the Suez Canal in July 1956; a direct challenge to British imperial ambitions (which might explain why we in Ireland took a very strong interest in it, too).

Successful exam preparation is partly about tactics and partly about luck,

content was perfect.

So, it was in October that year, I was one of a number of pre-registration medical students about to embark on a year of the sciences prior to learning medicine.

And looming over the years that followed, which I spent as an ophthalmologist rather than tearing up the road on a motorbike, is the austere and unlikely figure of President Nasser.

Peter Docherty is a retired consultant ophthalmologist from Derby

30 thedoctor | October 2019

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what’s on October 22 Critical appraisal workshop – part 2, London, 9am to 4pm

November 01 Planning for retirement – delivered by the BMA, Manchester, 9am to 4pm 01 Working together: overcoming gender bias in medicine, London, 9am to 5pm 15 SAS: Your wellbeing matters, Templepatrick, County Antrim, 9am to 4.30pm

19 Practical skills for improving personal leadership, London, 9am to 5pm 20 Practical skills... leadership and management for doctors, London, 9am to 5pm 29 Planning for retirement – delivered by the BMA, Oxford, 9am to 4pm

December 06 Planning for retirement – delivered by the BMA, Birmingham, 9am to 4pm

15 Excellence in medico-legal report writing, London, 9.30am to 4.30pm

Visit bma.org.uk/events for full details Download the BMA events app at bma.org.uk/eventsapp thedoctor | October 2019 31

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