The Doctor – issue 7, March 2019

The magazine for BMA members

thedoctor

Issue 7 | March 2019

On the edge of the abyss A ‘Brexit dividend’ of chaos and uncertainty for doctors

Taking exception

The doctors leading the way in reporting unsafe working conditions

LOLs and trolls

The one-sided world of social media sniping and the GP who fought back

The cutting edge

How the increase in knife crime is leading to new ways of working

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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

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.

The Doctor is a supplement of BMJ vol: 364 no: 8191

Senior staff writers Peter Blackburn (020) 7874 7398 Keith Cooper (020) 7383 6390 Staff writer Tim Tonkin (020) 7383 6753 Northern Ireland news email news@bma.org.uk Scotland correspondent Jennifer Trueland 07775 803 795 Wales correspondent Richard Gurner 07786 035 874 Senior production editor Lisa Bott-Hansson Designer Alex Gay

ISSN 2631-6412

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In this issue 4-5

Briefing Success in campaigns for presumed consent in organ donation and free sanitary products in hospitals

Welcome Chaand Nagpaul, BMA council chair Brexit poses a major threat to the NHS and patients.

Our health service relies on EEA (European Economic Area) doctors and medical researchers, the mutual recognition of professional qualifications between the UK and the EU, the smooth supply of equipment and medicines and access to European research programmes and funding.

However, the NHS has been given little understanding or consideration during the two and a half years since the referendum. As a result, the loyal and hard-working doctors caring for patients in our health service, who qualified in other countries across Europe, have lived through months of uncertainty – unsure about the stability of their employment, unclear about their future career aspirations and feeling unwelcome in the country where they set up home.

The shambolic handling of the Brexit process – and the resulting effect on our colleagues – is poignantly summed up in our cover feature, which tells several moving personal stories.

Among the EEA staff The Doctor spoke to is intensive care senior clinical fellow Michael Kalogirou, who moved his family from Greece to live and work here six years ago. The NHS needs Dr Kalogirou, he does not want to leave, but he is in limbo. His story echoes so many others around the country.

In another piece we look at the effect of one-sided online feedback on GP surgeries who can feel personally attacked and defenceless.

The March issue of The Doctor also features an in-depth look at the system of exception reporting. The exclusive investigation by our writers shows how exception reports are being used across the country and what life is like on the front line for junior doctors. It paints a picture of under-staffed wards, exhausted doctors acting up and concerns with patient safety. Not only does exception reporting build a true picture for the first time but it urges hospital trusts to take action to improve care for patients and the wellbeing of staff – and to do so based on good evidence.

In many areas, this process has been very positive, but lots of hospital trusts have much more work to do. Ultimately, we need a health-service culture that welcomes exception reporting and raising concerns as part of learning and continual improvement to provide safe, quality care.

6-9

Life on the edge Whatever happens with Brexit, doctors who qualified in other European countries have faced crippling uncertainty

10-13

Lies, damned lies How one GP fought back against hostile and inaccurate online reviews

14-19

Taking exception The doctors pressing for a more open culture of reporting excessive working hours and missed training opportunities

20-23

A cutting-edge approach An increase in knife crime has led doctors to explore new ways of working together

24-25

On the ground Our round-up of the issues faced by doctors at work, resolved with BMA help

26-30

Life experience What goes wrong when you stint on admin staff, and the theory and practice of breaking bad news

31

What’s on Keep on top of events

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WILSON: Delighted that sanitary products will now be freely available

Heart of the matter

briefing

A 20-year campaign waged by the BMA and others came to an end last month, as politicians endorsed legislation that will usher in an ‘opt-out’ organ donation system in England for the first time.

Set to come into operation by 2020, the change in the law means that there will now be presumed consent to donate the organs of the deceased for patients in need of transplants, unless it is clear they did not wish to donate – a decisive move away from the stated consent required under the traditional opt-in system.

With similar legislation already enacted in Wales and planned for

Current issues facing doctors

04

A campaign for dignity What price dignity? Well since you ask, 71 pence.

That was the estimated cost, per bed, per year, of providing sanitary products to patients, which the BMA uncovered in a Freedom of Information request.

Despite the negligible cost, the BMA also found that 42 per cent of trusts and health boards in the UK either did not supply such products at all, supplied small amounts or only provided them in an emergency.

Eleanor Wilson, the medical student whose successful call at last year’s BMA annual representative meeting for sanitary products to be provided fired up the association’s campaigning, said patients were having their dignity withheld from them. It was profoundly unjust.

Now, just a few months after Ms Wilson received overwhelming support from her fellow BMA members, she has also received support from NHS England chief executive Simon Stevens, who said all women and girls cared for by the health service would be able to ask for sanitary products free of charge from this summer.

The Welsh government has made a similar commitment, to be introduced ‘as soon as possible’.

Ms Wilson said: ‘I am so delighted that an issue, which doctors brought into the public domain only last June, has now been addressed for the benefit of so many women.’

It just goes to show what can be achieved when an issue is brought to the ARM, and there is an overwhelming moral case and good research underpinning it. Many other issues are raised there, and it can take a lot longer for the Government to be receptive. But campaigners on a wide range of subjects can at least look to the success of this initiative and realise that Whitehall is not always a brick wall.

in Scotland, the move to an opt-out system in England has been a long and arduous process, although the only ‘wait’ that really matters is the one faced by transplant patients, something the new bill should do much to ameliorate.

According to the NHS, patients needing new kidneys have to wait on average two and a half to three years before suitable organs become available for transplants.

While not as protracted, the wait for a liver transplant averages out at 135 days for adult patients and 73 days for children.

Organ transplantation undoubtedly

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has the ability to transform a recipient’s life, with the number of people alive thanks to donor organs surpassing 50,000 two years ago.

However, the sad reality is that many patients simply aren’t able to wait long enough to realise this possibility, with 411 people in the UK dying while awaiting transplants in the year to 31 March 2018 alone, and a further 755 removed from the list, mostly because of deteriorating health, and many of these are likely to have died soon after.

Delays in surgery are frequently owing to a shortfall in suitable organs resulting from an insufficient number of donors; a situation exacerbated by the traditional ‘opt-in’ donation

system, which requires people to state they wish their organs to be donated following their death or their family to agree to donation, when they are recently bereaved.

It was for these reasons that the BMA formally endorsed calls for a shift to presumed consent for donation back in 1999.

BMA head of ethics and human rights Veronica English said: ‘It will have a positive impact on donation rates but we believe that over time it will lead to a cultural change so that organ donation is seen as the norm, rather than as the exception.’

Keep in touch with the BMA online at

WRIGLEY: NHS needs to understand what will motivate doctors to stay

Together we stand It is not only the crumbling hospital estates and cramped GP surgeries that are ageing in the NHS – the staff are, too.

A report from the BMA – Supporting an Ageing Medical Workforce – reveals that 47 per cent of NHS staff are now aged 45 or over, with six out of 10 consultants or staff, associate specialist and specialty doctors and nearly half of GPs over the age of 45.

The causes will make for familiar reading. The NHS has been in the midst of a recruitment and retention crisis for many years. Perhaps most problematically, the health service has an often-justified reputation as an inflexible employer with an accompanying poor work-life balance and real risk of burnout.

The problem is exacerbated by the experiences of many doctors working in the NHS who are, in many cases, looking at early retirement as their personal health and wellbeing suffers following years working on the stretched front line.

These problems need to be addressed urgently, the BMA report suggests, with the development of part-time or flexible working ramped up, additional support for staff moving towards retirement, a free specialistled occupational health service and adequate rest facilities all serious priorities.

BMA council deputy chair David Wrigley said: ‘The NHS needs to understand why doctors retire and what will motivate them to stay working. Our report highlights the support required for those doctors who wish to work past retirement age including allowing flexible working arrangements, having time to practise the most enjoyable aspects of medicine and support with workload to prevent burnout.

‘Older doctors can contribute their

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skills in other ways and the NHS must recognise and support this, while the Government must review pensions arrangements for working doctors and for doctors in retirement so that they are not disadvantaged financially by deciding to return to the workplace.’

The BMA report also calls for employers to look at non-clinical opportunities for medical staff to move to – like working in management, teaching, research or as appraisers to ensure that doctors are able to contribute their skills in other ways to the NHS.

Read more online Survey to ‘spark debate’ on primary care in Scotland Brexit: put patients first, say doctors Call to roll out workers’ mental health guardians Risk of GPs owning premises reduced Read all the latest stories online at bma.org.uk/news

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LIFE on the edge Whatever happens with Brexit in the weeks ahead, thousands of doctors who qualified in another European country have suffered crippling uncertainty.

Tim Tonkin hears their concerns

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‘Brexit makes you feel like you’re not accepted’

hile the prime minister struggles to find a Brexit that pleases a few hundred MPs, there are a good few thousand doctors who feel considerably less consulted on the details, and who view what is happening with dismay.

Doctors who qualified in other EEA (European Economic Area) countries – 9 per cent of all those licensed to practise in the UK – have had their loyal service rewarded with years of uncertainty since the referendum in June 2016.

There are very many concerns the BMA has been highlighting on the implications of Brexit, especially in the event of leaving without a deal.

These include the supply of radioisotopes for cancer treatment, the end of reciprocal healthcare arrangements, and the return of a hard border between Northern Ireland and the Republic.

But in some ways, it’s the stories of individual doctors – many of whom were drawn to the NHS and who expected to spend their full working lives here – which are the most compelling rebukes to political intransigence and inactivity.

Senior clinical fellow in intensive care Michael Kalogirou came to the UK from Greece in 2013, after the challenging economic climate in his home country left him unable to secure employment.

Having never visited the UK before, Dr Kalogirou spent his first six months in the country alone before being joined by his wife

and two children.

‘I came from Greece in 2013 because there were no interesting hospital jobs. I wanted to expand my knowledge in intensive-care medicine, so I decided to come to the UK. ‘The NHS differed a lot from the system that I was used to in Greece which [back in 2013] was quite chaotic.

Here I found the NHS was much more organised and everything I wanted [in my job] was available. In Greece from 2009 to 2013 we lacked basic things like gloves and gauze, the situation there was very difficult when I left.’

After securing a job at the Royal London Hospital, Dr Kalogirou says he and his family began to adapt and start to enjoy their new lives in the capital.

‘We settled in to life in London quite easily. My kids went to an English school rather than a Greek school as I thought it would be of benefit to them to learn another language and experience a different school system.’

The cloud descends When the EU referendum result arrived in June 2016 he says it felt like a cloud had suddenly settled over his life and sense of belonging in the UK. ‘It’s not a good thing, [Brexit] makes you feel like you’re not accepted now, although in my everyday experience this is not the case,’ he says.

‘It is still not decided how it will happen; a no-deal Brexit is still in the air and seems like a high possibility now and that bothers me a lot.’

A policy paper on citizens’ rights published by the

Department for Exiting the EU insisted EU citizens and their family members living in the UK would be able to stay even in the event of a no-deal scenario.

The paper added that eligibility for the EU Settlement Scheme for all those already living in the UK by 29 March would also remain in place under no deal.

Having lived continuously in the UK for more than five years, Dr Kalogirou has been able to apply for settled status, which has given him and his family a certain degree of reassurance over their futures in the UK. However, he is worried that Brexit, particularly a no-deal scenario, could potentially make it harder for his family in Greece to come and visit.

He adds that he also worries about the overall effect leaving the EU could have on the UK economically.

He adds that because medical posts such as his tend to be offered on sixto 12-month contracts, he also has the lingering concern over the stability of his employment in the UK. ‘Until there’s a deal on paper that’s signed and agreed I will not feel reassured,’ he says.

Dr Kalogirou adds he still has a home in Greece and could return there to find work but adds that he and his family want to stay in the UK. ‘I have no imminent desire to go back; we’re quite happy and settled here and feel very happy doing the job that I do – it’s very rewarding. If the situation meant that I felt that I had to leave, it would not be an easy decision.’ thedoctor | March 2019 07

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CERONI: ‘After the vote, living in the UK felt “different”’

‘After the vote I did not feel as welcome in the UK as I had before’

Rights at risk As a process, Brexit appears to have been all about the necessity of tough decisions.

For European doctors who have come to the UK to train or work in the NHS, constant uncertainty and having to decide whether to leave or to stay is something they have had to deal with for more than two years.

A survey of EEA doctors published by the BMA in November 2018 reveals some sobering realities as to the outlook of European doctors working in the NHS less than six months away from the UK’s exit.

The survey found that 78 per cent of respondents were not convinced or assuaged by the Government’s pledges to protect their rights after March in the event of no deal.

This lack of trust is all too familiar to one Belgian junior doctor who arrived in the UK just a month after the vote to leave to join her partner, another EU citizen.

The doctor, who asked

not to be named, spelt out her concerns as to what the reality of life after Brexit might be for her and for the health service.

‘I came to the UK shortly after qualifying in Belgium at the end of July 2016 and started my first job in the NHS just over a month later,’ she says.

‘The result of the referendum was announced on the day of my graduation, although I had already finalised our plans to come here. Obviously, we were quite shocked and a bit uncertain as to how this [Brexit] would affect any future we might want to build in the UK.’ She adds that while being in a training post gave her some security towards being able to remain in the UK for at least the next few years, she is already concerned as to whether any qualifications gained here would be recognised if she moves to another part of Europe.

She says that the loss of freedom of movement post-

Brexit would have a significant effect on the NHS and describes Brexit negotiations as having been a ‘complete shambles’.

‘I feel a lot of politicians are just attacking one another because of their personal attributes and that a lot of the political parties are being very selfish and pushing their own agendas rather than trying to come to a compromise as to how Brexit should be carried out,’ she warns.

‘Looking back at the Windrush scandal it’s hardly reassuring that if something like that can happen to people who have been living here for 30-odd years, how can they [the Government] provide any assurance that something similar won’t happen to EU citizens 10 years down the line?’

Moving on In its survey, the BMA finds that although 66 per cent of respondents said they were committed to working in the UK, a sizeable 35 per cent were considering moving abroad.

‘A no-deal Among the reasons cited Brexit is still for this position were: – the UK’s exit from the in the air EU in general along with and seems the attendant effects of like a high negative attitudes toward possibility EU workers now and that bothers me – uncertainty over personal immigration status a lot’ – the Government’s treatment of EU citizens.

‘One of the reasons that my husband and I left was that we felt uncertain about our futures and our child’s future, even if the Government says that we are still welcome,’ says Italian junior doctor Federica Ceroni.

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Upon arriving in the UK in 2012, having gained her medical qualification in Italy the previous year, Dr Ceroni first worked in Basildon, followed by stints in Luton, Watford and eventually Great Ormond Street.

Despite intending to gain only a few years of experience in the UK, Dr Ceroni decided to begin specialty training in paediatrics.

‘Initially, I came to the UK just to gain a couple of years of experience in another country, mainly because I have English as my main second language and because my husband [who works in finance] was being transferred there.

‘I ended up staying longer and starting to put down roots. After Brexit, however, the situation changed. After the vote living in the UK felt “different”, difficult to explain.

I did not feel as welcome [in the UK] as I had before … it felt as if all that I had done while in the country had not been appreciated.’

While emphasising that most of her patients were sympathetic and apologetic regarding Brexit, Dr Ceroni says that after her husband, who works in finance, was relocated from the UK by his employer, she took the decision to take an out-ofprogramme career break and has now returned to Italy where if she wants to work as a trainee, she has to apply again, probably losing the years done in the UK, owing to how the Italian training system is legislated.

She has grave concerns for the fate of the NHS in the aftermath of the UK’s exit from the EU and feels the

referendum has permanently changed her perspective of the country.

‘Before the vote, the NHS was talked about as one of the priorities for Brexit in the sense that they make people believe if the UK left there would be more money for the health service,’ she says.

‘Obviously, this hasn’t happened and won’t happen because I don’t think the NHS is a priority for the Government at the moment.

‘The NHS will lose precious staff coming from Europe, not only doctors but nurses and other professionals who will not come or will go back or to another country because of the situation [in the UK].’

Following the association’s latest survey of EEA staff, BMA council chair Chaand Nagpaul wrote to Theresa May to urge her government to give further reassurances on the rights of EU citizens following Brexit.

He said: ‘Doctors from Europe are a much valued and integral part of our NHS. The past two and a half years of Brexit negotiations have been an unending ordeal for them. It is clear from the BMA’s latest survey that many of these doctors feel either uncertain about their futures in the UK or even unwelcome, despite the Government’s attempts to address these concerns.

‘While the BMA welcomes the Government’s pledges to maintain EU citizens’ right to remain even in the event of a no deal, ministers have a responsibility to offer further assurances while the final outcome of the UK’s exit from the EU is yet to be determined.’

BMA spells out risks of Brexit Following the referendum, the BMA wrote to the then prime minister David Cameron (pictured) warning of and condemning reports of xenophobic attacks on NHS staff across the UK. Over the past two and a half years the association has produced numerous briefings on a range of subjects relating to Brexit including the UK’s future immigration policy, reciprocal healthcare arrangements and the dangers of a no deal.

BMA Northern Ireland council chair John D Woods wrote to the former secretary of state for Northern Ireland James Brokenshire, outlining the unique risks posed by Brexit and, in particular, a return to hard borders could have for healthcare in Northern Ireland and the Republic.

In its asks for Brexit the BMA has highlighted the granting of permanent residence for EU doctors and medical researchers in the UK, as well as free movement for healthcare and medical research staff. It has also called for a commitment to a continued mutual recognition of professional qualifications between the UK and EU and for the Government to maintain access to European research programmes and funding.

At its 2018 annual representative meeting, the BMA formally endorsed calls that Brexit poses a major threat to the NHS and patients. thedoctor | March 2019 09

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Taking on the trolls GPs are vulnerable to anonymous, malicious and wholly inaccurate ‘reviews’ posted online. Keith Cooper finds out how one doctor responded

‘People have discovered the Twittersphere and the reviewersphere as places where you can put up anything you like’

T

ap, tap, tap. With a few key strokes, GP Naz Pambakian brings up the Google reviews of Crown Street Surgery in Acton, west London, where he has worked for three decades.

‘Biggest bunch of wallies you will find under one roof,’ he quotes from one without looking up.

‘I probably wouldn’t do anything about this. You do get a bit savvy about reading reviews, don’t you?’

Other posts about the surgery are more positive. ‘I am so impressed with the great service,’ one states.

‘Everybody is very friendly.’

They’re a mixed bag, like those for other practices across the UK. ‘Wonderful… shambles… best doctors going…’ are but three comments we easily found for different ones, all officially rated ‘outstanding’.

Crown Street Surgery is seconds from a precinct of supermarkets, a barber shop and market stalls, topped with colourful canopies. It’s where Dr Pambakian and his five partners care for 8,500 patients across an increasingly gentrified area, like many in London, where council blocks are felled and wealthier folk move into private flats, raised from the rubble.

We meet in his surgery on ‘administration day’. He’s in civvies of jumper and black jeans and begins talking about Harvey, son of TV celebrity Katie Price, who has been in the news for being cruelly trolled online.

‘I’m not in the same league, as Harvey,’ he says. ‘That poor kid and his mother have suffered a hell of a lot.’

Dr Pambakian thinks it’s about time doctors stuck their heads above the parapet about online reviews and he is happy to do so.

‘People have discovered the Twittersphere and the reviewersphere as places where you can put up anything you like without fear of recrimination,’ he adds. ‘Personally, I would like to see that change. We’ve had the internet for a fair few years but the law just isn’t evolving rapidly enough.’

Inaccurate claims So, what has pushed this GP to call time on the online commentariat?

He’s not against people offering personal views. ‘I’m very happy for people to subjectively say that I’m not a good doctor. No doctor can please everybody. Some love you, some hate you. That’s normal.’

What he cannot abide is how inaccurate claims are posted online and that, as a doctor, he and his practice are helpless to have them removed.

‘Under current practice, people can post whatever they like without worrying about the consequences,’ he says. Every review is emailed to the practice partners and the practice manager, who deals with them.

However, confidentiality rules prevent Dr Pambakian from going

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MATTHEW SAYWELL

PAMBAKIAN: ‘We’ve had the internet a fair few years but the law just isn’t evolving rapidly enough’

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MATTHEW SAYWELL

ONLINE RATINGS: Dr Pambakian keeps an eye on patient reviews of his GP surgery

‘Practices are left frustrated at the unwillingness to remove comments from these sites’

into detail about the one we’re here to discuss. He has shared his redacted correspondence with his MDO (medical defence organisation) about it and all identifying details are removed.

His first email to the MDDUS includes the text of the review and his draft response letter to the patient.

‘As my good name and reputation of 28 years is at stake, I would value a response very soon,’ it says.

The letter, which he never sent, says he is ‘somewhat puzzled’ by the ‘inaccurate’ review. He flags how the patient can officially complain, through the GMC, the Parliamentary and Health Service Ombudsman and his surgery’s website.

‘In my view, complaining about medical services via social media is an untried and tested medium.

I have grave concerns about the validity of it.’

The response from the MDDUS arrives within days. It warns against sending the letter as parts could be ‘misinterpreted as antagonistic’.

It suggests an apology, to ‘simply acknowledge this review’ and ‘invite the patient’ to submit a formal complaint in writing.

Dr Pambakian’s response is similarly swift. ‘The reply I received

from my “defence” organisation leads me to question which definition of “defence” is not being understood,’ it says. ‘I have been the subject of defamation of character… based on false evidence.’ It makes crystal clear his comments are not directed at the adviser personally.

‘I abhor the “Aunt Sally” approach to complaints in the NHS at present, ie: here are the dummies – feel free to throw anything you like at them without fear of recrimination or challenge,’ he says.

The heat of this exchange, almost two years ago, has somewhat cooled, from the calm tones in which Dr Pambakian reflects on the experience now. ‘At the time, I was quite stirred up,’ he says. ‘I felt the injustice of people putting things up which are just factually incorrect.’

He was irked by the MDDUS’s initial response but understands its advice.

‘They are looking after your back, ensuring you don’t inflame matters,’ he says. He sought advice about suing but was deterred by the risks posed by a costly legal fight. In the end, no letter was sent. ‘There would be a breach of confidentiality if I sent it to the wrong address,’ he says. He did what doctors do: sucked it up and included the complaint in his portfolio of feedback for the revalidation of his medical licence.

Lack of protection But that won’t stop him calling out ‘nonsense in the air’ when he sees it. He’s serious too about standing up to what he calls the ‘tweet, bang, send’ complaints which doctors must increasingly manage and which the GMC and MDOs insist doctors must take seriously.

There’s a story told by this close-toretirement GP which hints at a source of anxiety about this new fashion of complaints. ‘I’ve worked as an expert witness for [MDO] cases,’ he says. ‘In one I was involved with, the doctor had seen a patient, just one month before his retirement in 2008.

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The case finally came to court in 2016, so he spent the first eight years of his retirement with this damn thing hanging over his head.’

While the stress caused by online reviews is not as great as a trial in court, they do nevertheless place a strain on doctors and their staff.

Dr Pambakian proposes a way in which laws could be changed to catch up with the internet age.

‘If a patient puts up something which is factually incorrect, they should lose their right to confidentiality about that item and we should have the right to reply,’ he says. ‘This wouldn’t cover anything clinical. We don’t want to be able to say, “no, you’re wrong. The swab showed you had gonorrhoea”.

Nothing like that. Just administrative, ordinary issues outside of the clinical environment.’

The six partners at Crown Street Surgery have challenged social media postings by patients and families, which did not touch on clinical matters. Once, after a patient posted something ‘personally derogatory, bordering on racist’ about a member of staff.

‘As an employer, you have a duty to your employees as well,’ Dr Pambakian says.

He says he’s no longer angry about the inaccurate post but would sue for defamation if he won the proverbial lottery.

‘I would love to send a message that you can’t post things that are factually incorrect and expect to get away with it,’ Dr Pambakian adds.

‘There’s a point here to be made about what people can and can’t put up on Google.’

GMC advice The Doctor asked Google how it moderates comments posted on its review sites, how many requests it receives to have them removed and how its approach fits with its maxim to ‘not be evil’. The company’s response was to send us a link to its policies

on ‘user-contributed content’, which includes an option to ‘flag and fix inappropriate content’.

The GMC, which sets rules on how doctors should respond to complaints, admits online platforms are increasingly perceived as a problem, though it welcomes the new ‘avenues’ it opens for feedback.

‘It can be frustrating and upsetting for doctors to see criticisms on social media,’ says GMC medical director and director of education and standards Colin Melville. He urges a cautious approach. ‘Any reply could inflame the situation; our advice is that doctors should usually refrain.’

Dr Pambakian’s MDO, the MDDUS, from which he has sought advice about that one particularly painful comment, has seen a ‘growing range of cases’, its medical adviser Naeem Nazem says. These include ‘critical or abusive social media posts, purportedly from patients’, Dr Nazem adds.

The problems presented by online reviews are recognised by BMA GPs committee chair Richard Vautrey. Websites such as Google and NHS Choices too often aggregate small numbers of ‘unrepresentative comments’ to create ratings with ‘no basis in reality’, he says. ‘Practices are left frustrated at the unwillingness to remove comments from these sites.’

He raised GPs’ concerns about the ‘unfair, unrepresentative’ NHS Choices website in a letter to NHS England last year.

‘We would urge you to radically review how patients’ comments are made on NHS Choices and to remove the rating system that is currently displayed,’ it says.

Dr Vautrey wants change too, but it’s change that will have to come from the top.

‘Much more needs to be done by system managers to resolve this problem and produce more accurate information for patients.’

VAUTREY: Ratings often have no basis in reality

‘If a patient puts up something which is factually incorrect, they should lose their right to confidentiality about that item’

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NEIL TURNER

TRAILBLAZER: Cameron Spence promotes the merits and importance of exception reporting

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Taking exception Exception reporting can be a force for change in the health service – identifying rota gaps, missed training and excessive hours, which can demoralise staff and harm patient care. Tim Tonkin meets the doctors urging a more open culture of reporting

‘I

feel that this level of working is unsafe for me and for patients.

I find myself having to rush through tasks... Sometimes I do not have time to fully process patients’ results or go through their prescription forms as I am overwhelmed by the number of jobs to do.

‘Sometimes, I feel as if the consultants on the ward do not fully appreciate that I am only a junior doctor. The consultants still expect their urgent tasks to be carried out and this results in me having to stay late to finish tasks and print blood forms for the next day.’

That, and pressure from management to discharge patients before they are medically fit to go home, forms part of an exception report filed by a junior doctor from the North West Anglia NHS Foundation Trust.

It is one of tens of thousands of reports under a system introduced with the new junior doctor contract in England in 2016. Voices which may otherwise have been lost, their concerns unheard.

Exception reporting was designed to provide juniors with a means of raising concerns in real time about deviations to their work

schedule – an agreement setting out working hours, training and education also enshrined in the new contract.

The dual aim of the reporting system was to allow individual trainees to seek redress for instances where the terms of their work schedule have been breached, as well as helping departments to identify and address systemic problems resulting from understaffing or poorly arranged rotas.

There is a requirement in the contract for exceptionreporting data to be presented by guardians of safe working to trust boards and local negotiating committees so the information can be publicly scrutinised.

The Doctor sent FoI (Freedom of Information) requests to 129 NHS trusts to research the extent and content of exception reporting.

The 80 that responded said there were a total of 28,194 exception reports submitted between October 2016 and March 2018.

‘Only doctor on ward today, apart from consultant,’ one junior working for Burton Hospitals NHS Foundation Trust wrote.

‘I was required to cover both wards by myself, with no support’

‘No other juniors or middle grades; had three medical students – two until midday and one after. Was interrupted during ward rounds for essential clinical skills that could not be delayed. Medical students assisted with ward round but were unable to do the majority of jobs.’

‘There are gaps in our rota which means I am currently very unsupported on the ward,’ a trainee at the Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust warned.

‘This has been ongoing since I started this job and affected my predecessors before exception reporting existed to highlight shortages in this way.

‘There have been many days when I have been the only doctor on the ward which can be difficult if patients become unwell.’

Rest not assured The data obtained by The Doctor chimes with the findings uncovered by a BMA survey conducted ahead of the junior doctor contract review.

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staffing levels as accounting for breaches to safety and rest limits specified in their working patterns.

By comparison, unexpected emergencies accounted for only 30 per cent.

‘Due to [a] staff member calling in sick, I was required to provide ward cover to ward 19 all day,’ reported another junior working for Burton Hospitals trust.

‘Then it transpired that the rota coordinator had put another colleague on ward 20 cover all day, despite them finishing at 12.45. As there were no other foundation doctor 2s available, I was required to cover both wards (36 patients) by myself, with no support. I feel that this was unsafe for the patients as I was stretched too thin, and so was unable to review all of them in the course of the day.

‘I was also unable to attend departmental teaching during the day which counts towards my teaching attendance. I

managed to snatch 15 minutes for lunch but otherwise had no time for breaks during the day.

‘I raised that I was unhappy to be covering both wards but was told that there was no one else.’

Both North West Anglia and the Royal Bournemouth said they encouraged junior doctors to exception report and had worked to address concerns raised. Burton did not respond to requests for a comment.

Although there have been thousands of exception reports filed, it is clear that a large number of doctors have not done so – and this is not necessarily because everything is rosy in their hospital. The survey found 40 per cent of junior doctors had submitted at least one report (and some more than 20) but 56 per cent had never submitted.

Of the non-reporters, 19 per cent said this was due to them being dissuaded from

exception reporting. Of all the respondents to the survey, 62 per cent felt there were barriers to submitting reports.

Changing the culture This mixed picture does not come as a surprise to Dorset foundation year 2 Cameron Spence who, as BMA Wessex regional junior doctors committee chair, has spent ‘Part of the much of the past 18 months challenge of attempting to champion the merits and importance of exception exception reporting. reporting ‘When I first turned up a is that the fill-in rate is year and a half ago it seemed like not many people were very low’ using it [exception reporting] and it has taken a lot of persuading to try and get people to use it,’ he says.

‘We’re pushing back against a culture of not reporting things. Certainly, it seems to me like the most junior trainees are much more likely to be willing to put in a report than the people who have been in that system

How exception reporting works Exception reporting is a mechanism that allows junior doctors to highlight any instances of work that break from the agreed terms of their work schedule. These include: Having to work hours that exceed the total set out in the schedule, including the prospective estimate of hours actually worked while nonresident, on call

Where it has not been possible to take rest breaks. Doctors working shifts longer than five hours are entitled to at least one 30-minute break, with a second 30-minute break provided on shifts longer than nine hours

Where a doctor has had to miss out on educational or training opportunities

Where a doctor believes that the levels of support available to them while on shift were insufficient and/or potentially dangerous

An exception relates to any deviation, no matter how frequently they occur. There are no restrictions on what should be reported or indeed how many reports can be submitted. There is no need for reports to be preauthorised before they can be submitted.

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NEIL TURNER

before where that kind of thing [reporting] was strongly discouraged.’

In its contract review survey, the BMA found that 27 per cent of respondents felt that it took too long to file a report, with 22 per cent saying they were not sure how to go about submitting one.

Dr Spence says that increasing the ease and accessibility of the exception reporting process could be achieved through something as straightforward as a change in the type of software used, with systems such as Allocate allowing doctors to submit reports through their mobile phones while on the go, rather than at a hospital desktop.

‘It really puts some people off because if you’ve finished late you’ve got no time and the last thing you want to do is stay behind and fill in even more forms. Often people don’t have the details to hand to know how to complete a report.’

Valued efforts Dr Spence warns that even seemingly innocuous interactions between consultants and trainees such as the suggestion from seniors that ‘no other doctors on this rotation are

submitting reports’, risks dissuading someone from filing a report.

He says that changing the perception of exception reports among senior staff so that they are seen as a solution rather than a cause of problems is crucial, as is emphasising to trainees that reporting mechanisms can make a real difference.

‘There is a lasting legacy when things go right but a lot of the time, when you speak to people [about reporting], their response is “what’s the point?” and that nothing will change.

‘One of our medical rotations last year had the most exception reports submitted out of all the different job rotations at the hospital, most of which were submitted by one junior doctor.

‘Because of the volume of reports they [the trust] were getting it just became something they could not ignore. Eventually, that job got a complete overhaul of the rota, with extra staff involved including an extra consultant.

‘It’s now a much better job and better supported.

The trainee who submitted

SPENCE: ‘We’re pushing back against a culture of not reporting things’

all those reports has undoubtedly done a brave but really fantastic thing for all of the juniors who will go on to work on that job.’

An ingrained cultural wariness of what exception reporting represents appears to be one of the main and persistent challenges to the system being fully embraced by trainees and their senior colleagues.

When asked what they believed were the main barriers to trainees submitting reports, the contract review survey found that, for 59 per cent, it was the workplace culture in their team or department.

An even more common concern – expressed by 72 per cent – was that filing a report might damage professional relationships.

Make a difference

‘I raised that I was unhappy to be covering both wards but was told that there was no one else’

Postgraduate medical education fellow Craig Knott is all too familiar with these types of preconceptions which can form barriers towards greater uptake of exception reporting among trainees.

He, along with his colleagues and the guardian of safe working at Great Ormond Street Hospital in London, have sought to overcome these challenges by adopting a range of initiatives and strategies, which ultimately seek to engage staff and highlight the tangible change the reporting process can bring about.

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EMMA BROWN

this move is to address the concerns of trainees close to applying for consultancy, who have had bad experiences of exception reporting at other trusts and might be concerned as to the reaction of their supervisor.

Identify weak spots

started rotating the meetings around departments rather than having them held centrally.

‘We know from a previous [Great Ormond Street] survey that people felt it [exception reporting] wouldn’t make a change, so we’ve actually just started going out and spend a couple of hours, a couple of times a month, going around departments and ask what the challenges and issues are.’

Dr Knott says exception reporting is powerful in identifying where improvements could be made in rotas or staffing levels, but that spotting these problems relies upon sufficient numbers of doctors raising their concerns through the reporting process.

To encourage trainees to speak out, Dr Knott and his colleagues regularly promote periods of concerted reporting; where staff members are urged to submit reports together.

‘Part of the challenge of exception reporting is that

the fill-in rate is very low.

This means trying to use it as a way of seeing what the pattern is when you’ve got sporadic reports is difficult,’ Dr Knott says.

‘The other challenge that we particularly had at Great Ormond Street is that about 75 to 80 per cent of our trainees are in their last three years of training.

‘The vast majority of them are coming up to consultancy. [Often] they don’t want to be seen to be rocking the boat.

‘By going in and saying that we’re going to have a twoweek period where we really get everyone to exception report, that makes them feel they have got that safety in numbers.’

Other steps being planned at Great Ormond Street include the decision to ‘decouple’ educational supervisors from the exception reporting process with responsibility instead placed on deputy service managers.

Dr Knott says the aim of

Access to exception reporting has also been extended to non-trainee junior medical staff on local contracts rather than the 2016 one, so that there is parity between staff and to maximise opportunities for gathering report data.

Central to the approach COME taken at Great Ormond Street FORWARD: is to make sure that where Making change exception reporting has depends upon enough juniors contributed to changes in raising concerns, rostering or bringing in new says Dr Knott staff, these achievements have been highlighted among staff.

‘We had one department that, by looking at the pattern of exception reports over a period, we were able to recognise that they just needed another junior doctor ‘The on the shop floor,’ says trainee who Dr Knott.

‘By seeing that pattern and submitted going in we can meet with all those reports has the trainees, have a focused undoubtedly discussion and we were able done a brave to find out exactly where the problems were [and] then but really change work flows.’ fantastic BMA junior doctors thing’ committee chair Jeeves Wijesuriya says that in some ways it is too early to draw many conclusions about the success of the new system, given that it was only brought in from October 2016 for certain groups of trainees, and that it has only been available for use

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across the board since August 2017, the end of the transitional period between the old and new contracts.

He adds, however, that while there have been notable successes in improving working conditions through the use of exception reporting, these successes need to be built upon if further progress in addressing insufficient staffing and rota gaps is to be made.

‘Exception reporting can’t solve every problem but what it can do is help us identify those areas where trainees are being overworked, and where simple solutions can be put into place to solve that.

It can also give us a sense of where education and training are being missed and give us a picture of where there are systemic problems.

‘As with any system change it takes time to work, and what we have seen is that there are some places that have taken to it really well, and we’ve seen changes to rotas, adjustments to work schedules and in some cases, training being reorganised.

‘However, this success has been patchy and not everywhere has taken to it [exception reporting] well yet.

There are some employers who are still scared of exception reporting because they haven’t realised that this is a way of solving problems before they become bigger and addressing safety issues and rota gaps before they become bigger.’

Dr Wijesuriya says the negotiations between the BMA junior doctors committee, Department

of Health and Social Care and NHS Employers over the 2016 contract would enable the BMA to present and share data concerning the reporting system, in an attempt to further enhance its efficacy.

‘What is also clear to us is that this is also an opportunity to identify if training is being missed to make sure the quality of training is right.

‘For us, we’re more concerned about a place that has no exception reports than a place that has loads, because the latter suggests a workplace that has a culture of reporting and raising concerns and honest discussion, which is what we want to create.

‘It is the places that have none, or even the departments and specialties that have none, that are a concern.’

‘What we need to do is encourage good practice and try and identify the areas where people haven’t adhered to what’s right’

arrangements. As such, exception reports should be seen as an opportunity for improvement rather than recrimination.’

Dr Wijesuriya says it is essential that data from exception reporting is easily available on trust websites and provided to local negotiating committees, as is required by the contract, to increase transparency and awareness.

‘We’ve seen for example how at Derriford Hospital [in Plymouth] how the exception reporting data brought public scrutiny

WIJESURIYA: ‘An opportunity to make sure the quality of training is right’

to an area where trainees were being consistently overworked, and allowed them to change the rota pattern,’ he says.

‘Do we really want to be working in departments where nobody is flagging when they work above hours or identifying solutions to staffing problems or rota gaps? We have a responsibility to call those things out.’

Open and honest Consultant leaders have also expressed their strong support for exception reporting.

BMA consultants committee deputy chair Gary Wannan says: ‘Exception reporting is often seen as a mechanism used by and exclusively for junior doctors.

The reality, however, is that the reporting process, with its emphasis on highlighting issues of concern with the workplace, is something that can ultimately benefit all staff and patients.

‘As consultants, we owe it to our junior colleagues to listen to and support them when they experience things that are at odds with their contracted working

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o r p p a e g d e g n i t t u c A A

An increase in knife crime has led to hyperbolic headlines but it has also fuelled innovative working from doctors and calls for society to work together to tackle the problem.

Jennifer Trueland reports

n ‘epidemic’, a ‘crisis’, a ‘deadly Ramboknife crime wave’.

‘Bloodbath Britain’.

Tabloid headlines are not the most reliable guide but it’s clear the UK, and especially London, has a growing problem with knife violence. While the number of firearms injuries and deaths remains steady and – compared with the USA at least – incredibly low, knife violence has become a major social and political issue.

Any hopes this year was going to be better than the last disappeared within a few hours. The first fatal stabbing in London was in the early hours of New Year’s Day. A week later, 14-year-old Jaden

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h c a o pr Moodie was murdered in the east of the city.

According to the ONS (Office for National Statistics), recorded offences involving knives or sharp instruments went up by 12 per cent to 39,322 in England and Wales between July 2017 and the end of June 2018 (excluding Greater Manchester because of a technical issue with recording of crimes).

This is the highest figure since comparable data began to be collected in April 2010. The ONS says that, while these crimes remain ‘relatively rare’ and are mainly concentrated in metropolitan areas, an increase in this sort of offence has been seen in the majority of police force areas.

No ‘war zone’ For doctors, their role often goes beyond the concerted effort to save the lives of those rushed into hospital for knife wounds. Some are

‘We’ve had to expand our cohort of trauma surgeons’

also taking a lead in how the problem is tackled. As a first step – and a rejoinder to the screamier of those tabloid headlines – they say it’s important to get it in proportion.

You don’t, for example, compare it with a ‘war zone’ when you’re talking to Shehan Hettiaratchy, trauma lead at Imperial College Healthcare NHS Trust. Having served two tours of duty in Afghanistan as a British Army reservist, he knows what a real one looks like.

‘There’s a real risk about hyperbole,’ he says simply.

‘Healthcare professionals have a responsibility to take a sensible line. We have to reflect to the public what’s going on – yes, there’s a problem, but it’s not out of control; it is solvable.

‘If I hear people say it’s like working in a war zone, then there’s one thing I know, and that’s that they’ve not been in an actual war zone, where there is a completely different level of intensity. Our role as doctors can include interacting with the media – but I wish some of my [medical] colleagues would avoid the hyperbole.’

That’s not to say London doesn’t have a problem, which is affecting the NHS as it does so many other areas of society.

‘In our own centre, up to 18 per cent of major trauma admissions involve some kind of penetrative injury,’ says Mr Hettiaratchy. ‘That’s just under 500 last year. We’ve had to adapt our clinical response and make sure that frontline staff can do the necessary immediate interventions.

‘We’ve had to develop new pathways, such as getting people straight to the operating theatre, and we’ve had to expand our cohort of trauma surgeons who can deal with these time-critical injuries.’

And when looking at the reported increase in knife assaults, it’s important to consider that they might tell only part of the story. The GMC published new guidance in 2017 on doctors’ duties around confidentiality and reporting gunshot and knife wounds, detailing the reasons why they might or might not inform police about such injuries.

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BOYLE: ‘It’s everyone’s issue’

be leadership and in many cases that can come from local government,’ he says.

‘But any serious violence strategy has to be crossgovernment, and involve health, police and criminal justice.’

Media reinforcement

For example, might disclosing the information prevent the patient from engaging with health services or damage trust in doctors more generally? Or would not disclosing cause harm to others, be it an individual or the public more generally?

This was published against a background of research suggesting that more than 70 per cent of assaults never make it to the stage of a police report.

Poverty factor The causes of the increase in knife crime – a trend which runs contrary to the general fall in assault and violent crime since the 1970s – are not entirely clear, says Adrian Boyle, head of quality at the Royal College of Emergency Medicine.

‘Criminologists debate it a lot,’ he says. ‘What we do know is that it’s strongly associated with poverty and lack of opportunity.’

Asked what action is required to tackle the issue, Dr Boyle says: ‘We need a

coordinated multi-agency approach. That’s what we’ve seen in Glasgow with the Violence Reduction Unit, and in Baltimore – and that’s what works. It’s not just a police issue, or a health issue – it’s everyone’s issue.’

He sighs as he says it, suggesting that this is a case he has made patiently a number of times before.

Glasgow’s multi-faceted approach – now spread across Scotland – has won praise and international interest, and is widely believed to have reduced knife crime, although statistics comparable to those in England and Wales are not available.

Initiatives have included pink-shirted ‘navigators’ in emergency departments to talk to people involved in knife incidents, and a programme where medics go into schools to educate pupils and hopefully guide them away from participating.

Dr Boyle wants to see a comprehensive approach in England too. ‘There needs to

Although he acknowledges that published crime statistics from the police do not show the actual extent of knife-related incidents and injuries, Dr Boyle cautions against normalising the presence of blades on our streets.

‘There’s an anxiety that ‘Knife crime media coverage might be driving some of this is strongly associated [increased knife crime] with poverty because it might be making and lack of young and impressionable opportunity’ men believe they have to carry a knife,’ he warns.

Knife violence doesn’t only affect individuals, communities and health services; it also has a political dimension. As the statistics – and the human cost – have worsened, pressure

PINK PATHWAY: ‘Navigators’ guide people affected by knife violence

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PA

HETTIARATCHY: Knife crime is very distressing for staff, too

has been piled on the politicians deemed to have some responsibility for dealing with it.

London’s mayor Sadiq Khan, for example, has made tackling knife crime a priority (see panel, opposite). He concedes, however, that further action is needed.

‘We know that the causes of violent crime are extremely complex, involving deepseated problems in society such as poverty, alienation, mental health issues and a lack of opportunity,’ Mr Khan told The Doctor.

‘Although I am working tirelessly with local councils, charities and community groups on a public health approach to tackling serious violence, it’s clear we need to do more to support them in driving down not just knife crime but all forms of violent crime.

‘We have looked and learnt from cities like Glasgow and we know that they have had success in tackling crime with similar initiatives. In London, the Violence Reduction Unit will lead the capital’s response to understanding the causes of violent crime and working to stop it spreading by bringing

together specialists from right across the city.’

Staff suffer Mr Hettiaratchy agrees that a public health approach is the right way forward, and hopes that the efforts in London will help to tackle the problem at source. Meanwhile, however, he and his colleagues continue to cope with the arrival of (mainly) young men with potentially devastating or fatal injuries.

Does it feel frustrating?

‘Yes,’ he says, emphatically.

‘And it can be very distressing for staff, particularly more junior members of staff.’

His trust has formal mechanisms to support employees where required, he says. ‘The people who really bear the brunt are the nursing staff,’ he adds, particularly as emotions can run high – from patients, family and friends, who sometimes bring their extreme fears or desire for revenge into the emergency department.

‘Yes, it’s challenging, and can be frustrating and distressing. But what makes a good team is being able to support each other, and that’s what we try to do.’

Weed out the root causes London mayor Sadiq Khan (pictured above) has announced a suite of measures to tackle knife crime – and the causes of knife crime – in the capital.

These include: – a new Violence Reduction Unit for London, similar to that already in operation in Glasgow, bringing together agencies including police, local authorities, City Hall, health services, youth services and criminal justice agencies, to take a ‘public health approach’ to tackling violent crime – a knife-crime strategy that involves working with young people and communities, targeting law-breakers and supporting victims – investing £1.4m to provide youth workers in major trauma centres and place more youth workers in emergency departments to try to steer young Londoners involved in incidents away from violence – patrols using targeted ‘stop and search’ for areas worst affected by knife crime – investment in supporting young people to avoid or exit gang violence.

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

A working culture gone bad, a doctor denied extra pay because of management failings, and a wrongfully dismissed consultant – all issues that members have faced and overcome with the help of the BMA

Botched attempt at dismissal A hospital department was in a terrible mess. The management knew there were problems between staff but spent years hoping they would just sort it out between themselves. There had been complaints and counter-complaints.

There was one particular doctor whose relationship with colleagues appeared to be beyond repair. Their view was unanimous that they could not work with him. His employer clearly wanted him to go.

There is a lot of background here, but our focus is not on how everyone got to this stage, but on the fairness of how he was then treated.

Under the Employment Rights Act 1996, there are the established lawful reasons why an employee can be dismissed, and these include capability, conduct and redundancy. However, the legislation also allows it if the employer can produce ‘some other substantial reason’. An SOSR in the jargon.

An example often given is that of a personality clash between employees that makes it impossible for them to work together.

This seems generous to employers, given that they too might have a responsibility for such clashes arising, but it is a power that cannot be used indiscriminately and SOSR cases can and have been challenged robustly in court.

In this case, the employer made a mess of it. At first it avoided the SOSR process and instead encouraged colleagues to complain.

He was accused of failing to turn up for meetings, of undermining colleagues.

However, complaints (and countercomplaints) like this had been floating around for years and the employer could not just act on them when it was expedient.

So his BMA representative successfully defended him.

The hospital then made a token effort to reintegrate the doctor but, instead of trying any sort of mediation, a manager simply went to the colleagues he didn’t get on with and asked if they wanted him back. This was totally one-sided and did nothing to promote reconciliation.

So then the hospital attempted the SOSR route, but greatly weakened its case that the dismissal was necessary and inevitable given that none of the disciplinary allegations had stood up and no decent attempt had been made to establish whether the doctor really could be reintegrated into the department.

The BMA made it clear that the doctor would have a case for unfair dismissal, given the inept way in which the case had been handled. The employer, under this pressure, agreed a settlement of more than £100,000.

Settlements are never entirely satisfactory, and the BMA senior employment adviser involved said it’s always better to at least try to and resolve issues and keep members in their posts.

However, as the adviser says, there is a real world to deal with and it can be easier to do so when you can provide a buffer of more than a year fully paid as the member considers future options that will hopefully lead to a happier working life.

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Communication breakdown A staff, associate specialist and specialty doctor was appointed to a locum consultant post. He was told that it was a well-deserved promotion, and it wasn’t surprising given that the doctor is highly respected in his trust.

He would probably have been a consultant himself by now were it not for the very arduous GMC process by which SAS doctors need to demonstrate equivalent skills and experience to those who have been through specialist training.

The problem is that the staff who appointed him did not follow through with the most basic administrative procedures and tell the HR department.

He contacted the BMA when he was told, with a week’s notice, that his locum post had come to an end. This was hardly a great way to treat him, but the employment adviser also established that he had been

given no extra pay for the role, or a contract or letter of appointment.

To add to the confusion, he had also been asked to continue in the consultant role for the time being until it was filled with a permanent replacement. All because of a lack of communication within his place of work.

The BMA employment adviser told the trust that the doctor needed extra pay and back pay and, unless it was sorted soon, she would advise the doctor to protect his legal claim by applying to ACAS for early conciliation.

The member got his locum position back, with proper pay and a contract. The employment adviser, meanwhile, advises all SAS doctors to join the BMA so they too can take advantage of the employment support it gives.

Dismissed after raising concerns A consultant ophthalmologist has thanked the BMA for its support after a court ruled he was wrongfully dismissed.

Amar Alwitry successfully applied for a consultant post in Jersey but had his contract rescinded shortly before he was due to take up the post.

He had raised concerns about the number of programmed activities in his job plan, which exceeded those stipulated in his contract.

Mr Alwitry, who was brought up in Jersey, said it would have been an ‘honour to come home and work to protect and preserve the eyesight’ of its people, but instead his dreams of return had been taken away.

He said: ‘I am very grateful to the BMA for its continued support and funding, without which I might otherwise have been unable to pursue matters to this point.’

Read the full story at bma.org.uk/alwitry

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it happened to me Doctors’ experiences in their working lives

EMERGENCY ADMISSION: A teenager’s consumption of drink and drugs led to terrible news for his family

The bomb I threw at them Going into the relatives’ room I felt a strong sense of déjà vu.

Those present were sitting in the same places that I thought I remembered and looked strangely familiar.

I started as usual by introducing myself and asking what they had been told.

They knew their son had been found unconscious and rushed in by blue light.

I knew they would say that, and that the police officer outside wouldn’t know many details.

Then it struck me; they had been here before, in fact only three weeks earlier. Their son had overdosed on alcohol and his grandfather’s heart pills and had only survived thanks to some excellent work between emergency medicine and the cardiac and intensive care teams. His parents thought he had done it again and I knew they were right.

He had seemed well when he got home after the last admission. His mother thought he had turned a corner and didn’t understand what had happened.

It seemed like my cue to move the conversation onwards. I knew what I would say next would completely devastate the family, who assumed that this time was going to be like the last.

Unfortunately, I knew that it was not good news.

Training manuals tell us that it’s important to be clear about these messages and to provide them in an understandable and unequivocal way.

So, talk about someone having ‘gone’ or confusing accounts about resuscitation details need to be avoided.

It could be something like, ‘I’m very sorry but Sean was already dead when he was brought to us.’ (Pause)

‘His heartbeat and breathing had stopped for some time and it wasn’t possible to restart them.’

After that it doesn’t really matter what you say because they’ll be trying to absorb the bombshell you’ve just lobbed as it sears its way through their minds like a cautery knife.

They won’t hear anything else in the next 10 minutes so now is the time to call the bereavement coordinator.

After that they’ll see their 15-year-old’s body and their bereavement journey will move past denial to numbness, anger and guilt. In time, hopefully it can go much further.

Charles Lamb is an emergency medicine consultant. He writes under a pseudonym

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iSTOCK

the secret doctor

CLINICAL WASTE: Pressures on administrative staff led to a no-show clinic

Not a zebra in sight The Zebra Syndrome clinic runs three times a year and is the only one of its kind for miles around.

It has been developed by a highly specialised team of clinicians, offering patients and families a holistic service aimed at meeting all their needs in one place.

It is a flagship for best practice in ZS, and – despite benefiting from funds raised by Zebra Support UK – it’s extremely expensive to run.

The first time I went along, I could see why.

Besides registrars like me, the clinic is a wholeday commitment for one professor, two consultants, a nurse practitioner, three highly specialised physiotherapists, a physiologist and two healthcare assistants.

It’s a busy day for the patients, too: each would have two hours of consultations and assessments over the course of the day.

Only there weren’t any.

The staff hung around for a while, and then drifted off.

I was left on guard in the empty clinic, to alert them if anyone did show up. At

about 11am, one solitary patient appeared. Otherwise, I spent the day half-heartedly getting on with an audit in an abandoned consulting room.

It turned out the appointment letters had never been sent out owing to an administrative oversight.

The secretarial team was well-known to be overworked, poorly led and demoralised. This wasn’t the first such slip; we had recently had to reschedule a whole series of routine appointments, all booked to take place at 1am on a Sunday morning.

Our phantom clinic will have cost, at the most conservative estimate, several thousand pounds.

Appointments had to be rebooked, lengthening already-stretched waiting lists. Complex patients were left without care for months longer than was necessary.

It wasn’t a ‘serious incident’, however, and didn’t generate any negative publicity, so interest from the hospital’s middle and senior managers was minimal.

The secretaries, many of whom were regularly working unpaid overtime to keep up with the piles of chaotic

paperwork accumulating around them, were not to blame.

The fact that there were manifestly too few of them, and experienced admin staff who left were being replaced with barely literate school leavers, was.

There has been a lot of pressure on the health service to cut down admin costs during the past few years. Sadly, this has frequently meant sacking, or devaluing, hard-working medical secretaries and ward clerks, while the operational lead for quality assurance and the assistant head of eLearning continue to do just fine.

Whole clinics vanishing into a void of administrative incompetence because we can’t get our act together to recruit, retain and pay an adequate secretarial team reminds me of the proverb of the ship that was lost for a ha’porth of tar – possibly while senior management was busy rearranging the deckchairs.

By the Secret Doctor bma.org.uk/ thesecretdoctor @TheSecretDr thedoctor | March 2019 27

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the consultation The Doctor will see you now

Cardiff medical student Alexandra Adams has partial sight and hearing but this hasn’t hampered her passion for photography. Taking portraits of NHS staff, she captures their diversity, stories and emotions Many people come up to me and say, you don’t look like a medical student, you’ve got hearing aids and a cane. I’ve heard this kind of thing being said to other staff and students around hospitals, too. That’s why I started Faces of the NHS – to celebrate diversity among NHS employees. We’re all different, which we should positively embrace.

The funny thing is, I don’t see what I’m taking pictures of. People see me in the street with my white cane. I’ll suddenly stop and think, ahh, I need to take a picture of this lovely landscape or this bowl of food. People give me weird looks. ‘She’s visually impaired!

How can she do that?’ but I love taking loads of photos, flicking through them, thinking, huh, that’s a good angle. But then I feel there’s so much more meaning in a photograph.

For Faces of the NHS, I take portraits of doctors and other healthcare staff, porters, receptionists, canteen staff. Portraits can capture the emotions, the stories behind NHS employees.

I hated science when I was a teenager but I’ve always loved people and been interested in human behaviour. My own experience as a patient influenced my decision to study medicine. When I was 16, I was in hospital for a year and a half, after 20 stomach operations.

They went wrong, unfortunately. The experience made me want to be on the other side of the pillow to help other patients. That was when I started linking the clinical mix of people and science together. Medicine then became the perfect career.

I’m never going to be a neurosurgeon.

I’ve got to be realistic. Palliative medicine is something I’m really interested in. It’s a very patient-centred field. There’s more to it than treating patients at the very ends of their lives.

I’ve had 13 admissions to ICU in the past two years. My 10th one was very touch-and-go.

I was intubated for two weeks, had sepsis.

It was quite nasty. I’ve just been discharged after my most recent ICU admission and am only starting to build up my strength again. I was like, here we go again. Being a patient has given me empathy, maybe a slight advantage over other medical students when it comes to talking to patients.

This senior doctor sat me down and said: ‘Imagine you’re a patient. Would you want a blind doctor treating you? Absolutely not.’ Then I was sent home. That was quite upsetting. I’ve had some pretty bad experiences. I’ve been warned that the corners of a table are sharp. Don’t bump into them. I’m thinking, do you know, I’ve travelled the world on my own?

Sometimes you can’t tell whether people are trying to be nice or patronising. I do try and stick up for myself but it is frustrating.

Travel is an absolute obsession. I love the spontaneity, getting a taste for other cultures. I prefer travelling on my own but I’ve got into some palavers. I was stuck in a national forest, a desert and on the hard shoulder of a motorway in Hong Kong. It’s been quite disastrous at times but equally comical, and I wouldn’t change it for the world. I’ve had some amazing experiences. The hundreds of Polaroids of my travels are all on my bedroom wall, and I’m still counting.

Watch an interview with Alexandra Adams at bma.org.uk/facesoftheNHS

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ALEXANDRA CAUVI

thedoctor | March 2019 29

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explainer

Primary care networks are being set up to promote integrated care. What will it mean for GPs? entitlements; some are ringfenced (eg for a clinical lead and a contribution towards new staff costs) while other payments are for networks to decide the use.

How much flexibility will be permitted on the size?

What are they?

PCNs are groups of GP practices working collaboratively in a formalised structure, typically covering a population of 30,000 to 50,000 patients, and combining with other primary and community services and local organisations to ensure an integrated approach to health and care for that population. It is expected that all areas in England will be covered by one by July.

Why are they being established?

The intention behind establishing PCNs is to focus services around local communities, building on local GP practices to help rebuild and reconnect primary healthcare teams across the areas they cover through the network.

The BMA GPs committee negotiated a new directed enhanced service with funding entitlements in this year’s contract to fund PCNs because the ownership for leading local services should sit with GP practices. Only GP practices can

set them up. It is hoped they will alleviate workload pressures and allow GPs to concentrate more on the most complex patients.

Aren’t there already networks?

The thinking is that the practitioners involved will still have a reasonable chance of knowing the people they are working with, but that PCNs are large enough to have an effect and make economies of scale.

However, if practices think they have a good case for forming a larger or smaller network, they should make it to their CCGs (clinical commissioning groups).

Yes. In fact, most practices in England work in some kind of network. The difference is PCNs have the support and backing of a national contract and formalise the establishment of networks in a consistent way.

Could a large practice be a network in itself?

Will they offer new services to patients?

What kind of funding will be available?

Practices are being urged to talk to their neighbours about forming a network. Local medical committees are in an ideal position to coordinate and mediate where necessary and the BMA will provide advice and guidance. The new PCNs will submit registration information to their CCGs by the middle of May, with CCGs confirming the network coverage by the end of May. They are planned to go live in July.

There will be payments to practices for engaging with PCNs, and other payments direct to the network as

Find out more at bma.org.uk/gpagreement

Yes. From 2020 there will be the potential for additional funding of new services in line with the aims set out in the NHS Long Term Plan. These include medications review, supporting early cancer diagnosis and cardiovascular disease prevention and diagnosis.

Yes, particularly those practices which have 30,000 to 50,000 patients and cover multiple sites within a geographical area.

What happens now?

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what’s on

March 19-20 LMC conference UK, Lanyon Place, Belfast 20 Tackling work and life pressures with self care, CBT and mindfulness, Edinburgh, 9.30am to 1pm 21 Pensions taxation and retirement planning, Oldham, 7pm to 8.30pm 21 Pensions taxation and retirement planning, Reigate, 7pm to 8.30pm 26 Pensions taxation and retirement planning, London, 7pm to 8.30pm 26 GP contract roadshow, Liverpool, 7.15pm to 9.15pm 26 GP contract roadshow, Sussex, 7.30pm to 9.30pm, Crawley 27 GP contract roadshow, Cumbria, 1pm to 3pm 28 GP contract roadshow, Leicester, 7pm to 9pm 28 GP contract roadshow, Middlesbrough, 7pm to 9pm

29 Conference of medical academic representatives, London, 9.15am to 6pm 29 Tackling work and life pressures with self care, CBT and mindfulness, Glasgow, 9.30am to 1pm 30 Second year medical students revision day, Belfast, 8.45am to 9pm

April 02 Connecting LTFT trainees, London, 9.30am to 4pm 02 GP contract roadshow, Norwich, 7pm to 9pm 02 GP contract roadshow, Greater Manchester, 6.45pm to 9pm 04 Welsh junior doctors conference, Cardiff, 9.30am to 4.30pm 04 Practical skills... leadership and management for doctors, Birmingham, 9am to 5pm

05 Private practice conference, London, 9.30am to 5pm 09 Introduction to critical appraisal workshop, London, 9am to 4pm 25 Absence and leave management, Kirkcaldy, 9.30am to 4.30pm 25 Absence and leave management, Kilmarnock, 9.30am to 4.30pm 29 LNC chairs conference, London, 10am to 4.30pm

May 01 Armed forces conference, London, 9.30am to 4.30pm 09 Practical skills... for human factors in healthcare, Cardiff, 9am to 5pm 11 Third year medical students revision day, Belfast, 8.45am to 5pm

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

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