The Doctor – issue 9, May 2019

The magazine for BMA members

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Issue 9 | May 2019

Off and on again

Why is NHS IT quite so bad and how do we find the reset button?

Seven sisters

The female medical students who braved Victorian prejudice and still inspire today

In memory, in anger, in hope How a good doctor was lost, and what his death should teach the health service

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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

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: 365 no: 8199

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 Tackling the GP recruitment crisis, longer waits for cancer treatment, and can safe staffing be set in law?

Welcome Chaand Nagpaul, BMA council chair Doctors need to be cared for, too. If there’s one urgent lesson the NHS – a service facing soaring demand with growing rota gaps and staffing vacancies – needs to learn, this is it.

The statistics have made for grim reading for some time: waiting times are lengthening, bed-occupancy rates sit at unsafe levels, emergency department attendances are rocketing. And the frontline vacancy list sits at around 100,000.

The effect of living on this exhausting frontline is clear. New BMA research, highlighted in this issue of The Doctor, finds that eight out of 10 doctors are at a substantial risk of burnout. More than a quarter of the 4,300 respondents to a survey said they had received previous, formal diagnoses of mental conditions, and four out of 10 said they were suffering from psychological or emotional distress, which affected their work, training or study.

As a society we expect doctors to fix patients – but doctors can break too. Any one of us could find ourselves in circumstances inside or outside work which leave us needing help and support.

And too often that safety net is not there in our profession.

It is a message forced home by the tragic story of Alastair Watt, featured in this month’s issue, whose death was contributed to by the ‘stress and anxiety’ he experienced after returning to work from serious injury.

The BMA’s Caring, supportive, collaborative project aims to address these issues. We are building a consensus around the sort of culture the NHS needs – one where the workforce is valued and nurtured and which supports learning and development.

Together, I believe we can create an NHS that cares for doctors as well as patients.

The May issue of The Doctor looks at the concerning state of the NHS’s estates, facilities and IT systems. It will come as no surprise that, across the country, systems are outdated and buildings are crumbling. These deficiencies are directly impairing doctors’ ability to care for patients. We even have NHS leaders owning up to a ‘legacy of underinvestment’.

It is crucial that politicians and national health leaders find the political will and financial backing to address these problems. Failure to act now will result in drastic consequences in the future.

6-11

Lions led by dongles Where is the reset button for the lamentable state of NHS IT?

12-15

Precedent sept Seven women who braved sexism to pursue their dream of studying medicine continue to inspire today

16-21

The hard road back The death of consultant Alastair Watt following his return to work raises serious questions about the support doctors receive

22-25

Crumbling hopes Can the NHS really ‘transform’ when foolhardy PFI deals and budget raids have left much of the NHS estate shabby and debt-ridden?

26-27

Support: a scarce commodity Eight out of 10 doctors are at risk of burnout, finds a BMA survey

28-30

Life experience A tale of persistence, the problem with physician associates, and a baby born in emergency care

31

What’s on Keep on top of events

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briefing

GPs fighting hard to tackle recruitment crisis

Current issues facing doctors

The longest wait The Government has missed its targets on emergency department waiting times so many times that you wonder if it is all that bothered.

Perhaps ministers see it as nothing more than a couple of extra hours on the plastic seats, rather than the pain, worry and indignity that it so often means for thousands of patients.

It will be harder for the Government to brush off the BMA’s findings about the patients waiting for cancer treatment last winter in a health service once again close to breaking point.

Almost a quarter of cancer patients in England had to wait longer than the 62-day target for their first treatment following urgent referrals from GPs. This was the worst performance on record.

BMA council chair Chaand Nagpaul said: ‘Forcing a patient to wait two months for their first cancer treatment is shameful for a leading nation – and as a doctor, I can imagine only too well the distress this will cause them and their families.

‘It also places stress on the clinicians who treat them as they are well aware that the cancer may have worsened during the delay between referral and treatment.’

The analysis also finds that the number of people waiting to see a cancer specialist for more than 21 days rose to a historic high of 8,820, up from just over 5,000 last winter.

The other, more commonly cited, indicators of winter pressures also show an NHS in crisis. A record number of patients – 6.2 million – visited major emergency care departments during the winter period. The number of patients seen within the four-hour target (85.1 per cent) and the numbers waiting more than four hours for admission (214,000) were the second worst on record.

It has a huge personal effect on doctors, too. An emergency medicine consultant, in a blog on the BMA website, said: ‘I had no idea I’d be spending my days deciding which poorly patients to leave on the corridor and which to prioritise for my next space.

The level of risk involved is terrifying.’

It’s time for the Government to realise that waiting is not a neutral activity if you are an NHS patient in pain, and possibly with a worsening condition.

The only solution – as Dr Nagpaul clearly points out – is for the NHS to have the resources it needs. This may be a crisis at its most apparent in the winter, but it is far from just a winter crisis.

‘Harder than we thought.’

‘Difficult to say the least.’

The words of successive health secretaries about the Government’s pledge four years ago to increase GP numbers in England by 5,000.

Now, for the first time in 50 years, GP numbers have fallen across the UK relative to the population.

However sincere the Government’s intention – which still exists, but with the deadline now removed – it is undermined by its historic failure to tackle the causes of poor recruitment.

As BMA GPs committee chair Richard Vautrey (pictured) said: ‘Family doctors are under intense

pressure to meet rising demand from a growing population, many of whom are elderly and living with increasingly complex conditions, and in many cases, workload has become unmanageable, leading doctors to reduce their hours or retire.’

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This of course creates a spiral, where the workload gets heavier for those left behind.

The problem of retaining GPs has been greatly compounded by the Treasury’s highly damaging taxation rules, which mean many senior GPs, as well as consultants, are effectively penalised for taking on extra work or staying on longer when they are nearing retirement.

While there is undoubtedly a crisis in general practice, there have been some very robust negotiations on behalf of the profession.

The recently agreed five-year GP contract in England includes a significant rise in investment, the removal of indemnity costs, and the addition of 20,000 additional practice staff.

‘While these professionals will not replace GPs, they will, where appropriate, see some patients and allow doctors to prioritise cases where their expertise is needed,’ said Dr Vautrey.

He also said the GP Partnership Review, published earlier this year, had a number of positive recommendations that had the potential to boost recruitment and retention and improve working lives.

Clearly, the Government still has much to do, not least by putting the resources identified in the new contract to good use and allowing practices to work together via the new primary care networks.

However, as Dr Vautrey recently pointed out, there have been record numbers of trainees choosing general practice in the past two years. There is so much about this specialty, perhaps in its essence, as the eminent GP Ian McWhinney wrote, the ‘commitment… to a person, not to “a person with a certain disease”’.

It is in the Government’s hands to make this job, which is so much about humanity, possible for humans to physically do.

Keep in touch with the BMA online at

New laws can’t conjure up staff Legislation has been instrumental in pushing some of the biggest cultural and public health changes we have seen in the UK. So accustomed are we to fastening seat belts that it’s almost hard to believe that it was as recently as 1983 that wearing them in the front of cars became compulsory.

Similarly, the ban on smoking in public places was introduced in Scotland in 2006 – it’s barely a teenager in legal terms – but almost feels like it’s always been in place.

Perhaps the latest health-related legislation agreed by the Scottish Parliament will have equally seismic effects. The Health and Care (Staffing) (Scotland) Bill, passed at Holyrood on 2 May, places duties on health boards and the Scottish Government to plan for and deliver adequate staffing levels. Grown out of existing tools for planning nursing numbers, this legislation nevertheless expands from its origins to include others in the health and social care workforce, including doctors.

In theory, at any rate, it should compel employers to make sure there are enough staff available all the time to ensure that care can be delivered safely – and they will have to answer to Scottish ministers if they don’t.

In other parts of the world where safe-staffing legislation has been implemented – notably in Victoria in Australia – it has led to an increase of staff in place. Although the Australian precedent didn’t apply to doctors, could we see a similar effect in Scotland?

Sadly, the mere act of passing a law does not mean it will necessarily be fulfilled. As BMA Scottish council chair Lewis Morrison warned on the bill’s passing, there simply aren’t enough doctors to deliver the care the system demands. Vacancy rates

instagram.com/thebma

MORRISON: There aren’t enough doctors to deliver the care the system demands

remain high, placing more pressure on those doctors who are in post, and uncertainty with pensions and Brexit will only make matters worse.

Safe-staffing legislation rightly sends a message that it’s crucial to have the right number of suitably qualified staff in place. But Scotland won’t attract those much sought-after professionals unless it tackles recruitment and retention with vim and determination.

The bill was passed after engagement with the health professions – if it is to succeed, implementation must continue in the spirit of collaboration.

Read more online Independent investigation into sexism and sexual harassment at the BMA Senior doctors lose out on shared parental leave Junior doctor contract review GMC plans to speed up FTP decision-making Read all the latest stories online at bma.org.uk/news

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Lions led by dongles Doctors are let down every day by poor IT in the health service. Outdated software and basic delays in accessing records make a mockery of modernisation plans. Tim Tonkin looks for ways out of the jumble

A

s with death and taxes, IT problems are an inescapable aspect of modern life.

However, while the sum total of IT problems for many amounts to little more than the slow streaming of a TV box set, the consequences for doctors – whose day-to-day professional lives often depend on functioning IT – can be far more serious.

A survey carried out last year by the BMA found that nearly a quarter of doctors taking part said they felt the IT systems in their workplaces were not fit for purpose.

Aspects of technology singled out include the electronic health record and medical record, described as inadequate by 48 and 57 per cent respectively, with 43 per cent saying the same of electronic prescribing and 40 per cent of their e-referrals system.

‘I have lost hours of time sorting out my IT problems since starting my core trainee 2 post in August,’ wrote one junior doctor responding to the survey. ‘I’ve stayed late on call when I’ve lost all my work on the system and had to rewrite notes. I had no personal file and therefore no ability to save any work on a hospital PC for over two weeks.’

Thirty-two per cent of doctors told the

survey that they rarely had access to the requisite IT equipment to perform their jobs to the best of their abilities, with 56 per cent saying poor IT significantly increased their day-to-day workload.

Access denied Poor IT causes more than irritation. More than a third of doctors said it had a significant effect on their workplace stress levels.

‘My email was suddenly closed down leading to no access to patients’ blood results on an acute ward,’ reported another hospital doctor to the survey.

‘I have lost another two hours today unable to access a patient notes system and therefore delay in uploading very important ward-round notes and clinical plans. I am at my wits’ end.’

The causes of deficient health service IT span a number of areas, with outdated software and hardware cited by 63 per cent of those taking part in the BMA’s survey. However, the greatest culprits include having to work with too many different systems (74 per cent) – many of which are not interoperable and struggle to talk to each other (65 per cent).

It is on the back of these findings that the

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NEIL HODGE

COLEMAN: Long-standing issues with a patient records system

BMA has produced a new report, Technology, infrastructure and data supporting NHS staff, outlining how deficiencies with IT infrastructure are adding to workload and even compromising patient care.

Among its recommendations for improving the state of IT is an upgrade of all basic IT hardware to a nationally recommended standard, as well as providing fully functioning wi-fi and 5G to be made standard across the NHS. Doncaster GP David Coleman understands all too well the consequences of the basics going wrong when it comes to IT. As a partner at the Conisbrough Group Practice, he has had to contend with a raft of issues relating to IT on a near daily basis. One of these included a long-running problem with his practice’s clinical records system, EMIS, which is responsible for everything from appointment booking to hospital test results.

‘The primary problem we’ve been having over the past 12 months – which I have to say has improved after much back and forth – is reliability of the clinical connection,’ he says.

‘We were having lots of problems with our system crashing, being unresponsive and having the “spinning wheel of death”.’

Software downgrade Dr Coleman says instances of poor interoperability can even occur between pieces of workplace software that were supposed to work in tandem. To this end he cites his own practice’s experiences relating to the unintended consequences of an upgrade to their electronic documents management system, Docman.

‘We were told [by the CCG (clinical commissioning group)] that we were going to get this shiny, new piece of software [Docman 10] and it was going to be web based,’ he says.

‘Pretty much straight away we started running into a lot of problems… it was a lot clunkier and sometimes did not work. We thought it was maybe teething problems… but things went from bad to worse.’

The upgrade, which Dr Coleman has found to be incompatible with the EMIS system, meant that he and his colleagues continued to struggle to access more than 200,000 pieces of medical correspondence, something that places a considerable additional burden on his team.

‘Rather than being a timesaver and a useful tool it was actually an obstacle,’ he says.

A spokesperson for the company responsible for Docman declined to comment.

Crucial to understanding the health

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‘I’ve stayed late on call when I’ve lost all my work on the system and had to re-write notes’

service’s patchy relationship with IT, is understanding the legacy of the early 2000’s National Programme for IT. Launched in 2002 and commanding a budget of more than £11bn, the programme sought to revolutionise data sharing in the NHS by creating an integrated electronic care record for every patient designed to be easily shared across all parts of the health service.

Tenders for the delivery of services were put out across the five regional clusters of NHS England, with contracts being awarded to different providers in different areas.

Disputes over these contracts and the subsequent delays in the rollout led to many of the programme’s core objectives falling behind schedule and exceeding the original budget.

In 2010 the newly formed coalition government announced that the programme would no longer be run on a centralised basis, adding that ‘decision making and responsibility’ around IT development would instead be driven at local levels.

Lack of consultation

‘I have lost two hours today unable to access a patient notes system’

A report published by the public accounts committee that same year observed that the dismantling of the programme had resulted in the onus of developing IT systems compatible with those introduced by the programme falling on individual trusts, meaning that ‘different parts of the country will have different systems’.

It also noted how much of the waste and pitfalls experienced by the programme could have been avoided had the health professionals destined to use the systems been consulted from the outset.

Bristol consultant oncologist Adam Dangoor

understands the frustrations posed by poor IT services, as well as the potential benefits good use of digitisation and technology present for healthcare.

For the past two years, Dr Dangoor has been the joint CCIO (chief clinical information officer) at University Hospitals Bristol NHS Trust, a post which sees him liaise between the trust’s IT department and clinical workforce.

Like many of the doctors responding to the BMA’s survey, he cites issues such as having to navigate multiple, separate software programmes and lack of interconnectivity and data sharing between different trusts.

‘In clinic I’ve sometimes had up to 17 windows open on my computer including three different PAC [picture archiving and communication] systems for different trusts, test results systems, a dictation system for patient letters, and chemotherapy prescribing software,’ he says.

‘There are multiple different passwords for all the systems you are using at any one time. ‘[Another] one of the problems is that if we’re referred patients from outside [our trust] it’s quite difficult to look at their imaging if it’s from another centre. We either have to keep active passwords for the host hospital PAC system or have the images sent across electronically which means someone has to ring that hospital and ask for the images to be transferred to our system.’

Unexpected benefits Despite the existing challenges posed by IT, Dr Dangoor says it is important to acknowledge some of the advances that either had been or were in the process of being made.

‘Clinicians should note that, despite the

REGIONAL VARIATION: ‘Different parts of the country have different systems’

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CHARLIE BIRCHMORE

DANGOOR: ‘Data is in silos and it is not easy for organisations to share it’

challenges, we are already at the stage where we can sit at a computer and access a whole range of information about our patients from vital signs, blood results, medications, radiology images and clinical notes.

‘These are amazingly useful for consultants on call who can find out what is happening with their patients before even visiting the ward.

‘Going forward, electronic records will be based on directly entering data, as GPs already do. This will produce records that can then be searched and analysed to improve care which is much more powerful. We’re not there yet, but we’re making steady progress.’

Dr Dangoor believes improvements to IT would most likely be a ‘bottom-up’ endeavour, with regional health services, trusts and clinicians themselves taking a crucial role in development but says that there is still a place for an overarching, national approach.

‘Nationally we have to have open standards and data-sharing agreements,’ he adds.

‘NHSX and NHS Digital need to make sure that we have common standards; interoperability is key. At the moment data is in silos and it is not easy for organisations to share it, even between internal software systems.’

At a glance, the noises coming out of the Department of Health with regard to IT and the importance of interoperability and getting the basics right, appear to be encouraging.

Health secretary Matt Hancock is on record as saying he wants the NHS to become ‘the most technologically advanced health and care system in the world’.

He has also accepted that rectifying existing deficiencies in NHS IT is essential ahead of any future technological enhancements, and has sought to emphasise how the Government’s latest vision for NHS IT – ‘The future of healthcare’ – will not adopt the kind of top-down approach seen in the national programme.

There are, however, areas of disagreement and concern with aspects of Mr Hancock’s vision for IT, with his championing of the ‘GP at Hand’ mobile app being a case in point.

Launched in 2016, GP at Hand began life as a collaboration between private health firm Babylon and the Dr S Jefferies and Partners practice in south-west London.

Using mobile-based technology and artificial intelligence, the app is designed to allow patients 24/7 access to consultations via a text-based chat bot or video calls with a GP. The area’s CCG has warned that the listsize surge associated with GP at Hand has led to ‘increasing costs’ that, unless mitigated, could lead to other health and care services provided by the CCG being jeopardised.

Get the basics right Despite these concerns, Mr Hancock has described GP at Hand as a revolutionary service that he hopes to see extended, and has also strongly endorsed the development and use of artificial intelligence in providing healthcare.

The BMA, however, has warned that the promotion of new initiatives such as video conferencing should not come at the expense of existing ‘place-based care’ and that investment in GP practice IT infrastructure are pre-requisite to any such advance.

Investment in the basics and avoiding over-reliance on emerging technology is an outlook shared by Bengi Beyzade, GP partner at Clerkenwell Medical Practice and clinical IT lead for the Islington GP Federation.

Dr Beyzade warns that the mishandling

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MATTHEW SAYWELL

of the national programme left a legacy of mistrust among many doctors when it comes to government pronouncements on IT. He is wary of the drive to promote emerging digital technologies as a cure-all for the health service’s existing IT shortcomings.

‘The term AI is misused,’ he says.

‘We look at AI and we look at our sci-fi films and think of an intelligent, learning computer.

Is that really the AI they’re talking about now?

It’s generally a programmed algorithm that doesn’t seem to learn for itself.

‘I think it’s disappointing that they are being sold as a magic bullet now. They do have value but if false promises are being thrown out ‘In clinic I’ve there just for us to be let down, it will feed the sometimes lack of faith we have in government when they push IT on us.’ had up to Dr Beyzade says that while IT has always 17 windows open on my been a part of his general practice career, its functions are now so integral that when computer’ problems occur, everything else could come grinding to a halt.

‘IT has always been there [in general practice] but has become more and more embedded, and in order to continue your daily functions, you’re more and more dependent on it,’ he says.

‘Previously if you had an IT failure, you

BEYZADE: An algorithm is no ‘magic bullet’ for the health service’s shortcomings

could just about get on and see a patient.

There’s so much safety in place now that’s wrapped around IT in terms of access to educational resources like the British National Formulary or guidance on how to manage certain conditions that if you don’t have access to that resource [as a GP] you can’t function.’

BMA council chair Chaand Nagpaul says getting IT right is fundamental to the BMA’s vision for a technologically enhanced future NHS. In a letter to the health secretary [Dr Nagpaul] sent on 4 April, said the Government must prioritise investment aimed at rectifying the existing IT deficiencies in the health service, ahead of new and emerging digital technologies.

‘Basic hardware needs to be upgraded – doctors and clinicians should not have to take time out from caring for patients to fix malfunctioning systems.

‘Alongside good quality, interoperable IT – and the funding required to make this happen... national standards, patient experience, and staff education and training must all be considered as key factors to achieving a digital transformation for patients and the NHS workforce.’ thedoctor | May 2019 11

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DOUGLAS ROBERTSON

GIVING THANKS: Medical students Theresa Peltz and Rebecca Murphy Lonergan

Precedent sept Seven women’s efforts to overcome the sexism they encountered while studying medicine did not end as they had hoped – but they did clear the way for others to fulfil their own ambitions. Jennifer Trueland reports on their long-awaited recognition

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T

he names of seven women will be among those called to graduate MB ChB at the University of Edinburgh this summer.

One hundred and fifty years after they enrolled as the UK’s first female medical students, the ‘Edinburgh Seven’ will be awarded their degrees, albeit posthumously, and on an honorary basis.

Mary Anderson, Emily Bovell, Matilda Chaplin, Helen Evans, Sophia Jex-Blake, Edith Pechey and Isabel Thorne

will be honoured on 6 July.

This is not only for their academic achievements – says Edinburgh University principal Peter Mathieson – but in recognition of the significant contribution they made to widening access to a university education for generations to come.

One young woman who is glad to tip her hat to her forebears is medical student Rebecca Murphy Lonergan.

When she took up her place to study medicine in Scotland’s capital she had never heard of the ‘Edinburgh Seven’. Now, she is on a mission to ensure that as many people as possible get to hear about the pioneering women, as well as to continue their fight for gender equality in the medical profession.

‘When I did find out about the “Edinburgh Seven”, I felt very proud to know that I was at a university with such an important heritage,’ says Ms Lonergan. ‘We should all be grateful to them for fighting for the rights of women to study medicine.’

By the end of this year it is likely that Ms Lonergan will get her wish and more people will have heard their extraordinary tale. While the women won their fight to enroll as medical students at the University of Edinburgh in 1869, they were soon to find that the battle wasn’t over. They might now be honoured by institutions such as the university and medical royal colleges with degrees and exhibitions, but it was a different story back then; it also has some resonance today.

The story began with Sophia Jex-Blake, who, when

‘There was a big crowd waiting for them, calling them names and throwing mud at them’

she initially applied to study medicine at the University of Edinburgh (because she thought Scottish universities might be more enlightened than those in England), was told they could not make arrangements for just one woman. There was no suggestion that she could train alongside the men. She advertised for others to join her, six answered the call and they began their course.

From the beginning there was opposition in some quarters, explains Jo Spiller, who is studying the ‘Edinburgh Seven’ as part of a research master’s degree.

‘The most steadfast opponent was a man called Robert Christison, who was the Queen’s physician in Scotland,’ she says. ‘He thought women who wanted to study medicine must have “unclean motives”.’

Another man, a Professor Laycock, said in a debate held by the University Council in 1870, said that teachers might find they were harbouring ‘Magdalenes’ in their classes, according to a contemporary report from The Times.

Mud-slinging The boiling tensions surrounding the women being allowed to study medicine came to a head when they went to Surgeon’s Hall to sit an anatomy exam on 18 November 1870.

‘There was a big crowd waiting for them, calling them names and throwing mud at them,’ says Ms Spiller.

‘Then some students pushed a sheep through the door.’

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DOUGLAS ROBERTSON

LONERGAN: ‘We should all be grateful to [the ‘Edinburgh Seven’] for fighting for the rights of women’

‘I felt very proud to know that I was at a university with such an important heritage’ strides we’ve made.’

Having said that, Dr Moultrie concedes that discriminatory behaviour and attitudes persisted well into the 20th century, with some people still showing the prejudice that led the ‘Edinburgh Seven’ to be branded unnatural for wanting to study medicine.

‘At school, I remember one [male] teacher saying to me it was no job for a woman, although everyone else was very supportive,’ she says.

‘But that just spurred me on.

‘I also remember that after I’d qualified as a GP I was applying for a full-time partnership and wasn’t getting anywhere, so I asked a GP at one of the practices why I hadn’t been called for interview. He said they’d had lots of applicants so they’d put all the female applications in the bin – that was their first sift. I changed direction

PELTZ: ‘There is still some way to go before it’s the same for women as it is for men’

Pathfinders She believes parental leave arrangements were less developed than they are now, which could have made GPs wary of taking on female partners because they were worried about what would happen if they took maternity leave – something she hopes would not happen today.

As joint deputy chair of the BMA Scottish GPs committee, she believes that efforts to create and promote equality of opportunity continue in Scotland to this day.

‘I believe that being a GP partner allows women more self-determination, and the new Scotland-only GP contract promotes partnerships, reduces the risks associated with being a GP partner, and improves work-life balance.

‘But while that’s all good news, there is still work to

DOUGLAS ROBERTSON

sympathy, however, with supporters including famous names such as Charles Darwin.

Despite their efforts, and their undoubted capabilities, the university – backed by the court of session – ruled that the women would not be allowed to graduate, and that they shouldn’t have been allowed to enroll in the first place. However, the door had been pushed open, and by the end of the 19th century women were not only allowed to study medicine but to graduate and work as doctors.

For Glasgow GP Patricia Moultrie, the story of the ‘Edinburgh Seven’ is a reminder of how far women in medicine have come.

‘They were fighting to study medicine in 1869 – that’s less than a hundred years before I was born, and, as I get older, 100 years doesn’t seem very long at all.

It made me realise the huge

and took up a part-time partnership and combined it with other things, which suited me very well.’

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be done, for example, in examining the gender pay gap, which a recent report showed was worse in general practice.

‘We hope that the minimum income guarantee in the new Scottish GP contract and the intended move to an income range in phase two of the contract will help address that.’

As a teenager, it never crossed Theresa Peltz’s mind that her gender might hold her back. ‘I didn’t really think about it – I went to an all-girls school and I never felt there

‘He said they’d had lots of applicants so they’d put all the female applications in the bin’

was anything that I couldn’t do,’ she says.

Now in her fifth year studying medicine at the University of Edinburgh she is a little more circumspect.

‘I think there is still some way to go before it’s the same for women as it is for men,’ she says.

Although she was initially surprised when on placement in some specialties (notably surgery) to see how few women there were in consultant posts, she says she has not personally experienced any

discrimination.

‘Some of the more elderly patients have called me “nurse”, but that’s OK,’ she says. ‘They don’t know that nurses wear uniform and we don’t. Although I guess they don’t call the male medical students “nurse”.’

Nevertheless, she and Ms Lonergan and Dr Moultrie are now undoubtedly cheerleaders for the seven women who helped them to arrive where they are today.

Hopefully, by the end of this year, more will join them to recognise this debt.

The Edinburgh Seven’s contribution to medicine still reverberates today

UNIVERSITY OF EDINBURGH

Mary Anderson continued her studies in Paris when it became clear that Edinburgh would not award medical degrees to women. She wrote her doctoral thesis on mitral stenosis and its higher frequency in women than men.

Sophia Jex-Blake, (pictured above) who led the campaign, also helped set up the London School of Medicine for Women.

She was awarded the degree of MD at the University of Bern in Switzerland and was able to register with the GMC after qualifying as a Licentiate of the King’s and Queen’s College of Physicians of Ireland. She became the first female doctor to practise in Scotland, setting up in Manor Place in 1878.

Edith Pechey went to the University of Berne and passed her medical exams (in German). She practised in Leeds and India and was heavily involved in the movement for women’s suffrage.

Isabel Thorne was unable to take her degree (the Edinburgh University website says she was ‘thwarted by family commitments’) but became honorary secretary at the London School of Medicine for Women.

Emily Bovell gained her MD in Paris, sat Irish exams for medical registration, and worked in London before moving to Nice to help alleviate the symptoms of TB. Helen Evans married an editor of The Scotsman (which had been a great supporter of the women), had three children, then, as a widow, became a member of the executive committee of the Edinburgh School of Medicine for Women.

Matilda Chaplin married, moved to Tokyo where she founded a school of midwifery, then studied at the London School of Medicine for Women. She got her MD from Paris in 1879, sat her final exams at the College of Physicians in Dublin, then set up in private practice.

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The hard road back A

Alastair Watt was a respected, hard-working and super-fit consultant.

His death raises serious questions about how the NHS looks after its doctors when they return to work after illness. Keith Cooper reports

lastair Watt and his friends pushed off for a final cycle around the Brecon Beacons before heading home that day in April 2016.

Sunshine was forecast.

Their hotel held breakfast until their return. It was a welcome reprieve from life as a single-handed diabetes and endocrinology consultant at a busy district general in Devon.

Part way round his wheel was clipped. He fell to the road and hit his head. His severe injury landed him in intensive care and off work for six months.

One year and eight months after the accident, in December 2017, he was found face down in a field close to the home he shared with his wife, Ruth Watt, a GP, and their 12-year-old twins, a son and daughter. He was 45. At an inquest last month, Exeter and Greater Devon senior coroner Philip Spinney

recorded a conclusion of suicide. Dr Watt died after injecting himself with insulin.

He knew what he was doing, the inquest heard.

Stuck at home How did the life of this dedicated doctor, husband, father, a man who literally cried when he laughed, according to friends, come to such an awful end? One of the multiple reasons in this complex case was the ‘stress and anxiety’ he experienced returning to work after the injury, the coroner concluded, after hearing evidence from family, friends, and managers at the Northern Devon Healthcare NHS Trust.

So, what happened?

For the first few months, he was stuck at home, recovering, a bit bored and frustrated. This previously reserved man was more emotional, more chatty.

Personality changes are known

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‘He wanted to come back to work’

complications of head injuries.

‘All there is on TV is the Brexit vote and the US elections,’ Mrs Watt, who practises as Dr Taylor, said before the inquest. ‘He’d sit down for hours watching TV, getting more stressed. I would come home to this half-anhour monologue.’ He was keen to get back to work.

In June he started seeing a psychotherapist, Andrew Forrester, about the accident, the personality change. His ‘long-standing and increasing stress’ at work came up, Mr Forrester told the inquest.

Weeks later, Katherine Smith, the trust’s then group manager of unscheduled care, called.

‘He wanted to come back to work. I said, you can’t without occupational health clearance,’ she told the coroner.

He met Joyshri Sarangi, an occupational health consultant, in July. He was not fit to work yet but agreed to a ‘graded return’, building up time in clinics, where patient arrivals are measured, the inquest heard. A return to acute care with critically ill patients and on-call could come later. He was encouraged to write up a ‘return to work plan’. He did.

Back to work In September, he was passed fit for clinic work but not on call. ‘He was expressing some anxieties about what he might face,’ Dr Sarangi said.

Days later, he was back parttime. Still under the standard driving ban for head-injured patients, he cycled the 26 miles to North Devon District Hospital, Barnstaple, for a month, splitting the trip with a train when tired. Ian Lewin, a retired consultant colleague, shadowed his clinics for some weeks.

Alison Moody, a respiratory consultant, became a mentor for his return.

Staff noticed the change in his behaviour. ‘He was more outgoing,’ Ms Smith told the inquest. ‘It wasn’t unusual on the spectrum of people. But it was unusual for Alastair.’

Staff liked it, said his friend of 12 years, Stuart Kyle, a colleague and consultant rheumatologist who had been on the Brecon Beacons break.

‘He was a very controlled person. I felt that Alastair had been let out. He was aware that he was doing it,’ he told the inquest.

However, unbeknown to Dr Watt, that November Ms Smith rang Dr Sarangi about the personality changes,

WATT: With his wife Ruth

‘He was expressing some anxieties about what he might face’

citing concerns by some staff, the coroner heard.

‘I didn’t know whether it was normal or not,’ she said. ‘There were no clinical concerns.’

The managementreferral form requested a review of his fitness to work.

It suggested ‘physicians’ wanted Dr Watt back in the medical assessment unit which cares for patients with acute needs round the clock – a copy of the form, seen by The Doctor, shows.

Dr Sarangi declined to bring forward her planned January appointment with Dr Watt for concern of disrupting his recovery. There and then Dr Sarangi showed him the referral, the inquest heard.

‘It was important for him to have the full picture. He really was extremely upset, distressed and shocked. We took a few minutes to have a period of silence.’ Her advice was unaltered: continue with clinics, no on-call cover for the acute unit.

His wife said the referral ‘blew him sideways’.

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‘The referral it was inaccurate. He felt trapped, physically ill,’ she blew him told the inquest. Ms Smith sideways’ stands by it but admitted she ‘should have discussed it’ with Dr Watt first. He appeared calm when they met later. She thought he was ‘really cross’ but forgave her. ‘He said it would take him time to build up trust,’ Ms Smith told the coroner.

Coping single-handed That same month, in an email copied to his wife and seen

by The Doctor, Dr Watt told Ms Smith of his ‘isolation’, his struggle to cope singlehanded since Dr Lewin’s retirement in 2012.

‘Attempts to recruit a colleague have stalled,’ it added. Ms Smith told the

inquest there were ‘no applicants’ to replace Dr Lewin, despite years of recruitment drives. His post is still not filled, the inquest heard.

Dr Watt’s personality changes settled in early 2017. By March, he was working four days a week but feeling fatigued. He gave a memorable staff talk about cerebral salt wasting, a rare complication of his injury. ‘He said he was going to show some horrific pictures,’ Dr Kyle told the inquest. ‘It was his broken bike. His wit was back.’

By June, he was back five days, on his bike at weekends with Okehampton Cycling Club.

They called him ‘The Beast’ for his hill-climbing ability. He was planning an ‘integrated diabetes service’, a big project

and personal ambition to improve care for his patients.

In mid-June, he discussed a return to on-call with occupational health. Dr Sarangi suggested starting with six-hour stints. ‘He had some anxieties,’ she told the inquest.

He was never put on the rota.

Weeks later, he met Ms Smith and human resources staff for a ‘sickness absence meeting’, eight months after his return. They’re normally held within four weeks. ‘The focus was on supporting the return to work rather than sickness absence,’ the trust’s then director of workforce Darryn Allcorn told the inquest.

At the meeting Dr Watt flagged again his difficulties returning to work, his

VIEW FROM THE TOP: Dr Watt visiting the Pyrenees

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isolation and concerns about his job plan, the agreement between consultants and managers to balance hospital workload with doctors’ contractual obligations.

Dr Watt hadn’t been happy about his job plan before the accident, Ms Smith told the inquest. But she didn’t consider he bore ‘any greater level of stress’ than other doctors. Dr Kyle, an associate medical director at the time, said many departments were ‘under-recruited’ but that Dr Watt was ‘more vulnerable’ as a single-handed consultant.

‘Dr Watt was more vulnerable as a singlehanded consultant’ A job-planning meeting was set for 6 September, a date family and friends will never forget. It marked his ‘turn for the worse’, according to his therapist, Mr Forrester.

‘Significantly, from then on, his anxiety was growing,’ he told the inquest.

Days beforehand, he had good news. ‘He was really excited,’ Mrs Watt said before the inquest. ‘He came up to me, “look, I’ve found this article, I can show them. I can prove to the management that I am overworked”.’ It was an RCP (Royal College of Physicians) paper, proving he carried the workload of 2.4 consultants. ‘He felt the onus was on him to prove he wasn’t being some lazy bugger,’ she added.

hands quivering at the end of outstretched arms. ‘Our duvet was so wet. I had to strip the whole bed down,’ she told The Doctor.

This isn’t Alastair, she added. ‘I’ve been with him for 21 years. We’ve done our finals together. He got a bit anxious then. I was with him through his MRCP exams, which were hideous.

IVF, which is hideous. We’ve coped with all of that. I’ve never seen him like he was that night. Never.’

She called Dr Moody, his mentor, about the state he was in. Dr Kyle joined him at the meeting, as a colleague and friend. He arrived smartly dressed, as usual, but very agitated, the inquest heard.

‘He was slightly incoherent in his speech, flitting from one thing to another,’ said Dr Kyle.

‘We should never have done it. It caused a lot of anxiety to Alastair when he was already in an anxious state.’

Ms Smith agreed to reduce his workload, remove from the plan his on-call, and his role developing an ‘integrated

‘He told his therapist about “urges to end his own life”’

MAN’S BEST FRIEND: Dr Watt with the family pet Oscar in the Lake District

diabetes service’. It was agreed that a mentor outside the trust would be sought for extra support. He was off sick with stress for the rest of the week before a trip to the Alps with his cycling friends, Dr Kyle included. He was anxious at the airport, struggled up the first few hills but by evening was laughing, smiling and chatting.

‘We had nights when having a few beers, and he was crying with laughter,’ Dr Kyle told the inquest. Then they were back in the UK, waiting for luggage. ‘He turned to me and said, I can feel my anxiety coming back, my anxiety rising,’ his friend recalled.

He was back at work in September, catching up, and soon saw a different occupational health consultant, Mark Critchley.

Dr Critchley ‘strongly recommended’ that Dr Watt ‘doesn’t return to on-call work for six months,’ the inquest heard. He was now ‘anxious and depressed’ about future working arrangements, Dr Sarangi said. The same month, he saw his GP who

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noted rising anxiety ‘as a consequence of work stress’.

By early October, he was off sick for good.

Suicidal thoughts

CROSSROADS: One of the last pictures taken of Dr Watt in the French Alps in September, 2017

On the 16th his ‘stress at work is still apparent’, his GP statement to the inquest said. Days later, he was ‘angry, fearful, sobbing’, added his therapist. Two days on, his GP prescribed antidepressants. Dr Watt sent a new job plan to Ms Smith, raising concerns again about being single-handed.

She forwarded his email to colleagues, suggested a ‘catch-up’ to tackle his concerns. By this date ‘it was unclear’ who his line manager was, following a trust management shake-up, Ms Smith told the inquest.

That November, he was at his GP’s with ‘increasing, regular’ thoughts of suicide.

He was referred to Amaury Delgado, a consultant psychiatrist in the community mental health team. A day later, he was back at occupational health. Dr Critchley noted increased symptoms of anxiety but saw ‘no reason he couldn’t return to work in a few weeks’ time’.

There was no mention of suicide, the inquest heard.

The next day, he told his therapist about ‘urges to end his own life’. The next one, he saw Dr Delgado who put him at ‘mild to moderate risk’ of suicide. He changed Dr Watt’s medication, referred to a care coordinator, and put him on a talking-therapy waiting list as his own private therapist was soon taking a break. Contact with his GP and therapist continued.

Towards the end of November, on pay day, Dr Watt found his salary was dramatically cut. ‘Are they trying to punish me?’ Mrs Watt recalled him saying in our interview. ‘He was absolutely distraught. I advised him to email them. It’s probably a catastrophic mistake, not malice,’ she added. It was an administrative error, the inquest heard. Payroll had without warning stripped months of ‘overpayment’ for its previous failure to adjust his salary, following the disastrous September job-planning meeting.

Dr Delgado noted a ‘significant deterioration’ in Dr Watt in early December, the inquest heard. He was yet to start NHS therapy. By this time, he was barely leaving the house, he was so ashamed of

being off sick. The weekend after the pay cut, he watched his son play rugby, a game that he loved, having once trained with the Saracens and played for Barts and the University Hospitals, London team.

Days later, he was unusually anxious about a furniture delivery.

‘He was shaking, beside himself. It was off the scale,’ Mrs Watt told The Doctor. His care coordinator visited the next day, offered advice, and left him some worksheets, the inquest heard. The next, his wife found him highly agitated at home.

‘He was saying, I’m going to prison. I have caused harm. I am single-handed. My patients with diabetes insipidus, I’ve done the wrong thing,’ she told the inquest. She texted his friend and colleague, Dr Kyle, for advice. ‘He said, this is nonsense. I went around the house to look for him.

He was gone.’

Flawed support The intense anger, the grief, of Mrs Watt makes for a moving interview. ‘I want to get it out there, get it out there,’ she begins. ‘Jobbing doctors on the ground have this huge pressure, there’s a lack of 20 thedoctor | May 2019

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EMILY FLEUR

We’re not superhuman

resources, then something happens and it can make you vulnerable. How then are we supported? Alastair wasn’t.

There were very complicated reasons why. The man became fearful and there are other doctors out there facing a culture of fear for other reasons.’

She’s not satisfied by the trust’s account of its support for her husband. The trust says it will ‘look closely at the outcome of the inquest’ for further lessons. The trust says it has learned from the ACAS report into his death last year.

Inquests do not examine or pin blame. It’s an obvious source of frustration.

Despite the grief, or even because of it, you sense Mrs Watt will not stop searching for answers. ‘My children and I will never get over the death of Alastair,’ she says. ‘Our children should still have their father to watch them play sport, sample their baking.

We have lost him forever,’ she says, covering her face with both hands, and then one.

The BMA’s wellbeing support services are open to all doctors and medical students.

They’re confidential and free of charge. Call 0330 123 1245

LACK OF SUPPORT: Doctors work in a culture of fear, says Ruth Watt

‘My children and I will never get over the death of Alastair’

Doctors face illness and injury like everyone else, so why are they often so poorly supported? A leading psychiatrist tells of the ‘deep malaise’ in NHS management Alastair Watt was a highly respected colleague and passionate patient advocate. He was a father, a husband, a doctor. He was one of us. He was under tremendous pressure in his job before his severe head injury, the only consultant in a diabetes and endocrinology service designed for two. He had significant vulnerabilities when returning to work. This much is obvious.

Northern Devon Healthcare NHS Trust accepts there were shortfalls in its handling of Dr Watt’s return to work.

Others may be revealed, following the inquest. It’s agreed to look and improve. But we all know what it’s like in our highly politicised NHS. Face-saving is too often favoured over apologies or admissions of errors. Target chasing too often trumps patient care. Staff are expected to flex and flex, then flex again, under ever-increasing pressure.

We’re not expected to break.

Well, doctors do break, as the awful and complex case of Dr Watt shows. We might be trained to operate in stressful situations. But we’re not invincible. No one is. We’re certainly subject to sudden, unpredictable life changes, like the injuries and mental ill health which we help heal.

Something has to change. Our country depends on doctors to care for patients in the NHS. Is it too much to expect the NHS to care for its staff? It’s no wonder so many posts in our service remain unfilled.

All Dr Watt wanted to do was return to work. But he couldn’t see a way back. His work stress began well before his severe injury. He’d been single-handed for years. He flagged these concerns again and again to his managers with increasing desperation, before and after his injury.

It would be easy but wrong to think this could be fixed with a tweak to corporate rules or staff structures. No. The tragic case of Dr Watt betrays a deeper malaise in NHS management and politics and their attitude towards staff.

That their doctors and staff are made of super-resilient stuff or should be. We’re not. We’re human. We and our vulnerabilities need as much care as anyone else that we care for ourselves.

Phil de Warren-Penny is a consultant psychiatrist and chair of the BMA southwest regional consultants committee

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Pictures are for illustrative purposes only and not necessarily current NHS building projects.

13/05/2019 09:54

Crumbling hopes The NHS is being challenged to ‘transform’ but budget raids and foolhardy PFI deals have left many hospitals and GP practices debt-ridden, shabby and barely able to provide safe care. Peter Blackburn reports

‘W

e have a legacy… of underinvested buildings, we have a legacy of buildings where there wasn’t proper due diligence done… we have a large number of fairly tired GP surgeries, of health centres where there’s a real need for reinvestment and there’s a real need for change.’

Those are not the criticisms of an NHS campaigner or opposition politician, but the honest critique of John Westwood, director of asset management, NHS Property Services, speaking at a Westminster Health Forum event earlier this year.

His admission comes as the NHS seeks to transform itself – in the face of vast, rising demand and growing complexity of patient need – with a new long-term plan focusing on community care, joined-up services and prevention. But Mr Westwood is right. The crumbling NHS estate threatens to undermine patient safety and care in the present – let alone attempts to transform in the future.

As Lord Bradley, non-executive director of Pennine Care NHS Foundation Trust, said in opening the conference: ‘I think the effective delivery of the direction of travel of the long-term plan, with the move again stated from hospital-based care to more community-based care, more prevention, more intervention, more diagnostics, more early referrals, cannot be achieved unless there is a significant improvement in the estate

in which the workforce are delivering those services.’

Austerity effect The biggest underlying problem, as so often is the case, is about money.

In recent years NHS capital coffers, which are supposed to contain around £5bn a year, have been repeatedly raided to prop up revenue costs (with around £3.3bn surviving each year) – a result of underfunding of NHS budgets and the Government’s austerity regime.

Money for much-needed capital investment has therefore been limited and the result is a whopping backlog for maintenance repairs standing at around £6bn. The evidence is often painfully clear to anyone visiting a hospital.

Speaking at the conference, Robert Naylor, who was commissioned by the Government to produce two reports looking at NHS estates, said the problem was very serious indeed.

He said: ‘Services will collapse, things like ventilation systems in operating theatres and so on. If we don’t address that we are going to have a series of one-off big issues in the NHS. There have been several issues in London hospitals recently, which are really challenging: floors collapsing, systems just simply failing in the middle of an operating day – and these are things that we really have to address.’

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‘Services will collapse, things like ventilation systems in operating theatres and so on’

finance projects also stretching the public purse.

In the 1990s and early 2000s, John Major’s Conservative Government and Tony Blair’s successive Labour governments pursued PFIs (private finance initiatives), with enormous and misplaced enthusiasm.

There are around 700 active PFI deals in the UK – across all sectors – and Government estimates suggest the eventual cost, by the 2040s, to the taxpayer will be £199bn.

Private matters After the collapse of Carillion last year chancellor Philip Hammond confirmed PFIs were over – and said no more deals would be signed. While for many that was welcome news, it provokes further questions about the future of the NHS estate in an environment where significant capital investment from the Government is unlikely.

So, where is any investment likely to come from?

The first answer, as unpalatable as it may be to many, appears to be land sales.

Sir Robert’s second report – commissioned by Jeremy Hunt before leaving his post as health secretary – was based entirely on London, where the vast majority of the NHS’s highvalue land is situated.

The report remains unpublished owing, according to Sir Robert, to the Government’s failure to claim a majority at the last general election and its ‘controversial’ contents – despite local health leaders acting on its contents already.

Sir Robert told the conference he was focusing on four or five big London projects, working with local leaders in a consulting role: the move of Moorfields Eye Hospital to St Pancras, fixing the backlog maintenance totalling around £1.5bn

of Imperial College Healthcare, looking to make some money out of the ‘hugely valuable’ Royal Brompton hospital site in Kensington and two more secretive projects – one looking to redevelop the primary care estate in London and another project on which Sir Robert would not be drawn.

The Doctor requested a copy of Sir Robert’s second report under the Freedom of Information Act but the Department of Health refused, citing commercial sensitivity.

The lack of transparency around the process is troubling – particularly when such significant financial decisions, affecting the public purse, are being made. But it would appear land sales will be a primary factor in raising money to develop the NHS estate, regardless.

But could things be done differently – if we assume the NHS has land which is not needed?

Well, Sir Robert certainly thinks there could be, with primary care at the top of his hit list – but it remains unclear in what guise. And if that money doesn’t come, he adds, it will need to be replaced by the public purse.

He said: ‘If there isn’t going to be any more private sector investment then the chancellor has got to dig a lot deeper into his pockets to replace that which would have come from the private sector and of course that will create a political problem because it will affect the balance of

MOORFIELDS: Changing site under a major redevelopment

‘More early referrals cannot be achieved unless there is a significant improvement in the estate’

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payments and national debt. It’s a big issue that has to be solved.’

In March the Government committed to a ‘review’ of private financing options for public infrastructure, so answers to this big question may be forthcoming – although the timeline for that is unlikely to be hasty if recent examples such as the long-promised social care green paper are anything to go by.

Needs a lift One of the potential options for the NHS is growing the use of the LIFT (Local Improvement Finance Trust) scheme – which sees locally based joint ventures between community health partnerships, a company run by the Department of Health, and a range of private sector partners. There have been 49 LIFT companies set up around the country already, developing 339 integrated community facilities worth more than £2.5bn.

Mark Day, acting chief executive of Community Health Partnerships, said the projects could continue to offer a solution to the NHS: ‘The benefits of LIFT go far beyond the new shiny buildings that we all see.

The intention was that we develop long-term partners… particularly the management services providers who actually run the LIFT companies, people have been there for the long term, and lots of people have got very deep NHS experience.’

Unlike with PFIs, the chancellor has not ruled out the continued use of such schemes but their future role remains unclear.

1,000 practices in England asked doctors and practice managers about their experiences with property ownership and management. Only half of practices said their premises were suitable for present needs and around eight in 10 said their practices were not suitable for future needs or anticipated population growth.

The survey also found that GP premises are, on average, 35 years old and some practices had been waiting for years to hear whether funding for improvements would be given.

BMA GPs committee chair Richard Vautrey said: ‘Many practices are desperate for refurbished or new premises to be able to provide good standards of general practice and many others are so tight for space that they can’t accept new patients.

I’m also aware of practices that are at risk of failing Care Quality Commission inspections, simply because they haven’t received the necessary funding.’

In truth, national action is the only way to address problems as big as those facing the NHS estate.

That means political will, a long-term genuine funding plan for capital projects and clinical involvement and transparency in decision making.

As things stand it appears the NHS is just stumbling on, making plans behind closed doors, at risk of making big decisions – like land sales – which cannot be reversed and will only bring money in once.

‘Practices are desperate for refurbished premises to be able to provide good standards’

‘[Without] private sector involvement the chancellor has got to dig a lot deeper into his pockets’

Unfit for purpose A major BMA survey earlier this year revealed that only half of GP practice buildings in England are fit for purpose, with surgeries too small to meet the demands of growing populations.

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BHUGRA: ‘We should examine how terms and conditions in which people learn and practise could be improved’

Support: a scarce commodity The pressure on doctors is placing many of them at risk, according to research – but will something decisive finally be done about it?

Keith Cooper finds out

T

he human cost of stress, pressure and an unsustainable workload has been laid bare by a BMA survey, which has found eight out of 10 doctors are at a substantial risk of burnout.

More than a quarter of the 4,300 respondents to the survey said they had received previous, formal diagnoses of mental conditions, and four out of 10 said they were suffering from psychological or emotional distress, which affected their work, training or study.

Younger and junior doctors, medical students and those

working longer hours are more likely to suffer from mental ill health, the survey found.

It also pinpoints a strong relationship between the use of alcohol, drugs and selfmedications by doctors with current or previous mental health diagnoses – with 62 per cent using them as a coping mechanism. Alcohol, drug use and self-medication are more common in consultants, those working shorter weeks, doctors aged 64 and above, and men.

The survey uncovered worrying evidence of inadequate or no support

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‘Medical students are surprisingly stressed, which is a bad sign, as these are some of the most energetic, enthusiastic people’ for doctors when sought.

Medical students were most likely to find help didn’t meet their needs, while older, staff, associate specialist and specialty doctors, and overseas-qualified doctors were most likely to say support was not there when requested.

Supporting doctors The survey is part of a larger project led by BMA president Dinesh Bhugra to find ways to improve the mental health of the medical workforce and so improve patient care. The second research phase of the project will look in more detail at the issues raised by the survey. The results are due to be published in the summer.

Professor Bhugra says that while stress is in the nature of medical practice it could affect doctors differently, depending on whether they are trainees, consultants, GPs or SAS doctors.

‘Medical students are surprisingly stressed, which is a bad sign, as these are some of the most energetic, enthusiastic people who want to help people by going into medicine.

‘Informally, I’ve heard that some of these stresses come from financial problems and debt. They are also feeling that as they learn on simulators, on dolls and with actors that they do not develop the same empathy with patients.’

He is concerned about the lack of support in some medical schools, calling for more research to pinpoint any geographical differences in

stress rates and support levels.

‘As the only organisation that looks after doctors in all specialties and across the UK, we should examine how terms and conditions in which people learn and practise could be improved.

That’s my challenge to the BMA and I hope it takes this on board.’

He hopes that the BMA will repeat the survey of doctors’ mental health regularly. ‘The longer people struggle on without support, the more chronic their conditions become, the more difficult it is to treat.’

Consultants don’t cry Also published this month are the findings of a separate study by Swansea University of junior doctors’ experience of mental illness, the stigma they face, their struggle for support and the effect it has on their professional lives.

‘It got to the point where I was almost catatonic in my room all the time,’ one doctor told researchers. ‘I was making it to work, just doing what was required, then coming back. But I wasn’t making any advancements.’

Another was told by a colleague, ‘if you’re crying this much you shouldn’t be a consultant’.

The Swansea study found the trainees were reluctant to disclose their illnesses for fear of the effects on their careers, and struggled to access support, especially in rural areas. Some also found it difficult to return to work after time off sick.

‘I went back, nothing was said of it,’ one said. ‘I selfreferred to occupational health. I basically got sort of a generic letter back, giving me an appointment in May. I was due back in February.’

The Swansea report recommends special provision for doctors in training with mental ill health and for employers to tackle the stigma of mental illness in the medical profession.

Professor Bhugra says more is needed to be done to address the stigma of mental health and to improve the support to doctors. ‘We must create spaces where all doctors, trainees, SAS, GPs, can go for support,’ he adds.

‘We invest a tremendous amount of money in training doctors to leave them to fall by the wayside. It just isn’t fair on them or society.’

‘We invest a tremendous amount of money in training doctors to leave them to fall by the wayside’

There is always someone you can talk to...

BMA wellbeing support services are open to all doctors and medical students.

They’re confidential and free of charge.

Call 0330 123 1245 and you will have the choice of speaking to a counsellor or taking the details of a doctor who you can contact for peer support.

For more information go to bma.org.uk/yourwellbeing

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

This month, our regular look at the support given to doctors experiencing difficulties at work covers the preservation of terms and conditions and a long battle for the right pay Transfer trepidation

Persistence pays off

TUPE regulations, which preserve employees’ terms and conditions when they are transferred to new employers, are a vitally important protection.

Although TUPE (Transfer of Undertakings [Protection of Employment]) protects terms and conditions, the new employment contract doesn’t have to have exactly the same wording as the old one. So, it can be difficult to work out if the new contract is genuinely as good.

A salaried GP worked for a private company which was taken over by another one. Her new contract was set out in a different order, with different titles and different terms. Even her annual leave seemed unfamiliar, as it was calculated in hours instead of days. This can often cause confusion when it’s not clear how many hours are being deemed to constitute the working day for the sake of the calculation.

So she contacted the BMA, and an employment adviser worked through it with her. Given that this column is so often about the hidden and hideous pitfalls in employment contracts, it’s refreshing to report that the new one she was offered was acceptable, and in some ways better than its predecessor.

The GP said she received ‘valuable timely advice’ and would probably agree with the employment adviser’s view that it’s a good idea to contact the BMA when faced with something as important as a new contract.

If you’re fighting pay and conditions battles on behalf of members you have to be organised. It’s often on the detail that cases are won or lost.

So, every time there’s contact between BMA member relations staff and a doctor they’re helping, or an employer, a note is made on the BMA’s system.

In this case, there were more than 200 such notes. It shows that BMA membership brings not only access to expertise, but also to dogged persistence.

A consultant was being underpaid.

His employer had made an error with his salary point, the point at which he should have been paid when appointed, taking account of previous experience and training.

Calculating pay can be difficult because, naturally, hours change, employers change, career breaks are taken. But employers are often far too slow to rectify errors once they are pointed out.

As the situation had already persisted for some time, the first job was to work out what the member should be being paid. This meant taking into account all of the previous increments and pay circulars.

Then, armed with this knowledge, it was time to get on to the employer. And on, and on, in this case.

It took two years to resolve this case, but it was worth it. The BMA claimed several years’ back pay and secured almost £30,000 for the member, who praised the employment adviser’s professionalism and commitment.

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the secret doctor

If we sign it, we own it ‘Can I have an X-ray for this patient’s wrist? I think it’s broken,’ said the triage nurse.

‘Sure,’ I said. ‘I’ll just come and take a quick look at it.’

‘Oh, it’s OK,’ she answered, slightly disgruntled. ‘I’ll ask someone else.’

She was highly experienced and just as able to recognise a fractured wrist as I am. The signature on the request for ionising radiation, however, would be mine. Likewise, if I’m prescribing something on the request of a specialist nurse, I’ll always check their calculation. They’re no more likely to get it wrong, but in the final analysis the responsibility lies with the prescriber.

Long ago when I was a very newly qualified doctor, I followed the hastily given advice of a senior nurse and stitched a laceration with inadequate equipment to hand. The nurse was nominally supervising me as I barely knew how to suture but she was busy dealing with a number of more urgent matters. The patient came to no actual harm, but it was messy and embarrassing.

Afterwards, the nurse – nicely – reproached me.

‘I thought you told me to do it that way!’ I complained.

‘Maybe,’ she said, ‘but you’re the doctor.’

It was galling at the time, but she was absolutely right.

Being a doctor means taking responsibility. Of course, nurses often carry heavy responsibilities too, but if a doctor and a nurse disagree then generally the final decision, and therefore the potential blame, belongs to the doctor.

For that reason, I worry about the introduction of ‘dependent’ roles such as physician associates. If they’re clerking in an emergency department, or seeing patients in a GP surgery, someone – some doctor – will need to sign prescriptions and scan requests for them.

Either the doctor can review the patient again, duplicating effort (and bemusing the patient), or they can swallow their professional scruples and rubber-stamp the request. Neither is ideal.

If we trust non-doctor practitioners enough to ask

them to perform doctor-like roles, we need to trust them to do so independently. That doesn’t mean they can’t ask for help and advice, of course, but they shouldn’t need a doctor’s signature for every decision they make.

Alternatively, if we don’t trust them to request tests and make management decisions, we shouldn’t try to use them as replacement doctors. To separate the decision-making part of a doctor’s role from the responsibility-taking part seems unreasonable.

There’s nothing magical about the title ‘doctor’, and professional boundaries are not cast in bronze.

Many nurse practitioners and physician associates can and do achieve great expertise. But in a system that relies on clear allocation of responsibility, the current awkward compromise risks putting us all in a false position.

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and finally...

Spring in her step For those of us who after a long winter are feeling somewhat jaded and tired of the continual fight that emergency medicine has become, there’s nothing more life affirming than a trip to the country, where life is exploding everywhere.

Fields pulsate with gangs of newborn lambs racing and bouncing on spring-loaded legs, surrounded by their anxious bleating mothers prepared and equipped to inflict mortal damage on anyone venturing to the wrong side of their fence.

But it’s not just animals who reinvent themselves with a new springtime generation: humans do it too. Although we don’t encourage deliveries (or anything else to do with obstetrics) in the emergency department, occasionally they happen, and when they do they often create a little buzz of excitement.

Obviously, they help the resus room statistics too –

with one patient brought in and two coming out rebalancing the normal flow in the opposite direction.

The 16-year-old who came to us in advanced labour categorically denied any possibility of pregnancy, but the evidence of an emerging head in her perineum was difficult to rationalise with her version of reality. One could only conclude that although her mind may have been elsewhere at the crucial time the previous summer, her body had indeed participated in the biology of life creation.

And now she was a mother confronting all the responsibilities that this lifelong condition confers.

Not having received any antenatal care, nor having mentally prepared herself in anticipation of her new role, one feared that her foray into motherhood wouldn’t end well.

However, this would be to ignore the effect of maternal

hormones on the average mammalian mind. If it was a movie the scene would have included long lingering looks, pink fluffy baby smiles and gurgles and a dramatic musical crescendo. However, our version was about the new mother trying to bond with a slimy, wrinkled, low birth weight infant, which at the time was being stuffed into a portable incubator.

We found out that the new mother had fully embraced her maternal instincts when a week or so later she returned with her now pink and fluffy baby to thank our staff.

Clearly this was a young lady whose transformed life now had an unexpected extra meaning and purpose, and if that isn’t life affirming I don’t know what is.

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

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what’s on

May 18 Junior doctors conference, London, 9.15am 21 Staff and associate specialists conference, London, 9am to 5pm 23 Pensions taxation and retirement planning – delivered by Chase de Vere Medical, Altrincham, Greater Manchester, 7pm to 8.30pm

June 23 Pensions roadshow – what’s the potential impact for you? Killyhevlin Hotel, Dublin Road, Enniskillen, 6pm to 8.30pm 29 Pensions taxation and retirement planning – delivered by Chase de Vere Medical, Nottingham, 7pm to 8.30pm 29 Pensions roadshow – what’s the potential impact for you? Crowne Plaza, Shaws Bridge, Belfast, 6pm to 8.30pm 30 Pensions taxation and retirement planning – delivered by Chase de Vere Medical, Canterbury, 7pm to 8.30pm 30 Pensions taxation and retirement planning – delivered by Chase de Vere Medical, Swansea, 7pm to 8.30pm

05 Recruitment, selection and contracts of employment, Edinburgh, 9.30am to 4.30pm 05 Primary care networks conference for clinical directors, London, 9.30am to 4pm 06 SAS professional development day, Glasgow, 9.30am to 4.30pm 14 Recruitment, selection and contracts of employment, Bellshill, North Lanarkshire, 9.30am to 4.30pm 19 Practical skills... leadership and management for doctors, London, 9am to 5pm 24-25 GP general update, Birmingham, 9.30am to 4.30pm 23-27 BMA annual representative meeting, ICC Belfast, 2 Lanyon Place, Belfast

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

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