The magazine for BMA members
thedoctor
Issue 18 | February 2020
Held back The hospitals banned from spending their own money to improve care
Undermined and overlooked SAS doctors speak out about their working lives
Life choices Your views sought on physicianassisted dying
Wearing many hats Making best use of doctors’ skills from outside medicine
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thedoctor
The Doctor BMA House Tavistock Square London WC1H 9JP Tel: (020) 7387 4499
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Call a BMA adviser 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.
Editor Neil Hallows (020) 7383 6321 Chief sub-editor Chris Patterson Senior staff writers Peter Blackburn (020) 7874 7398 Keith Cooper (020) 7383 6390 Staff writer Tim Tonkin (020) 7383 6753 Scotland correspondent Jennifer Trueland 07775 803 795 Senior production editor Lisa Bott-Hansson Design BMA creative services Cover: Mark Harvey
The Doctor is a supplement of The BMJ. Vol: 368 issue no: 8233 ISSN 2631-6412
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In this issue 4-5
Briefing Why we’re still Europeans, rooting out racism, and reviewing the emergency care targets
Welcome Chaand Nagpaul, BMA council chair In NHS England’s much-vaunted Five Year Forward View a grand promise was made: parity of esteem for mental health alongside physical health. Yet, more than five years later, any sort of equality – whether in access, resource, education and training, estates or outcome – is still very much the exception rather than the rule. And a report in this edition of The Doctor has revealed the Government is to put another significant barrier in the way of boosting investment in mental health trusts in England, with ministers looking to freeze £1.7bn of ‘cash reserves’. The money, held by mental health trusts and used by NHS leaders to keep the health service in the black overall, could be put towards vital building or repairing of crumbling hospitals and other facilities. The Government has different ideas, and as the Nuffield Trust’s Sally Gainsbury says in the piece, this legislative change would mean ‘mental health is likely to be at the bottom of the pile’. As part of the feature, The Doctor spent time at a mental health trust in Bradford, where a lack of investment in facilities is having a major effect on staff and patients. Here, doctors and nurses spend crucial working hours patrolling corridors to ensure patients are not harming themselves in parts of the hospital not fit for purpose. Staff spend moments of reflection in their cars outside the building because there is nowhere else for them to go. Poor environments in mental health hospitals are harmful to patients and staff – and the BMA is calling for the promise of parity of esteem to be honoured and underpinned by parity of resource. This issue of The Doctor also looks at the experiences of staff, associate specialist and specialty doctors – in the context of a recent GMC survey. For far too long they have been the victims of bullying and discrimination, with staff reporting belittling, humiliation and threatening or insulting comments or behaviour. In our feature, doctors explain the sense of ‘powerlessness’ they feel as a result of negative behaviour. This feature illustrates how crucial it is employers follow the guidance in the BMA’s SAS charter, and that locally employed doctors are listened to, appreciated and valued.
6-9
Change at Waterloo How taking injured veterans to – of all places – a former battlefield can be valuable therapy
10-13
Banned from getting better Why hospitals wanting to improve care for mentally ill patients are being held back
14-17
In the nick of time A doctor, a police officer and a former soldier all rolled into one
18-19
Life choices The BMA seeks members’ views on physician-assisted dying
20-23
Undermined and overlooked Thousands of SAS doctors speak out about their working lives
24-27
Balm of hurt minds The extraordinary things patients do in their sleep
28-30
Life experience
31
What’s on? thedoctor | February 2020 03
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briefing Current issues facing doctors
McCARTHY: Doctors have so much to share with each other
04
We’re still Europeans In many ways, not much changed the day after Brexit. On 1 February, there were still tens of thousands of doctors keeping the NHS afloat from Ireland, Greece, Romania, Italy, and every other member state left in the EU. Medical researchers continued to work with colleagues working across the two dozen European research networks. UK-trained doctors reported for work as usual in EU hospitals and other institutions. Public health officials in the UK and the EU continued to collaborate. Brexit may now finally mean Brexit but that doesn’t mean decades of collaboration and mutual accord across the European continent – in the interests of good medical practice and patient care – will now be wound down. ‘Britain’s doctors will still strongly remain part of Europe’s medical community,’ said European Union of General Practitioners vice-president Mary McCarthy. ‘Doctors in the UK and their colleagues across Europe have so much to share with one another, and medicine, the medical profession and the whole continent’s health is far stronger when we work together.’ Dr McCarthy was speaking at Keeping Europe healthy: the European medical profession in a post-Brexit Europe, an event held by the BMA in the European Parliament. The BMA’s representatives there will continue to press for hard-fought-for measures which enshrine the rights of a pan-European workforce. It will also campaign for the UK’s role in European research, improved patient care, open borders between Northern Ireland and the Republic of Ireland, and a continued smooth passage for medicines and medical devices from the EU. ‘British medicine is European medicine,’ said Sarada Das, deputy secretary general of the Standing Committee of European Doctors, of which the BMA is a member. ‘We must protect the achievements that EU cooperation has brought,’ she added. bma.org.uk/brexit
g n i t o Ro out m s i c a r ‘It feels like something that separates you from fellow students – an additional challenge that only a small percentage of individuals have to go through. The majority of students are completely oblivious to these extra issues.’ This was how one black British fifthyear medical student described racial harassment while at university, following a round-table event into racism at UK Caring, supportive, medical schools hosted last year by the BMA and Equality collaborative and Human Rights Commission. The impact of racism, undermining behaviours, and racial inequalities in medicine have received increased attention in recent years, through wellpublicised studies such as the GMC’s Fair to Refer report and the objectives of the BMA Caring, supporting and collaborative vision for the NHS. However, awareness of the effects of racism in medical schools, while not as well-publicised, is no less important. A member survey carried out by the association found that BAME (black,
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HANCOCK’S FOUR HOURS: The health secretary eyes the emergency-care targets
The measure of NHS pressures
portive,
asian and minority ethnic) students were four times more likely than their white counterparts to describe bullying and harassment as ‘often’ rather than ‘sometimes’ a problem. In response to these concerns and policy changes endorsed by the association’s annual representative meeting, the BMA has drafted a charter aimed at medical schools setting out clear and comprehensive guidelines on how for the NHS academic institutions should prioritise and address matters concerning racial harassment. It includes supporting individuals in speaking out by putting in place a code of conduct, with specific reference to racial harassment. BMA council chair Chaand Nagpaul said: ‘Medical students are the future of the profession. They need to know that they can expect an inclusive and safe environment at medical school and on work placements.’ bma.org.uk/nhsfuturevision
a future
vision
‘It is far better to have targets that are clinically appropriate and supported by clinicians.’ It was an interesting turn of phrase from health secretary Matt Hancock, as he hinted at the removal of the four-hour emergency care targets in England in a media interview. Doctors across the country could have been forgiven for wondering where the Government’s sudden desire to make decisions based around clinical appropriateness and support had come from. After all, how many major NHS reorganisations or plans had been genuinely clinically driven in recent years, under successive governments? ‘We will be judged by the right targets,’ Mr Hancock said. ‘Targets have to be clinically appropriate. The four-hour target in [emergency departments] – which is often taken as the top way of measuring what’s going on in hospitals – the problem with that target is that increasingly people are treated on the day and are able to go home. It’s much better for the patient and also better for the NHS and yet the way that’s counted in the target doesn’t work.’ Some might question whether Mr Hancock’s thinking had been influenced by other events. After all, last month it was revealed the NHS had continued to make new entries in the record books – for all the wrong reasons. Perhaps these targets have simply become too embarrassing? Winter pressures, the pensions crisis and remarkable demand from patients, unmet by increased resource, left NHS staff working in a service which posted record lows in performance against the four-hour target and the highest ever number of 12-hour waits in emergency departments, figures released in January, which covered December, revealed. The question is whether there is a viable alternative. The Royal College of Emergency Medicine does not think one exists. Doctors have long recognised that targets can have unintended consequences, forcing staff to focus on hitting them rather than what can sometimes be more pressing patient needs, but BMA emergency medicine lead Simon Walsh said replacing them does not address the ‘fundamental’ issues of capacity and resourcing in the NHS. ‘Whatever way you look at the state of emergency care, the picture is bad. Against the four-hour target, the emergency care system has been woefully underperforming despite the extraordinary efforts of frontline staff, with the most recent figures highlighting that emergency departments had their worst month on record in December,’ he said. NHS England is piloting alternatives to the four-hour waiting target in 14 NHS trusts, the full findings of which have yet to be released. Dr Walsh said any change would need to be properly evaluated, backed by evidence from the pilots, and agreed with clinicians to ensure patient care is improved and safety maintained.
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PAUL COOPER
‘It joined up recent conflict sufferers with the history of the old’
THIS MIGHT HURT: Mick Crumplin (below) with a capital amputation set and archaeologist Sam Wilson (right, pictured far right)
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Taking injured military veterans to excavate a historic battlefield which still yields body parts might not seem the most obvious therapy but the results have been impressive. Tim Tonkin meets volunteers, including the surgeon who is an expert in the ‘horrendous’ practices of old
Change at Waterloo ‘F
hopefully begin to open up to one another. The experience of the veteran who discovered a British musket ball, potentially fired by a member of his own regiment some two centuries previously, represented a small discovery in archaeological terms but a hugely significant one personally. ‘He described it as being an incredibly powerful and emotional experience that helped him get through some stuff and brought some stuff to light that he hadn’t really thought about and had clearly been suppressing,’ says Capt Evans. ‘Veterans all too often suffer in silence because they don’t feel like they have permission to speak, don’t want to seem weak or to burden other people.’
History as therapy While not formal clinical treatment, Capt Evans says the project, which is also staffed by a variety of health professionals, has made a real difference to those who have taken part in it. Retired surgeon and military medical historian Mick Crumplin is one of
EVANS: Veterans too often suffer in silence MATTHEW SAYWELL
rom [finding] this one musket ball, he was incredibly overcome with emotion and started thinking about things that he hadn’t really talked about for a very long time.’ Former Army captain Mark Evans recalls the experience of a fellow military veteran participating in Waterloo Uncovered, the charity which he co-founded after leaving the Army in 2010. The project is perhaps unique in that it seeks to help serving and ex-military service personnel, many of whom might be struggling with mental or physical health issues, by engaging them in archaeological work around the battlefield of one of Europe’s most iconic military encounters. Capt Evans, along with his friend and fellow Coldstream Guards officer Major Charlie Foinette, set up the project in 2015, the bicentenary year of the battle, and the size of its expeditions to the battlefield have continued to grow in size and scale. By bringing together current and former members of the military alongside archaeologists and health professionals, Capt Evans says the project provides a safe and structured environment in which those with shared experiences and challenges can
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CHRIS VAN HOUTS
HIDDEN HISTORY: Amputated leg bones (right), archaeologist Eva Collignon (below), retired surgeon Mick Crumplin and artefacts at the Military Surgical Museum CHRIS VAN HOUTS
those who has lent his support to the project. Indeed, his participation is perhaps the logical conclusion to a life-long passion for the Napoleonic era. ‘As a child I had always admired these ridiculous uniforms of the Napoleonic period,’ he says. ‘I’d always had an interest in military history and that spurred me to start studying the campaign of Waterloo.’
Napoleonic surgery
ALEX CAUVI ALEX CAUVI ALEX CAUVI
As a pupil at Wellington College, itself established in honour of the British field commander at Waterloo, he had opted to study medicine having been one of the few students in his year not to go into the Army. During his career he trained at Middlesex Hospital, and worked at others in the capital, Essex and Wiltshire, before completing his surgical training in Birmingham and practising in North Wales. His first medical history book Men of Steel focused on surgery in the Napoleonic wars. He has also researched the medical histories of a range of conflicts, from the battle of Agincourt to the war in Afghanistan. ‘The Napoleonic wars were not a massive breakthrough [for medicine]. But they had a lot of good surgeons evolving who understood the demands of the military. The wars give you the emergence of military surgery, how people were trained and an increasing respect for surgeons.’ He says surgeons were on a ‘rising curve’ compared with physicians who were, for example, yet to have the benefit of antibiotics which were not developed until more than a century later. Having donated a number of his own artefacts to the Military Surgical Museum at Mont-Saint-Jean farm in Belgium – the site of an allied military field hospital during the battle – Mr Crumplin became involved more directly in the work with Waterloo Uncovered. With roughly 6,000 wounded soldiers treated
at Mont-Saint-Jean in 1815, the location has seen a number of significant archaeological finds, including limbs amputated and discarded following surgery. ‘That was a very important time for me because it joined up recent conflict sufferers with the history of the old,’ he says. ‘I took the veterans around the museum. I was a little bit hesitant to take amputees around and tell them about what happened [back then] because it was so horrendous in those days compared with these days. [However], it worked and I think they were very interested. ‘What really appals me [about] the number of programmes and books – and there are thousands – on military history is how little medicine comes into the story. ‘It’s a distasteful subject to many I think, it’s something they [historians] feel readers wouldn’t be interested in but I think that’s wrong. The history of medicine is a very popular item on the school curriculum, you can’t know enough about it, it’s a huge subject.’
Veteran support Waterloo Uncovered aims to support veterans across five areas – including physical and mental recovery and health and wellbeing along – with issues relating to employment, education and the transition to civilian life. Those participating in digs encompass a wide range of health needs, from those dealing with psychological trauma to amputees and those with mobility issues resulting from wounds or training injuries. ‘One thing we both knew from our own experiences is that injured soldiers have a tendency to deteriorate quickly in terms of their interest, enthusiasm and mental health,’ says Capt Evans. ‘It’s not unknown for soldiers with long-term injuries to fall by the wayside.’ Having served in Afghanistan in 2008, Capt Evans says that he himself battled with PTSD resulting from his experiences on the front line.
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CHRIS VAN HOUTS
ALEX CAUVI
DUG UP: A British Army soldier and Waterloo Uncovered finds officer Hillery Harrison clean musket balls
FOINETTE: Set up the project with Army friend Mark Evans
After receiving treatment during and after leaving the Army he eventually turned to archaeology, a life-long passion, as something to focus his energies and attention on. These early forays eventually led to what would become Waterloo Uncovered, after Maj Foinette was asked by his commanding officer to stage a tour of the Waterloo battlefield for troops from his regiment. In April 2015 he and Maj Foinette, who are both archaeology graduates, took 20 people out to Waterloo, half of whom were injured, serving soldiers and the rest volunteer archaeologists. A follow-up expedition of twice the size as the original saw veterans joining serving soldiers – with last year’s dig seeing between 130 and 150 people involved. Capt Evans says the ease with which those who have been in the armed forces can open up and discuss their experiences with civilian health professionals is hugely varied. ‘For me there was a real breakthrough when I started talking to a woman who was non-military,’ he says. ‘That for me was the moment where I found I could open up, [however] for other people it will be exactly the opposite; that they found they could not talk to a civilian about what they’d been through and that they needed to talk to somebody that had been there [the military].’ For those who fall into the latter category, Capt Evans says that bringing former soldiers together to uncover and examine remnants and artefacts from a 200-year-old battle enables people to reflect on their own experiences of war and the armed forces. ‘The fact that you are allowing people who have been in the military to talk about military things inevitably means they end up talking about their own experiences,’ he says. ‘The archaeological process is about finding the little bits that help you try and understand what may or may not have happened [in the past]. A lot of what PTSD is, is being caught up in a world
GERADA: Impressed by the holistic approach
where you struggle to make sense of your own past, and memories can change as you focus on different things – archaeology helps remind you that the past is confused and fragmented.’
Dig deep GP and BMA council member Clare Gerada saw the charity’s work first-hand after attending a dig last summer, and was impressed by the holistic and inclusive approach it took to supporting those with mental health issues. ‘Waterloo Uncovered is a truly unique project in that it brings together people from different walks of life and with varying health needs and uses a shared interest and activity, in this case archaeology, to reach out and try to care for and empower those in need,’ she says. The mental health and personal and social challenges faced by those who have left the armed forces or who are seeking to transition to civilian life can be complex, and veterans can sometimes be hard to reach through conventional health services. ‘Waterloo Uncovered’s emphasis on inclusion and education, and what it seeks to do for those who have taken part, is an excellent example of the important role that socially prescribed and collaborative working can have in improving health.’ Additional research by Alex Cauvi To find out more about Waterloo Uncovered and how to volunteer, visit www.waterloouncovered.com/contact-us
‘The mental health challenges faced by those who have left the armed forces can be complex’
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MARK HARVEY
SHORA: ‘Because of this confined space, there are more incidents of violence’
HELD BACK: Lynfield Mount has dark corridors, poor temperature regulation and a lack of green spaces
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Banned from getting better Mentally ill patients are often treated in shabby, outdated facilities which are anything but therapeutic. Yet hospitals with money to invest in improving care are being prevented from doing so by the Government. Keith Cooper reports
T
he front desk that greets you at Lynfield Mount Hospital, Bradford, is encased in glass, the friendly receptionists peering out from inside. Wards are reached through four locked doors, along characterless halls with an institutional magnolia colour scheme. You buzz in, you buzz out. You’re left in no doubt about where you’re heading. The wards are windowless. There are four corridors, arranged in a ‘cruciform’ design common to churches and some prisons, around an artificially lit central hub. Here patients, often 25 to a ward, mill around as a nurse switches her eyes, as if checking traffic, down each corridor in turn, some brightly lit, others in darkness, shadows gathering in their corners. Noise builds easily off these walls and low ceilings, a common cause of complaint from patients. Staff are used to it. This is the facility the NHS has for patients with severe mental ill health in Bradford, West Yorkshire. It’s where you come when you’re ill, anxious, depressed or suicidal in this city, a once proud international centre of the textile trade. Now it’s like many other de-industrialised towns and cities. The core of inner-city poverty, Gothic Victorian towers and rotting hulks of factories, ribs showing through their rafters. More affluent areas, such as the spa town of Ilkley, cluster on its outskirts.
acute and inpatient services. His fluency in Urdu, Hindi, and grasp of Punjabi is an obvious asset in a patch with a large Asian but changing population. Some 100 languages are heard here, says deputy chief executive Liz Romaniak – an obvious challenge for talking therapies, a mainstay of treatment. ‘We have got the knowledge, skills and expertise of the 21st century but the building is from the 1960s,’ says Dr Shora. ‘We are not able to offer the caring and therapeutic environment we want to help people recover,’ he admits. ‘It’s a locked, dark place. Because of this confined space, there are more incidents of violence. There are issues with noise, the temperature is not well regulated, there are not a lot of green spaces.’ Patients need a calm environment to get better, Dr Shora adds. ‘But here it can be intense and difficult some days. If there’s been violence on the ward, it can affect patients, as well as the staff, including me. We support each other, we do our best.’ These and other problems at Lynfield Mount are far from unique. The poor quality of mental health hospitals is called ‘a major obstacle’ for good care nationwide in the 2018 wideranging report, Modernising the Mental Health Act, by consultant psychiatrist Professor Sir Simon Wessely. ‘People are often placed in some of the worst estates the NHS has, just when they need the best,’ the report adds and calls for extra investment. So, are better places for people with mental ill health arriving any time soon, here and elsewhere? Dr Shora and trust managers are not optimistic.
‘We are not able to offer the caring and therapeutic environment we want to help people recover’
Hostile environment Sarfaraz Shora, consultant psychiatrist at Bradford District Care NHS Foundation Trust, is open about the state of the wards he oversees as clinical director for
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MARK HARVEY MARK HARVEY
TRAUMATIC SITUATIONS: There are no proper rest facilities for staff, such as Sarah Calvert (right) and Angie Bethell (left)
BACKLOG: Deputy director of estates Simon Adamson says £7m are needed for repairs
While the Government is increasing funding for staff, it plans also to tighten its grip on the ‘capital budgets’ which trusts use for repairs and new buildings. All of the 40 new hospitals prime minister Boris Johnson announced in his election campaign are acute ones, leaving less, many fear, in the pot for mental health trusts (see box, ‘Not allowed to spend their own money’). Leeds Royal Infirmary, up the road from Lynfield Mount, will be one of the first in line. ‘There’s a lot of talk about parity of esteem between physical and mental health,’ Dr Shora says. ‘But acute hospitals, for physical health, are getting investment. That is good but we’re sitting here in a building from the 1960s. ‘When you look at parity, on the ground,’ Dr Shora adds, ‘for professionals in mental healthcare, it does not feel the same.’
therapy. Bedrooms with their own bathrooms. All things that Lynfield Mount lacks. Gone would be the overwhelmed outdated drains, which wash sewage across shared facilities’ floors after heavy rainfall. Staff would at last have changing and rest rooms. ‘We can manage quite difficult situations,’ says ward manager Angie Bethell. ‘They can be quite traumatic for staff. If they’re upset, you can say, go off the ward, take 10 minutes. Usually, people go and sit in their cars.’ It makes you wonder why anyone would work here. ‘If we said, the building’s not right, we won’t work here, then no one would and what would happen?’ says Sarah Calvert, an assistant ward manager. Despite the conditions, nursing students do often return for jobs when qualified, she adds After four years here, Dr Shora says it is his passion for mental healthcare and Bradford that keeps him in post. ‘If you didn’t have that passion and drive, you wouldn’t survive on these wards.’ Yet, after decades standing here, this dark and frankly depressing place feels out of place in a health service for treating – not stigmatising – mental ill health. For while it still stands, Dr Shora points out, it can only add to it. ‘Patients say it feels like an institution. It’s confined, it’s locked. It has a history that adds to the stigma. That’s the feeling the patients get on the wards.’ It’s a bad feeling which only extra investment will replace.
‘We’ve got the ambition to make a change, we just need the capital to do it’
Investment blocked The cost of replacing Lynfield Mount is about £50m, says the trust’s deputy director of estates, Simon Adamson. ‘We’ve got the ambition to make a change, we just need the capital to do it,’ he says. Meanwhile, it must deal with a £7m backlog of repairs and must-dos, including replacing sash windows, known ‘ligature points’. ‘Without this work, we wouldn’t be able to deliver safe care,’ he adds. A new hospital would be of a modern design, with an open reception leading to public space, a café, then semi-private areas, before wards. Each one would have access to gardens, gyms, calm spaces for relaxation and 12 thedoctor | February 2020
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Figures analysed by The Doctor show that MHTs (mental health trusts) in England have grown their cash reserves but are prevented from investing it in decent facilities
£1.7bn
£1.6bn
£1.5bn
£332.7m
£236.4m £1.4bn
2017/18
2018/19
2017/18
MHTs in deficit
2018/19
MHTs’ surplus
2017/18
2018/19
MHTs’ cash reserves Source: NHS Improvement
Not allowed to spend their own money The way new hospitals and other healthcare buildings are funded is to be shaken up with big implications for MHTs (mental health trusts). Under a new ‘health infrastructure plan’, ministers want a more ‘coordinated’ approach. To do this, they will ‘freeze’ £1.7bn, which individual hospital trusts have banked for improvements. This £1.7bn sits in MHTs’ accounts as cash reserves, which they’ve been encouraged to stockpile to balance out the large deficits of many other hospitals. This keeps the NHS in the black overall. Nuffield Trust senior policy analyst Sally Gainsbury says foundation trusts hold most of the NHS’s capacity on capital expenditure in their accounts. ‘Depressingly, the Department of Health has responded to this by proposing to change the law to prevent them spending this money. What is the point of having money in your bank account if you’re not allowed to spend it?’ Curbing foundation trusts’ freedom to build or repair hospitals – without raising the capital expenditure limit – would lead to a ‘levelling down’ of available funding. ‘Mental health is likely to be at the bottom of the pile,’ she adds. Bradford District Care NHS Foundation Trust’s Liz Romaniak says the infrastructure plan would also create a ‘competitive environment for capital’ in which MHTs could fare badly. The 40 new hospitals listed in the
plan are all acutes. ‘These very large projects would tie up lots of the available capital,’ Ms Romaniak adds. The days of MHTs being able to build up reserves are also ‘over’, she says. After eight years of cutting costs, her trust’s surplus fell from £4.8m in 2017/18 to £1.8m last year. It’s part of a national trend of deteriorating finances in mental health, our analysis shows. ‘We are at a crucial point now,’ Ms Romaniak says. ‘We are getting very complex, unwell, patients. Our services are overheating and the ageing infrastructure is exacerbating these difficulties.’ Such difficulties are felt by MHTs across England, says NHS Providers senior policy adviser David Williams. ‘Patients are being placed at an increased level of risk from ageing and often unsafe mental health facilities. Too many are still treated in dormitory-style accommodation. Many are being treated in facilities which may hamper their recovery. For staff, it is extremely demoralising.’ NHS Providers and the BMA are calling for Government to grow capital investment in the NHS. ‘Poor environments in mental health hospitals are harmful to patients and staff,’ BMA mental health policy lead Andrew Molodynski says. ‘We need a proper parity of resources in mental healthcare to create therapeutic environments for patients and a working environment which doesn’t burn out our staff.’
‘Patients are being placed at an increased level of risk from ageing and often unsafe mental health facilities’
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ED MOSS
MASUD: Has overcome resistance to pursue his career
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ED MOSS
In the nick of time There was a police officer, a soldier and a consultant... and they were all called Syed Masud. But doctors with such a mix of skills are not always given the chance to use them to best effect. Neil Hallows reports
S
yed Masud’s dad was a doctor. He was from a traditional Asian family for whom education was everything. As a boy, he knew what he wanted to be. And it wasn’t a doctor. His dressing-up costumes of choice were military fatigues and police uniforms, rather than a plastic stethoscope. Not so unusual, perhaps, for someone to weigh up other careers before finally succumbing to medicine. But where Dr Masud is possibly unique is that he has also done the alternatives. He has been an Army officer. He remains a police officer. And as well as being an emergency medicine consultant, he has worked for three air ambulance services, is a police force medical director, and been the chief medical officer at Wembley National Stadium. Dr Masud appears to be the ultimate poster boy for a portfolio career. Diversifying careers is increasingly popular, and those who have several medical roles at once say –
perhaps paradoxically – it can make it easier to control workload, and the variety helps prevent burnout. What Dr Masud is also keen to tell us is how the NHS, and other big organisations, succeed or fail in harnessing the skills of doctors who, literally, wear a number of hats. The first thing that strikes you about Dr Masud is the degree of intense focus. Not so much seize the day, as seize it, triage it and have it medevaced in seven minutes. He has served in war zones, Gaza and some dark streets in east London but when he says his main fear is that of under-achievement, it’s plausible. His toughness, however, is as much a product of what the ‘system’ has put him through. As a student, he had to argue for his future as a doctor and an Army officer when he was found to have dyslexia in his final year. ‘The medical school said I could have written down the wrong drug and killed somebody.’
A professor and a brigadier spoke up for him, and it gave him a lifelong commitment to help ‘gutsy’ juniors and students who turn to him for help.
Struck down ‘I couldn't get the policing thing out of my head’
In the Army he sought deployments with the same high level of commitment he gave to avoiding parades and posh dinners. He served with specialist units and seemed to have perfectly balanced his childhood dream with the medical career his mother, in particular, was infinitely keener for him to pursue. Then, disaster struck. Not an injury, despite serving in places such as Bosnia, Kosovo and Northern Ireland but the entirely unexpected onset of diabetes. He could have continued in the Army, but realising it was going to limit him from some of the edgier activities, chose what was a very viable alternative, the Great North Air Ambulance. Still quite junior, he was thedoctor | February 2020 15
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then persuaded to go to the Royal London to pursue emergency medicine specialty training. Technically, that was three careers before the end of his 20s, but, with hindsight at least, one led clearly to the next. The fourth, however, was anything but inevitable. Seeing an advert on the tube, he applied to the Metropolitan Police as a special constable. ‘I couldn’t quite get the policing thing out of my head.’ His deanery had a ‘wobbly attack’. ‘They said we can’t have a specialist registrar on the streets of London. They asked, what would you do if there is a stabbing and you can’t do a thoracotomy? ‘I said the police say that saving life comes first and the GMC says the same. If I don’t have the kit, there’s not much I can do about it, but if I can help the public and my colleagues by blending my skills, I don’t think there’s a problem.’ It gives an insight into how the NHS values skills and experiences outside medicine. On the one hand, application forms seem to expect junior doctors will find time to be Olympians and concert pianists in their spare time, but when a doctor wants to pursue an outside interest, of direct relevance to their specialty, it can be awkward and inflexible. This is particularly the case when trainees want to pursue out-of-programme activities for reasons such as a career break, training, research or clinical experience. BMA junior doctors committee chair Sarah Hallett says access ‘remains far too rigid and inflexible at present’.
‘The deanery had a wobbly attack’
She says: ‘Stories like those of Dr Masud show how the ability to combine a medical career with other interests can retain talented doctors in the profession, and allow them to develop complimentary skills. ‘The BMA has been working with education bodies such as Health Education England to improve flexibility, on projects including the LTFT [less-than full-time] category 3 pilot in emergency medicine, paediatrics and obstetrics and gynaecology, which allows junior doctors to work LTFT without needing to provide a reason. Much more remains to be done, however.’ Fortunately, in Dr Masud’s case, Gareth Davies, an emergency medicine consultant at the Royal London and at the time medical director of the London Air Ambulance, took a more flexible view. ‘He said, “Syed, if we don’t have people like you who can put on other hats, we’ll never know how we can transfer skills, knowledge and culture to medicine to improve, integrate and collaborate. Go and fill your boots”.’
Secret mission While he did his share of padding the streets, Dr Masud saw a chance in the Met to apply his medical skills more directly. He set up a panel to improve the force’s clinical governance, addressing equipment and training needs and pressing for greater consistency. ‘There was some great stuff of police officers saving lives, but there was no documentation. There was also not such good stuff going
on, with minimal governance and multiple opinions and thoughts, bringing that together was the real start of clinical governance in this area.’ He also did some training with CO19, the Met’s Specialist Firearms Command, not as an armed officer but in sharing expertise. And then there was the day when an inspector turned up at his hospital – by now the John Radcliffe in Oxford, where he had moved after the Royal London. ‘He said this is a highly secretive mission, it’s very dangerous, actually. We are asking you to be the medical component of the team to take Tony Blair into Gaza.’
Held back He is not bragging when he says it wasn’t frightening. ‘I was wired differently. I feel complete when I’m doing it. I’m not a sitting-there-talkingto-people type. I’m not good as a surgeon who can take someone’s heart and repair it. I’m quite base. I can do this, I can keep people alive and I seem to be OK at it.’ The disappointment was that he could not do more of it, and there is no formal role for doctors in hazardous police operations. ‘In America, in France, many other countries, there are doctors who are part of police forces on the front line, part of SWAT teams. If you look at Paris after the attacks, there were very specialist doctors wearing black kit in the front, going in the door.’ Military special forces have officers serving with them, he says, because ‘they realise that in pre-hospital care we can save more people with
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advanced stuff if we get to them quickly enough’. With road accidents, there are well-established systems for getting an advanced critical care doctor to the scene. With police operations, meanwhile, the ambulance service needs to determine whether it is safe before any medical teams can go in. There is what he describes as a ‘medical vacuum’ in such incidents, which could make the difference between life and death. ‘I can’t save someone who has been shot, with a penetrating injury, an hour down the line,’ he says. Clearly, staff need to be protected, but that’s where the highly trained specialist doctors, able and willing to cope with the risks, come in. Dr Masud also makes clear that doctors from any specialty could benefit the police force in other capacities. He would ‘love to see a psychiatrist’ in the force, given their expertise in many areas including detention practice.
out of a patient’s pocket, it’s not his job to arrest him. Confidentiality is not an absolute obligation for doctors, but disclosures are limited to circumstances when the doctor or others are at risk of serious harm. As for the ‘doctors in black’, the elite but still hypothetical unit, Dr Masud continues to work on a force-by-force basis to convince senior officers of the need. He has dedicated more than a decade to changing systems and potentially convincing people of the role of special pre-hospital emergency
medicine doctors on the front line of specialist police operations. He says it took three or four decades from the first developments in roadside critical care and the use of helicopters to achieve the status of a recognised sub-specialty. ‘Hopefully there will be junior doctors who carry on the fight. Who knows – in five or 10 years’ time, somebody might say, why haven’t we done this before?’ If this happens, and if he is still up to it, Dr Masud will no doubt be the first to join.
‘In many countries there are doctors who are part of police forces on the front line’
EYE IN THE SKY: Dr Masud in front of an Air Ambulance helicopter
Mutual benefits For Dr Masud, the benefits work both ways and are felt every day. Plenty of emergency care work has a policing aspect to it. ‘There may be a prisoner who comes in, there may be a rape or assault case, or drugs case, or domestic violence.’ Dr Masud had two years away from his consultant job in Oxford to train and work full-time as a police officer, and is now force medical director of Thames Valley and Hampshire police forces on a voluntary basis, as a special constable. He stresses, however, that if a bag of cocaine were to drop thedoctor | February 2020 17
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A call to reconsider the BMA’s stance on physician-assisted dying has prompted it to survey its members on the best way forward. Jennifer Trueland reports
Life decisions I
t’s one of the most contentious ethical issues we face – and doctors are at the heart of it. Physician-assisted dying, sometimes called physician-assisted suicide, gives rise to strong views among supporters and opponents in the medical profession – and the public more broadly. Following a motion passed at last year’s BMA annual representative meeting, the association is asking members what they think. The organisation represents doctors and medical students with a wide range of views on this issue, and so wants members to complete an online survey about what they think the BMA’s position should be. ‘This is a tremendously important issue, and one that provokes strong feelings,’ says BMA medical ethics committee chair John Chisholm. ‘We hope as many of our members as possible will respond to the survey so that we can ensure any future decisions on physician-assisted dying, and our work on this issue, are informed by what our members think.’
Polling members The BMA’s policy is to oppose physicianassisted dying in all its forms. At last year’s ARM, doctors asked it to poll members on whether it should change this stance to adopt a neutral position with respect to a change of law on physician-assisted dying. ‘A position of neutrality would mean the BMA neither actively supported nor actively opposed a change in the law to permit physician-assisted dying,’ Dr Chisholm stresses. ‘It would not mean that we would be silent on the issue – we would continue
to represent our members’ professional interests and concerns but without expressing support or opposition to such proposals.’ Physician-assisted dying is illegal in all four countries of the UK, although there have been various attempts to change or challenge that. This includes private members’ bills (or their equivalents) at Westminster and Holyrood, and numerous challenges to the position through the courts. All have been unsuccessful in changing the law, but at the same time have raised public awareness of the issues.
‘This is a tremendously important issue, and one that provokes strong feelings’
Doctors’ involvement Some forms of physician-assisted dying are, however, legal in other jurisdictions, including Switzerland, where some UK citizens have chosen to travel to die. Others include the Netherlands and the state of Oregon in the USA. Legislation permitting some forms is also in place in other US states such as California, Washington (State and DC), Maine, Hawaii and New Jersey, and in Canada, Belgium, Luxembourg and two Australian states, Victoria and Western Australia. ‘The one thing that is common to all these pieces of legislation is that there is, to some degree, a requirement for doctors to be involved or consulted as part of the process,’ adds Dr Chisholm. ‘This underlines why it is such an important issue for the medical profession to debate and discuss.’ The BMA has prepared
CHISHOLM: The BMA must be informed by what members think
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What is the law on physician-assisted dying in the UK? Northern Ireland
Scotland
Euthanasia is illegal and could be prosecuted as murder or manslaughter. ‘Assisting or encouraging’ another person’s suicide is illegal under s.13 of the Criminal Justice (Northern Ireland) Act 1966, which extends the Suicide Act 1961 to Northern Ireland. The Public Prosecution Service examines individual cases to decide whether to prosecute. That decision is guided by offence-specific guidelines published in 2010.
Euthanasia is illegal and could be prosecuted as murder or manslaughter. There is no specific offence of assisting or encouraging suicide in Scotland. Any suspected offence would be dealt with under homicide law. (1) The COPFS (Crown Office and Procurator Fiscal Service) makes the decision whether to prosecute. There are no offence-specific guidelines in Scotland and the decision will be taken on the basis of the general prosecution code. A legal challenge to compel the COPFS to produce offence-specific guidelines failed in 2015. The last known prosecution was taken in 2006, in an unreported case. (2)
England and Wales Euthanasia is illegal and could be prosecuted as murder or manslaughter. ‘Assisting or encouraging’ another person’s suicide is prohibited by s.2 of the Suicide Act 1961, as amended by the Coroners and Justice Act 2009. The Director of Public Prosecutions examines individual cases to decide whether to prosecute. That decision is guided by offence-specific guidelines published in 2010. Since April 2009, there have been 152 cases referred to the Crown Prosecution Service, three of which have been successfully prosecuted. (3)
1. Lord Advocate, Frank Mulholland QC. Written evidence on the Assisted Suicide (Scotland) Bill (ASB 178). 2. Scottish Parliament (2015) Official Report: Health and Sport Committee, Tuesday 13 January 2015. Session 4. Scottish Parliament: Edinburgh. Para. 24. 3. Crown Prosecution Service (2019) Latest Assisted Suicide Figures, Update as of 31 July 2019.
More information can be found online at bma.org.uk/PAD resources so that members can make an informed comment on the survey. These include: –– a summary of the arguments for and against physician-assisted dying –– a map of the situation elsewhere in the world –– background on the position in the UK –– a document on the BMA’s policy position to date –– information about public and professional opinions on the issue –– information about the survey itself. You can also listen to a discussion between Dr Chisholm and BMA policy lead on physician-assisted dying Ruth Campbell about the survey and some of the issues. All the resources can be found on the BMA website. Members will receive the survey by email in February, from Kantar, the independent research company conducting this survey on the BMA’s behalf. If you haven’t received an email, you should
visit www.bma.org.uk/PAD for information about who to contact to participate. The results of the survey will not directly determine the BMA’s position but will be published ahead of this year’s ARM and used to inform discussion and debate on policy at that meeting. BMA representative body chair Helena McKeown, who chairs the ARM, wants as many as possible to participate. ‘The survey’s purpose is to reveal what our members – from all disciplines, branches of practice, stage of career, and geographical areas – think on this issue. This is vital because it means that when the RB is reflecting on the BMA’s position, it will have this information to hand. This information will also help us to respond to any future legislative proposals and put us in a stronger position to engage on your behalf in the event of any future legal change. ‘This is an important discussion for doctors, as well as the wider public, and we want you to have your say.’
‘We hope as many of our members as possible will respond to the survey’
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Undermined and overlooked SAS doctors often feel bullied and sidelined, according to new GMC research. But changing attitudes and some enlightened employers give cause for hope. Tim Tonkin reports
‘N
‘All I’ve asked for is to be treated fairly and with respect and this often doesn’t happen’
o offence, but we need a proper gynaecologist to do this.’ ‘It wouldn’t look good if your department had an SAS doctor as clinical director.’ These are just two of the comments received by one senior staff, associate specialist and specialty doctor and tutor from a clinical director and appraiser respectively. They will be familiar to very many SAS doctors, and those who are locally employed, who have long reported bullying and discrimination. Doctors from foundation and postfoundation level can be classed as locally employed and fall under no single nationally defined contract but rather are employed on fixed-term arrangements with employers. The latest, and one of the most significant, surveys to support this was published last month by the GMC. It was the first the regulator had carried out of SAS and LE (locally employed) doctors’ workplace experiences. Of the more than 6,000 doctors taking part in the survey, 30 per cent of SAS doctors and 23 per cent of LE doctors say they had experienced bullying, harassment or being undermined by a colleague in the previous 12 months. For SAS staff, the most common forms of harassment included belittling and humiliation (26 per cent), rudeness and incivility (27 per cent) and threatening or insulting comments or behaviour (16 per cent), with
‘ s p a a
these categories being respectively reported by 27 per cent, 30 per cent and 15 per cent of LE doctors.
Powerless Added to the findings relating to bullying is the 61 per cent of SAS doctors who either disagreed or strongly disagreed when asked whether they felt the role of an SAS doctor was viewed as a positive career choice in the medical workforce. ‘I think what this report has shown is the problem is greater than we thought it was,’ says Fiona MacRae (pictured), an associate specialist in anaesthetics based in the north west of England and chair of the Mersey SAS committee. ‘Bullying isn’t always in-your-face style nastiness, it can be more subtle such as sidelining, ignoring or otherwise treating someone differently. ‘It’s the sense of powerlessness and lack of autonomy.’ Of the 30 per cent of SAS doctors who experienced incidents of bullying or harassment, only 9 per cent reported the incident. For LE doctors this figure came to just 6 per cent. For those who stayed silent, 34 per cent of SAS doctors and 33 per cent of LE doctors told the GMC they had done so out of fear of adverse consequences, while 40 per cent and 35 per cent respectively said they didn’t think reporting an incident would make a difference. Dr MacRae says she has on more than one
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MATT THOMAS
‘It’s the sense of powerlessness and lack of autonomy’ thedoctor | February 2020
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CAIRNS: ‘A lot of employers have no concept of what an SAS doctor is’
‘Specialty, associate specialist and locally employed doctors are vital to our NHS’
THOMAS: Works for a ‘supportive’ trust
occasion been told by colleagues to fetch someone ‘more senior’, despite being one of the most experienced staff members in her department. ‘I work fully independently but I feel I’m often kept at arm’s length, sidelined and passed over for opportunities,’ she says. ‘It’s never a level playing field. All I’ve asked for is to be treated fairly and with respect and this often doesn’t happen.’ Dr MacRae supports the idea of an independently appointed anti-bullying champion being employed at every trust who would be able to listen to and rule on complaints brought to them. She feels confusion or even ignorance of SAS job titles means the seniority and experience of members of the grade is not clear and underestimated as a result. ‘Trainees can be “pigeonholed” at different levels by their specialty training level, so you can know how close to consultant level they are. We don’t have those sorts of labels for SAS doctors and I think that confuses people,’ she says.
Upside Yet the picture painted by the survey’s findings is far from clear cut. 72 per cent of SAS doctors and 75 per cent of LE doctors either agreed or strongly agreed they felt they were valued members of the teams they worked in. 52 per cent of SAS and 62 per cent of LE doctors also responded this way when asked whether they felt they had the opportunity to participate in workplace decision making. Precisely the same proportion said they felt a senior colleague would be open to their opinion in the event of a disagreement. BMA Northern Ireland SAS committee chair Carole Cairns acknowledges the GMC’s survey is a mixed bag, with sources of positivity alongside causes of concern.
‘Personally, I have had a great career and always felt fully accepted as part of the team,’ she says. ‘However, I’ve come across [other SAS doctors] who have not even been allowed to remain in the room while the consultants are discussing something.’ Dr Cairns says poor understanding of SAS job titles in relation to expertise and experience, as well as lack of awareness of the role played by SAS doctors in the workplace, needs to be addressed. She adds that more should be done to promote the SAS career path to younger doctors to dispel the idea that the grade is merely a ‘stop-gap’ role for those unsure as to what direction to take their careers. ‘We should be talking about three cohorts of permanent doctors: consultants, GPs and SAS,’ says Dr Cairns. ‘A lot of employers and trust management have no concept of what an SAS doctor is. They need to have an understanding of the definition and we need to make sure this goes right to the top. ‘Additionally, quite a lot of SAS doctors do not receive induction. If we made this compulsory this would help put them firmly into the mind of employers as a distinct group of doctors.’
Recognition Greater recognition, be it of clinical experience or contributions in the workplace, has been another long-standing cause for frontline doctors and the BMA staff, associate specialist and specialty doctors committee. This desire was overwhelmingly reflected in the survey, with 70 per cent agreeing that recognition of SAS doctors on the GMC’s online register would help to support the career development of members of the grade. Associate specialist in child and adolescent mental health Victoria Thomas says she opted
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to return to the SAS grades after completing her CESR (certificate of eligibility for specialist registration) and becoming a consultant, because of the flexibility afforded by the AS role. Dr Thomas, who works for Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, says there are signs SAS doctors are starting to get the recognition and consideration that had traditionally been insufficient or absent, at local and national levels. ‘Our trust is incredibly supportive of SAS doctors,’ she says. ‘There have been a lot of initiatives around things such as supporting people doing CESR, having an active SAS forum and a full commitment to the SAS charter. There does now seem to be greater recognition [of SAS doctors] not just at my trust but nationally.’
Marginalised Dr Thomas’s optimism is backed up by some of the report’s more encouraging findings. These include a majority of SAS doctors (57 per cent) reporting having access to SAS tutors or advisers in their workplaces, and 83 per cent stating they received one or more SPA (supporting professional activity) session per week. For LE doctors, 54 per cent reported having one or more SPA a week while 74 per cent have a named person in their departments to support them with CPD (continuing professional development). 74 per cent of SAS doctors and 49 per cent of LE doctors said they trained others as part of their jobs. However, when asked to rate the level of support received from their trusts or boards in this capacity, the picture is mixed. While 38 per cent of SAS doctors describe support as either good or very good, 54 per cent label it as indifferent to poor. This contrasts to 51 per cent and 44 per cent respectively for LE doctors. Commenting on the report’s findings, BMA SASC co-chair Amit Kochhar expresses his regret that many members of his grade continue to feel marginalised and overlooked in their careers and workplaces. He says: ‘Specialty and associate specialist and locally employed doctors are vital to our NHS, which is why it’s crucial that they, like any other member of staff, feel supported and valued as they carry out their life-saving work.
‘These doctors have long felt overlooked, so it’s disappointing to see this theme reemerge in this latest survey – particularly that more than a quarter of SAS colleagues disagreed or strongly disagreed their working environment is a fully supportive one. ‘While many employers recognise the [SAS] charter and the needs of this important part of the workforce, today’s survey has made clear that more needs to be done to ensure all SAS and LE doctors are properly listened to, appreciated, and above all, valued – regardless of where they work.’
KOCHHAR: ‘These doctors have long been overlooked’
‘SAS doctors have not even been allowed to remain in the room while consultants discuss something’
GMC survey: exhausted and burnt out – 41 per cent of SAS doctors in the UK either agree or strongly agree that patients they are responsible for are correctly coded to them. However, 44 per cent disagree or strongly disagree with this – While 30 per cent of SAS doctors in the UK work completely autonomously, 58 per cent work under some degree of supervision and 12 per cent do not work autonomously at all – 66 per cent of SAS doctors say they had access to an e-portfolio to track CPD progress. However, 30 per cent of this total had to pay for access rather than having it provided for free by their employers – 43 per cent of SAS doctors and 41 per cent of LE doctors describe their work as emotionally exhausting to a high or very high degree with 56 per cent of SAS doctors and 46 per cent of LE doctors saying they feel burnt out by their work either somewhat or to a high degree – 61 per cent of SAS doctors say they see themselves continuing in their roles in a year’s time compared with just 22 per cent of LE doctors, while 30 per cent say they will consider joining a formal training programme in the future compared with 71 per cent of LE doctors.
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SARAH TURTON
BALM OF HURT MINDS For Guy Leschziner’s patients, sleep is not a remission from their ills, but often where the trouble really starts. He tells Peter Blackburn about the things that go bump in the night in his study of sleep disorders
DOT TO DOT: A model used in Dr Leschziner’s sleep centre to show the placement of electrodes during sleep studies
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SARAH TURTON
‘T
o be honest, I’ve seen most things.’ He’s right. Guy Leschziner’s patients include a woman who rode a motorbike while fast asleep, a man who would eat everything accessible, including blocks of lard, and wake up bloated and sick, and one who slit her own throat. Others have set their houses on fire, or committed crimes, all while supposedly restful and dreaming. Dr Leschziner – the clinical lead at the sleep disorders centre, and clinical neurologist, at Guy’s and St Thomas’ NHS Foundation Trust – really has seen it all. These experiences are now being shared with the wider world. Through a series of radio features, podcasts and books Dr Leschziner is helping to lift the veil of mystery around nocturnal habits. Where did the draw to study sleep – and, ultimately, explain the science of sleep to thousands of readers and listeners – come from? As a 14-year-old, Dr Leschziner set his heart on becoming a doctor: ‘As a kid I was always fascinated by science and biology. If I remember rightly, a cardiothoracic surgeon came into school and gave a lecture and I just thought, this is fascinating – this is a beautiful illustration of how the real world meets science, and this is something I want to do.’ It was Oliver Sacks – much-loved author of The Man Who Mistook His Wife For a Hat, who referred to the brain as ‘the most incredible thing in the universe’ – who inspired Dr Leschziner’s initial specialty of neurology. ‘I remember thinking it was absolutely fascinating how this lump of fatty tissue could define every aspect of us from a physical and psychological basis,’ Dr Leschziner says. ‘During my undergraduate degree I was asked to go away and write an essay on the functions of dreaming and it dawned on me that sleep had much more of a function than just making sure we aren’t tired in the morning. ‘After that I was lucky enough to train at Guy’s and St Thomas’ – one of the first sleep centres in the UK.’
LESCHZINER: Severe sleep disorders have lessons for us all
‘It was absolutely fascinating how this lump of fatty tissue could define every aspect of us’
Night rider The sleep centre is a million miles from the daily chaos of emergency departments and hospital wards of most of the NHS in 2020. Every night, 10 patients are monitored – some for full polysomnography, where brainwaves, movements, heart rates and oxygen levels are tracked; their every move captured by infrared camera. The diagnoses are varied and range from the common – sleep apnoea and narcolepsy – to the downright bizarre. In his book, The Nocturnal Brain: Nightmares, Neuroscience and the Secret World of Sleep, Dr Leschziner vividly details the cases of patients such as Jackie who went for a moonlight motorbike ride, a woman who slit her throat and wrists with a kitchen knife and another young woman from Ireland who was found eight miles away from home with her handbag and keys, having walked all the way without shoes. Dr Leschziner and others have recently discovered that being awake and being asleep is not an on-off situation – and, actually, while deep sleep and full wakefulness ‘lie at extremes of a spectrum… it is possible for us to be in both states at the same time’. Some patients find their situations terrifying – and some amusing. Some of his cases involve gentle stories of sleepwalking kindness, such as Alex, who filled tumblers of water for each of his house mates, leaving them on their bedside tables, during the night. thedoctor | February 2020 25
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issues that may have dogged them for decades. To an outsider it looks like a grim task – to put a label on night terrors or gripping insomnia – but while revelations about past trauma or diagnoses which require further treatment or life-changing equipment can be unhappy events, it is not a field where the news delivered is always bad. As Dr Leschziner says: ‘There are lots of people who have been suffering greatly as a result of their conditions for many years. To find out it is a real condition and they have the prospect of treatment to improve their lives is often a major relief.’
Some are more concerning, and can even involve perpetrating crimes. There have been several cases where people have committed murder in their sleep. While Dr Leschziner admits in some cases the defence is a ‘convenient excuse’, he explains how the assessment is carried out. ‘You are looking for correlates on their sleep studies that at least suggest they have a propensity towards this type of event and then a lot of it is based on the history: have they gone to the doctor complaining about these issues and are there people in the family who say they do these kinds of things?’
The introspective society It is a fascinating field – but much of the work is more common. And demand is booming thanks to a huge rise in the interest of the public in sleep – and the monetising of that interest by lots of companies that produce sleep trackers, or support services. ‘My own personal hope is there is a bit of a backlash to that,’ Dr Leschziner says. The rise in interest correlates with a wider awareness of the importance of sleep, as well as an increasingly ‘introspective’ society. He says the anxiety that introspection brings can itself contribute to the deterioration in quality of sleep. In recent years he has become a sounding board for thousands concerned about the quality of their sleep – or fascinated by the science behind what happens when we close our eyes and drift off. Dr Leschziner presented a three-part radio series called Mysteries of Sleep, last year had his book on the secret world of sleep published and recently starred on a six-part podcast discussing sleep with comedian David Baddiel – ‘an extremely present, intelligent and likeable person’. He is also putting together a new three-part radio series for the BBC.
Provide answers Talking about the topic in the public eye, and writing books, was never something Dr Leschziner had envisaged but nevertheless he says the process has been ‘extremely enjoyable’. While that work continues, it is the work with patients that drives Dr Leschziner. Between 13,000 and 14,000 patients are admitted to the centre annually and they all need help with 26
An extract from Dr Leschziner’s book explains how the study of sleep disorders can improve everybody’s hours of slumber
‘There are lots of people who have been suffering greatly as a result of their conditions for many years’
We think of sleep as a tranquil act, when our minds are stilled and our brains are quiet. The act of sleeping is a passive one, and is associated with a blissful unconsciousness and the delight of waking refreshed. The only awareness we might have of something happening in the night are the fragments of a dream. That is, at least, for most of us. But for many of the patients in my sleep clinic, their nights are anything but this. Rather, a night in the sleep laboratory, where I admit my patients to study their nocturnal behaviour, is punctuated by shouts, jerks, snores, twitches or even more dramatic goings-on, and the torture of poor or even no sleep at all. The normal expectation of waking up feeling ready for the day ahead is rarely found among my patients, or indeed their partners. Their nights are tormented by a range of conditions, such as terrifying nocturnal hallucinations, sleep paralysis, acting out their dreams or debilitating insomnia. The array of activities in sleep reflects the spectrum of human behaviour in our waking lives. Sometimes these medical problems have a biological explanation, at other times a psychological one, and the focus of the clinical work that I and my colleagues do is to unravel the causes for their sleep disorders and attempt to find a treatment or cure… ...So why is it that I’m writing about these patients? And, more importantly, why should you read about them? Many of the stories that follow are about patients with extreme sleep disorders, at the very limits of the spectrum of human experience, and it is by studying these extremes that we can learn about the less severe end of the spectrum; by understanding how these patients are affected by their sleep disorders, we come to know a little about how we ourselves are affected by our sleep. Doctors love stories; we love telling them and we love hearing them.
thedoctor | February 2020
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10/09/2018 09:43
January 2019
A wall of our making
Breaking the artificial barriers between physical and mental health
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08/10/2018 11:15
Issue 6
|
February 2019
Can the NHS Long Term Plan really make a difference?
How does it feel?
A junior doctor’s working life told through seven emotions
A job’s worth
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
13/05/2019 10:50
The magazine for BMA members
Issue 13 |
September 2019
Excluded from school, pregnant at 16, then a job in the chip shop.
This is Laura. Dr Laura Why a better social mix in medicine benefits us all
A plan or a wish list?
Can the Government keep its pledge to improve mental healthcare?
09/09/2019 11:25
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March 2019
On the edge of the abyss A ‘Brexit dividend’ of chaos and uncertainty for doctors
Would you pay to work? Doctors driven out of the NHS by punitive pension tax rules BIL
L
ork w ilitie a tr sib ex o n y on sp arl g e re kin ier ng Ta av tiri He t re No
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£9
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MA
RK
ALT
Double standards
ER
Streets ahead
Good care for the homeless – why is it so rare?
10/06/2019 10:09
Issue 14
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October 2019
Belittling
What kind of culture do you work in?
07/10/2019 11:14
20190098 thedoctor p1 v10.indd 1
The magazine for BMA members
11/03/2019 10:46
Issue 11
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The winning entries in this year’s BMA writing competition
A spectre calls
Your NHS ghost stories
07/12/2018 09:27
Issue 8
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The pressures threatening to overwhelm the NHS this winter
April 2019
Singing on prescription
When fresh air or company is the best treatment available
A neglected killer
How a fragmented health service is failing patients with asthma
Glaring oversight Eye surgeons angry at a rationing ruse
08/04/2019 10:39
Issue 12
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August 2019
Going viral
Fake news costs lives – the rise of anti-vaxxers
08/07/2019 09:47
Issue 15 | November 2019 Issue 15 | November 2019
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July 2019
My patients went to the Moon
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If you could change one thing ...
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An interview with the Apollo 11 doctor
NHS England subjects GPs to lengthy checks – but is secretive about its own performance
Told to go home
The overseas doctor who overcame early setbacks to become a leading consultant
Doctors confront the European refugee crisis which politicians have ignored
How the increase in knife crime is leading to new ways of working
June 2019
Revealed: The consultancy companies chewing up NHS resources
Facing up
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The cutting edge
11/02/2019 11:11
Issue 10
Be listening
Speaking up How David Nicholl braved a politician’s insults to warn about a no-deal Brexit
05/11/2018 11:45
Issue 7
The one-sided world of social media sniping and the GP who fought back
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May 2019
The surgeon who gave up a ‘useful job’ to become an MP, on finding a role in Westminster
LOLs and trolls
Fresh hopes for SAS doctors to win the recognition and opportunities they deserve
The magazine for BMA members
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‘Why am I here?’
The doctors leading the way in reporting unsafe working conditions
Have confidence
14/01/2019 10:39
Issue 9
A cause for complaint The GP practice left on the brink of collapse by an NHS England investigation
Taking exception
Asking what managers with funny sounding titles actually do
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Nice place for a holiday...
Promises, promises
Homelessness – the victims, the politics that fuel it, and those working to tackle the human cost. The Doctor investigates a needless epidemic
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Leaving Saddam
The NHS through the eyes of an Iraqi doctor
... but how can doctors be persuaded to work in remote and rural areas?
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The magazine for BMA members
Issue 5 |
The ‘whistleblowing tsar’ on why doctors should speak up
A doctor’s baby was removed at birth – we go to court to uncover concerns about her care
Issue 4 | December 2018
Taking the biscuit
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Born of injustice
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Doctors sound the sleep deprivation alarm
Can a health service battered by austerity make the bold investments it needs?
Why is the Home Office trying to deport doctors in the midst of a recruitment crisis?
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They come here
Celebrating immigrant doctors
Right to remain
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Ending the silence
The NHS reboot needed to beat the bullies
| November 2018
thedoctor
Healthcare’s future hangs in the balance
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Look out for Papering over the cracks? our reader survey in next month’s issue 14.03.20
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Brexit: why breaking up is never easy
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Issue 16
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December 2019
Calling it out
11/11/2019 09:28
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Tackling sexism in the NHS 09/12/2019 12:11
10/02/2020 10:39
Often, this column is about doctors who check their pay to find it wasn’t as much as they expected. In this case, the pay wasn’t there at all. The doctor contacted payroll and was told his monthly salary had been sent to his ‘new’ bank account, the one he had told them about. But there was no such account, and there had been no such message from the doctor. He contacted the BMA, whose employment adviser pressed the doctor’s HR department to pay the wages into his correct account, and find out what had happened. It emerged the doctor and three colleagues had fallen victim to a fraudulent ‘phishing’ email which appeared to come from the employer’s
ESR (electronic staff record). Once they had logged in to the ESR, the fraudsters were able to change the employees’ bank account details and redirect their pay to other accounts. The employment adviser said that good working relationships built up over years with staff at the hospital helped resolve the problem quickly. The money was refunded to the doctor and the crime was reported to the police and counterfraud authorities. There have been similar cases, which should act as a warning. Gone are the days when phishing emails could be easily spotted by their bizarre spelling and promise of lost oil millions. They’re often smart, and those at the receiving end have to be the same.
Patients who’d rather stay put ‘So, you’re chucking me out then?’ The patient looks resigned, his wife is close to tears and their daughter has her arms folded and a face like thunder. One of the bits of bad news we have to break in the hospice is that we will be starting to plan transfer of care to another part of the service. At home or in 24-hour care, they will be seen regularly by the amazing community Macmillan Team, and attend day centres or outpatient clinics, or have home visits from consultants depending on need. Or, as patients accurately interpret it, discharge from the inpatient unit. The fact remains that not even the best nursing home can be like the hospice in terms of staffing, and the thought of going home, even with several homecare calls a day and some night sits, provokes great anxiety. With fewer beds than we really need for our population, we can never be a long-stay unit. We ask referrers to make sure the patients know this, and that
Doctors’ experiences in their working lives
it happened to me
on the ground Highlighting practical help given to BMA members in difficulty
Pay stolen by fraudsters
once they are stable we will be looking for alternative venues for care, unless their prognoses is short. Patients and families frequently deny all knowledge of this conversation; many professionals will be familiar with the phenomenon of patients hearing something very different from what we wanted to communicate. The message patients hear is they’re not dying fast enough, which for some is bad news in itself. I explain that now we have their symptoms under control they don’t need such intensive palliative care and this is a positive thing. They will usually grudgingly agree with this, and can also see that if we did keep everyone for the rest of their lives there wouldn’t have been beds to admit them in the first place. Maybe one day we will have some more beds, but even then, I suspect we will never meet the demand. Becky Hirst is a consultant in palliative medicine
28 thedoctor | February 2020
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the secret doctor
LICENCE TO HARM: ‘The good is often hard to quantify, while the harm is painfully clear-cut’
First do no harm? I wish Primum non nocere (first, do no harm) doesn’t actually appear in the Hippocratic Oath but it is what most people will think of first if you ask them about it. It is certainly more sensible than much of what actually does appear in the original oath, which includes a commitment not to perform abortions, undertake any kind of surgery or – by a strict interpretation – provide first-aid classes. Which is odd, really, because actually as a doctor I feel I often do a great deal of harm. More, anyway, than I would expect to get away with in day-to-day private life. Outside work, I almost never stick a needle in somebody, or persuade them to swallow things which will make them feel sick or tell them something which is going to ruin their day, if not their year. On a bad day, practising medicine can feel like doing people an unending series of small harms. Every painful procedure, however necessary, every item of bad news broken, however unavoidable, every drug side-effect, however necessary the drug – they all do harm. And that is leaving aside the more profound harm we all hope to avoid inflicting: the missed diagnosis, the surgical complication, the treatment delayed or misprescribed. Of course, I know that is not really what first do no harm is supposed to mean. Perhaps do no net harm would be more accurate? Except even that isn’t always quite right – what about the patient who dies of neutropaenic
sepsis from the chemo that didn’t, in the end, buy them any extra time? The neonate who struggles through three painful weeks of invasive care and then doesn’t make it after all? However you reckon up the balance, we haven’t done them much good. During a career, naturally, we all hope to do more good than harm. In medicine, however, the good is often hard to quantify, while the harm is painfully clear-cut. If you managed your patients’ chronic conditions so well they didn’t have strokes, you’ll never know it. Even when someone recovers from a serious illness, it is hard to allocate the credit between medicine and the natural healing process. There’s no ambiguity, however, about the wince when you insert the arterial blood gas needle. So how about this, instead: accept the harm you have to do but never take it lightly. Think carefully, for every patient, about what you can really give them, and what it might cost them to receive it. Remember, medicine’s licence to inflict harm in a good cause is an integral part – perhaps the central part – of the unique trust society reposes in our profession. No one can practise medicine without doing harm, whatever Hippocrates might say, and no doctor should ever forget it. By the Secret Doctor bma.org.uk/secretdoctor @TheSecretDr thedoctor | February 2020 29
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explainer
Punitive pension taxation rules which are driving doctors out of the profession are set to be reformed – but will the changes go far enough? What’s new with the NHS pensions crisis? The Government has initiated a new Treasury-led review tasked with finding a solution to the punitive pension taxation rules. About time. How long has this been going on for? The BMA has been pressing ministers for a decent solution for 18 months. Each day we hear more stories of senior doctors facing huge, unexpected, tax bills for modest increases in their pensionable pay. How bad is it? Very bad. Doctors face six-figure tax bills for taking on extra responsibilities or climbing the career ladder, with some effectively paying to go to work. Earning £1 over the ‘tax cliff’ can land you with bills of up to £13,500. Many are, unsurprisingly, cutting back hours in response. Meanwhile, waiting lists have hit record levels.
That is bad. So what’s the Government’s plan? According to credible media reports, the Treasury favours raising the threshold income of all workers to £150,000. This, the reports say, would solve the problem ‘for the majority of doctors’. Prime minister Boris Johnson has pledged to shorten waiting lists. So will that solve the problem? It will help some but it isn’t the best solution for doctors or the public purse. The complexities of the pension scheme mean doctors earning less than £150,000 could still be caught out, leaving a strong incentive to cut hours. Analysis by the BMA and the Institute for Fiscal Studies, a respected tax research body, shows that the reported proposal is more expensive than the BMA’s option.
So what is the BMA’s preferred plan? The BMA is calling for the removal of the annual allowance, including the taper, in defined benefit schemes, such as the NHS pension scheme. This would be the fairest, most effective long-term solution, resolving the issue for all doctors affected, as well as being cheaper for the public purse. Sounds good. So what can I do? You can find out more and ask your MP to support our proposal by following the link below. Great, thanks. When will we find out which way this goes? The Treasury is expected to announce the results of its review of pensions tax in the Budget on 11 March. To find out more, visit bma.org.uk/pensions
30 thedoctor | February 2020
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What do you want from your career? Our one day masterclasses help you develop practical skills to achieve your career goals. ‘I feel empowered to make changes that I really believe will make a difference’
what’s on
Masterclass graduate
February
Masterclasses – Leadership and management –T ime management and taking control – Effective communication – Critical appraisals – Train the trainer
bma.org.uk/goals
19 London and Southern regional SAS assembly, London, 3.30pm to 6.30pm
17 BMA joint regional council (Eastern, London, South East Coast and South Central) on climate change, London, 6.30pm to 8.30pm
26 BMA public health medicine conference, London, 9.30am to 6pm
20 BMA retired members conference, London, 9.30am to 4.45pm
March 03 Practical skills... time management and taking control, London, 9am to 5pm 04 BMA UK consultants conference, London, 9am to 5pm 06 Planning for retirement – delivered by the BMA, Cardiff, 9am to 4pm
23 CESR seminar for SAS grade doctors, London, 1.30pm to 4.45pm 25 BMA armed forces conference, London, 9.30am to 4.45pm
April 02-03 Train the trainer, London, day one 9am to 5pm, day two 9am to 4.45pm 03-04 BMA medical students conference, London, day one 11.45am to 5.45pm, day two 9.30am to 4.45pm 23 Practical skills for improving personal leadership, London, 9am to 5pm
26 Critical appraisal workshop – part 2, London, 9am to 4pm 27 Medico-legal conference 2020, London, 9.15am to 4.45pm
10 Practical skills... for effective communication, Cardiff, 8.45am to 4.15pm
Visit bma.org.uk/events for full details Download the BMA events app at bma.org.uk/eventsapp thedoctor | February 2020 31
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GET INFORMED HAVE YOUR SAY Physician-assisted dying 2020 BMA member survey Don’t miss out on the chance to have your say on physician-assisted dying. We are currently surveying our members to inform a debate at the 2020 annual representative meeting on what the BMA’s position on physician-assisted dying should be. If you are a BMA member and you have not received an email invitation to participate in the survey, you should: 1. check your inbox for an email from BMAsurvey@kantar.com with the subject line BMA survey on physician-assisted dying 2. check whether the email has been directed to your junk mailbox 3. if you are still unable to locate the email contact Kantar by email at BMAsurvey@kantar.com or by telephone on 0800 051 0899. Before you take part, make sure you get informed on the issue by accessing the briefing materials at: bma.org.uk/PAD
Get informed. Have your say. bma.org.uk/PAD
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