The Doctor – November

The magazine for BMAfor members The magazine BMA members

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Issue 15 | November 2019 Issue 15 | November 2019

The pressures threatening to overwhelm the NHS this winter

11/11/2019 09:28

thedoctor

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0300 123 1233 @TheDrMagazine @theBMA The Doctor is published by the British Medical Association. The views expressed in it are not necessarily those of the BMA. It is available on subscription at £160 (UK) or £225 (non-UK) a year from the subscriptions department. All rights reserved. Except as permitted under current legislation, no part of this work may be photocopied, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical or otherwise without the written permission of the editor. Printed by YM Chantry. A copy may be obtained from the publishers on written request.

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

The Doctor is a supplement of BMJ vol: 367 no: 8222 ISSN 2631-6412

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In this issue 4-5 Briefing

Will the winter crisis dominate the general election?

6-9

For Mags

Mags Portman died from mesothelioma, and may have been exposed to asbestos as a junior doctor. Her husband Martin continues her battle for justice

Welcome Chaand Nagpaul, BMA council chair A ‘corrosive environment’. A ‘brutal’ workplace. Patients having cardiac arrests in hospital corridors and doctors setting up makeshift toilets in emergency department bays.

Emergency departments more crowded than ever. Deep concern for the plight of homeless patients or those with mental health conditions.

These are the stories told to The Doctor by staff working on the front line of the NHS during a summer and autumn of unprecedented demand, ahead of what is likely to be the worst winter on record.

When hospitals and GP surgeries, places of care and compassion, sound more like war zones, it is clear urgent action is required. While it should not take a general election for politicians to take note, the BMA has produced a manifesto for change in the NHS. It demands parliamentarians prioritise the NHS, its workforce and its patients – from addressing Brexit-related medicine shortages, to waiting lists, workforce gaps and public health cuts. The manifesto for health is the blueprint from which the NHS can grow and thrive.

Also in this issue of The Doctor we look at the continuing pensions crisis, visit a smallholding in Wales to find out how cultivating nature can affect doctors’ wellbeing and speak to the family of a doctor who died from mesothelioma.

We look at how cuts to substance-misuse services are undoing the progress vulnerable people have made to tackle their addictions through the eyes of service users and staff on the front line in York.

In the briefing section of the magazine you can read about the joint Medical Women’s Federation and BMA conference, held at the BMA on 1 November. It was fascinating to hear about the role of the medical profession in tackling gender inequality – and to learn and contribute to discussions about developing a ‘listening-up’ culture in the NHS.

10-13

Animal instincts

A pioneer of physician mental health describes how the culture of medicine can compound difficulties for doctors

14-15

Annual pay: -£27,000

A consultant shocked to receive a pensions tax bill greater than her annual salary may be forced to reduce her commitments

16-19

On the cusp of collapse

Doctors describe their intense struggle to cope with what may become the worst NHS winter on record

20-21

Under covered

Care is being affected by a lack of clarity in medical insurance policies

22-25

In recovery

When cuts to drug and alcohol services have become the norm, how did campaigners in one area manage to win a reprieve?

26-30

Life experience

A vanishing job offer, public fear of sepsis, and the BMA writing competition

31

What’s on Keep on top of events

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ALARM BELLS: ‘The NHS is hurtling towards an unprecedented crisis this winter’

In spite of Brexit

briefing

There is an irony in that – in an increasingly globalised and uncertain world – many individuals and nations have become ever-more inwardlooking and divided.

Whether the concept of ‘taking back control’ is being applied to

Current issues facing doctors

The winter crisis election

ISTOCK

There are many hazards to holding a general election during winter – icy routes to polling stations, the electorate hiding behind doors rather than answering them and students halfway between university and home.

However, perhaps the biggest risk for politicians looking to secure a majority in Parliament next month is going to the polls during what may be the worst winter crisis in the history of the NHS because, according to projections from the BMA, that is very likely to happen.

The association’s analysis covered in this issue suggests that lack of recovery from the worst-ever summer, staff shortages, a predicted cold winter and bad flu season, as well as the effects of Brexit, are contributing to a ‘perfect storm’ for the NHS. Emergency care attendances and admissions are projected to be even worse than last winter – and that’s the case with the best-case scenario as well as the worst.

BMA council chair Chaand Nagpaul said: ‘Staff are already coming under extreme pressure, trolley waits are at a worryingly high level, [emergency department] targets are not being met and, as such, the BMA predicts the NHS is hurtling towards an unprecedented crisis this winter.’

There’s the NHS where doctors work, and then there’s the slippery fish of election leaflets. The one where 40 new hospitals are being built (34 of them, it turns out, being rather more conceptual than physical). The one where ‘the NHS is not for sale’ – a neat rhetorical sleight of hand because of course the NHS is not actually, literally up for sale, but by saying it, politicians distract from legitimate fears of private outsourcing.

Back in the real world, there are clear and urgent areas where action is required. They are set out in the BMA manifesto, which draws on the expertise and experience of its members.

The manifesto offers a coherent recovery plan, taking in such areas as Brexit, the pensions crisis, workforce gaps, fair pay, and NHS resourcing.

Politicians might think they can’t win. Mention the NHS and they’re accused of hoofing a ‘political football’. Omit to mention it and it means they don’t care. But they’re not being asked to keep a hushed silence. Far from it. Talk, promise, argue, debate – but about the real NHS, not some pantomime prop brought out at elections.

CHOPPY WATERS: Doctors’ maintain a strong need and wish to cooperate across Europe

national sovereignty or national borders, sentiments around separation and isolation have become dominating factors in much of our recent politics.

By contrast, disease famously cares nothing for borders, and it is with this in mind that medical organisations such as the BMA have sought to emphasise the risks posed by Brexit, particularly a no-deal scenario, to standards of health in the UK and the rest of Europe.

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SARAH TURTON

BOWDEN-JONES: Gender inequality is rife

On matters of public health and the practice of medicine, doctors tend to be of the view solutions are more likely to be found through solidarity rather than separation.

Examples demonstrating the potential of cooperation in the medical profession abound, from the eradication of smallpox to the existence of cross-border health services on the island of Ireland.

With this in mind, the decision taken at the EJD (European Junior Doctors Association) conference this month agreed the BMA will continue to be a member of its organisation whatever form a future Brexit might take.

The move came following an intervention by the Irish Medical Organisation, which insisted the UK’s continued membership would ‘maintain good relationships’ and ‘exchange good practice in medical training and the delivery of healthcare’.

Allowing the BMA to continue to represent the UK’s junior doctors at a European level following Brexit is welcome, significant and far more than a mere symbolic gesture.

The association has previously lent its support to efforts to lobby the EU on the implications Brexit has for patients and doctors in the UK and the rest of Europe.

The BMA plays an important role within the EJD. Former BMA junior doctors committee joint chair Kitty Mohan is its president, while former JDC chair Ellen McCourt was recently elected as its next medical workforce committee chair.

The BMA’s continuing full involvement in the EJD, along with that in other pan-European organisations such as the European Union of Medical Specialists, the Standing Committee of European Doctors and the European Union of GPs, means the UK and BMA will continue to have influence in European healthcare policy whatever form Brexit takes. bma.org.uk/brexit

Keep in touch with the BMA online at

Speak up, listen up Debates about gender inequality often focus on pay and rightly so. The gender pay gap stands at 17 per cent between female hospital doctors and their male counterparts but clearly that’s not the end to unequal treatment.

‘Gender inequalities are prevalent across many parts of medicine and it is vital that we understand what all of those challenges are,’ is how MWF (Medical Women’s Federation) president Henrietta Bowden-Jones put it at its first-ever joint conference with the BMA. MWF vice-president Chloe Orkin talked of the time she was ‘trolled’ on social media, for a post flagging research she had presented which was widely broadcast in the media.

Countess of Chester Hospital clinical fellow Chelcie Jewitt told of her campaign ‘Everyday Sexism in the NHS’, something she set up after being belittled by a consultant after a series of night shifts. Palliative care consultant Sabrina Bajwah fought and fought for a hospital trust to treat female doctors fairly when applying for clinical excellence awards after taking maternity leave.

That there’s still much to do will surprise few. One key to tackling gender inequality, offered at the conference, was to create a ‘listeningup’ culture in the NHS. It’s as simple as it is obvious but it will require significant attention from medical leaders, female and male.

‘We spend a vast amount of resources to get women to speak up when more work needs to be done on the listening and inviting,’ Ashridge Hult International Business School professor of leadership and dialogue Megan Reitz told the conference.

‘Listening up is a bit of a deaf spot.

We need to look at ourselves in the

instagram.com/thebma

mirror: how do we perpetuate the cultural habits here?’

BMA council chair Chaand Nagpaul said the association was committed to being a ‘learning organisation’ and welcomed its closer working relationship with the federation.

‘Who better to learn from than the MWF,’ he added. bma.org.uk/equalitymatters

Read more online Gender inequality: call to focus on listening Doctors’ advocate Clinical excellence reworked – the tax bill that put a consultant’s future at risk Stress undermining retention, says GMC Read all the latest stories at bma.org.uk/news

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PORTMAN: ‘There’s a sense of injustice; this was an avoidable death’

DEAN ATKINS

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Mags Portman, an internationally renowned consultant, died aged 44.

Her husband Martin believes her death was the result of exposure, as a junior doctor, to asbestos, which is found in many NHS buildings.

He speaks to Jennifer Trueland about their battle for justice

For Mags g ‘Comment: Malignant lookin , right-sided pleural disease s for which the differential lie lioma between primary mesothe (which seems unlikely in a patient of this age), and metastatic disease. the ‘NB Whenever I have seen in comment “seems unlikely en this patient because...” writt that in a radiology report, then differential turns out to be the correct diagnosis…’

T

his is from a blog written by the eminent sexual health consultant Mags Portman, who died this year, aged 44.

She had been diagnosed with mesothelioma – a cancer caused almost exclusively by exposure to asbestos – two years before that.

The quote above is taken from the report of the CT scan that formed part of the diagnosis process; the wry comment that follows is characteristic of someone who charted her experience of terminal cancer with admirable candour and even humour.

Dr Portman, who was lauded internationally for her role in making pre-exposure prophylaxis available to people with HIV, is one of a small but significant

number of doctors and other healthcare workers who have fallen victim to this particularly aggressive form of cancer.

Her husband, Martin Portman, believes she was exposed to asbestos when she was a junior doctor working at Law Hospital in South Lanarkshire.

‘At that time it was a former army barracks, mainly constructed from Nissen huts with asbestos products throughout the whole site,’ he says.

Mesothelioma is a rare cancer, with around 2,500 diagnoses in the UK each year. According to Mesothelioma UK, nine in 10 cases are linked to exposure to asbestos.

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settings – such as construction work – workers in other occupations can also be affected.

Commonplace material ‘Mesothelioma is indiscriminate,’ says Ian Toft, a partner with law firm Irwin Mitchell, and head of the asbestos-related disease team in Leeds. ‘It can affect everybody. Asbestos is in lots of public buildings, including schools, libraries – and PORTMAN: hospitals – and although it’s ‘Even the care been banned for around 20 professionals years, so you shouldn’t get it in were surprised by the diagnosis’ newer buildings, there’s still a lot of it around.’

Healthcare workers including doctors who develop mesothelioma tend to have been victims of what is called ‘bystander ‘It was a massive, exposure’ – because they massive shock. It haven’t handled it as a direct took such a while part of their jobs but they were in an environment where for it to sink in’ asbestos was disturbed.

This means it’s very hard to pursue claims because doctors understandably don’t remember every occasion where they might have been around, for example, when construction or maintenance work was going on in the background.

‘One of the difficulties is ‘Asbestos is in lots that it’s such a long period of public buildings, of time between potential including schools, exposure and developing mesothelioma that it really libraries and tests your memory,’ says Mr hospitals’ Portman, who is pursuing a case started by his late wife.

‘Mags felt the onus was on her to remember specific occasions when there was work going on, which of course would have been incidental to her reason for being there. There’s quite a

lot of pressure on potential claimants to come up with detailed evidence when you’re going back that far.’

Dr Portman was diagnosed in January 2017 after seeking medical attention for symptoms including a persistent cough. ‘She was slightly concerned – being medically trained she knew what the potential outcomes might be,’ says Mr Portman, who works in healthcare IT. ‘She had a chest X-ray and then was told to come back immediately and have a CT scan.

‘She knew then that something serious was likely to be the outcome of this, but I think the rest of the family and those around her were probably in a state of disbelief.

It was so unlikely that you just simply wouldn’t expect it. Even the care professionals were surprised by the diagnosis; they didn’t want to believe it until it was proven by biopsy.’

‘We’d never worked with it’ Obviously, the diagnosis had a huge effect on the family,

especially on their sons, then aged six and nine. ‘It was a massive, massive shock. It took such a while for it to sink in. Myself and Mags went through various stages of near-panicking. Not only was it shocking because of the seriousness of it, and we didn’t know how long Mags had to live – it could have been just a few months – but also wondering where it had come from. I mean asbestos – we’d never worked with it. Mags had the house tested because this stuff is deployed in different places in different forms.’

For a period of around six weeks, the couple were ‘emotionally turned inside out’, he says. They told the boys as soon as they could.

‘They knew there was a problem before diagnosis and when Mags was diagnosed with cancer (although at that time we didn’t know what type) we told them that she had cancer. When we knew it was mesothelioma we told them, and we told them that she was expected to die.’

Despite everything they

FAMILY LIFE: Dr Portman with her two sons

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Dr Portman in Paris last year

were going through, the family managed to have some good times in the months that lay ahead. ‘We were really close anyway, but this ironically really did bring us together as a family. Mags was asking the question, “what good can you get out of cancer?” almost, and we did have a good family time if you can separate out the awful cancer bit from us just having time together as a family.’

Avoidable tragedy Dr Portman’s death was reported to the coroner’s office in England so there is likely to be an inquest.

Lawyers Irwin Mitchell are investigating the case, which Mr Portman hopes will have several positive outcomes.

‘Although Mags didn’t feel unduly angry about what happened, there’s a sense of injustice; this is an avoidable death,’ he says. ‘She worked in an area of medicine that was preoccupied by prevention, and yet she had a terminal diagnosis from something that was preventable.’

He would like to see more awareness raising about the risks to healthcare workers of exposure to asbestos.

‘Mags really blundered into

a situation because she went to work and assumed she was safe. There was no way that she knew there might be a safety problem there. I know that hospitals and other public buildings have to keep an asbestos register but this is information that is generally hidden away. Maybe it should be more widely circulated so that people can find it more readily and maybe it would inform their choices about where to work.’

And there is no doubt that asbestos is still in many, many healthcare buildings across the UK. A BBC investigation last year found out (via requests under the Freedom of Information Act) that around nine in 10 hospital trusts in England knew of asbestos in at least some of their buildings.

Terribly missed Claims are beginning to have a financial effect on the NHS. A Freedom of Information request to NHS Resolution demonstrated that there had been 1,229 related claims submitted since 2004, with about half settled in favour of the employee.

Back in Leeds, life goes on for Mr Portman and sons

Edward and Freddie.

‘At the moment, I think we’re kind of doing OK,’ he says. ‘Telling the boys that Mags had died was absolutely the worst thing I’ve ever had to do, but I think they’ve coped really, really well. They miss her terribly and will often say that they miss her and are thinking about her, but they’re getting on with their lives.’

He pauses for a moment, then adds thoughtfully: ‘They’re enjoying themselves when they should be enjoying themselves. They’re looking to the future. Edward – our oldest boy – has just started secondary school and it’s a big school with lots to do, and he’s coming home and being very enthusiastic demonstrating what he’s been finding out. It very much reminds me of Mags, actually.

What’s happened hasn’t held them back from being inspired by things.’

‘Telling the boys that Mags had died was absolutely the worst thing I’ve ever had to do’

Risk-awareness research under way Mesothelioma UK is funding research to explore the experience of healthcare workers with mesothelioma with the aim of developing recommendations for increasing awareness of the risk to this group. Called the MAGS study (Healthcare Workers Mesothelioma Asbestos Guidance) in honour of Mags Portman, it has been paid for partly by donations from her friends and family.

Researcher Peter Allmark, who is based at Sheffield Hallam University, says the research is largely qualitative and seeks to find out the experiences that healthcare workers have with mesothelioma, including how they feel treated by other healthcare workers.

Find out more at www.mesothelioma.uk.com

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Animal instincts Debbie Cohen is a pioneer of physician mental-health research and practice. She tells Keith Cooper how the culture of medicine can compound difficulties for doctors – and the lessons learned from her farm in Wales

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e’re heading to Debbie Cohen’s smallholding, deep in the Welsh countryside, to find out how husbandry of rare breeds and woodlands might help the medical profession she cares for so much.

‘My new found life has inspired some of my thinking about physician health,’ Professor Cohen, an occupational medicine specialist, says in her email invite. Intriguing.

Rocking about in a cab on a holey path through driving rain it’s clear these pastoral views, though barely visible, must be informing this inspiration. What could be better for you than a way of life out here?

It seemed clear but we’re way off track, just another misconception on which we’re kindly corrected around Prof Cohen’s farmhouse table, as rain hammers the roof and spills off a slaughter slab outside.

Loose talk about ‘burnout’ is one of her major bugbears. Telling doctors to be more ‘resilient’ under pressure? No, not acceptable. Sending medical students threatening letters for taking time off for mental illness? Also unacceptable.

Mindfulness activities? ‘They might work,’ she says. ‘But we need to think beyond them.’

‘What does that mean?’ she jabs, then beams. ‘Mindfulness activities can be fine but you can’t just tell people to go on a course. It’s very tick-box. I talk about policies, practice, and platitudes. This is what some hospitals or medical schools do. Platitudes.

We’ve done this, we’ve ticked this box, it’s OK. Well, it’s absolutely not OK.’ What are needed are interventions that are thoughtful, based on evidence, which

also respect the whole ‘ecosystem’ in which doctors and medical students study and work, Prof Cohen says. ‘Junior doctors are leaving.

Consultants, my age and a bit younger, are saying, I’ve had enough, I’m out of here,’ she adds. ‘We’re losing talent from both ends.

There’s also lots of evidence about mental illness in doctors and medical students. We need to do more about it. What we have is not enough.’

Supporting doctors Months into ‘retirement’, as she calls it, she’s as frank about the bad things facing the profession as she is positive about the good that sensible interventions can do.

Prof Cohen is widely recognised as a pioneer of physician mental health research and practice. She set up the Medic Support service for medical students and doctors in Cardiff University in 2001 and another service in Wales (called HHP Wales), more recently, which is funded by the Welsh Government and offers all doctors in Wales access to eight sessions of cognitive behavioural therapy for free.

Despite her recent September retirement, as director of student support and the Centre for Psychosocial Research, Occupational and Physician Health in Cardiff, you sense that she won’t. She’s still lead for mental health and work at the National Centre for Mental Health, Cardiff University. Her latest job is chair of the abstract review committee for the International Conference on Physician Health, organised by the BMA next September in London in conjunction with the American and Canadian medical associations.

‘Basic humanity is what the conference is

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MATTHEW SAYWELL

GRUFF GUIDES: Prof Cohen with Ronnie (left) and Rupert (right), one-and-a-half year-old twin Golden Guernsey goats

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MATTHEW SAYWELL

‘Invincibility’ No one working in a pressured NHS will be helped by being put on ‘resilience courses’ or by being told to ‘empty their bucket before they go to work’, she adds.

‘Treating a waterlogged field is not just about planting trees or fixing a drain. We need to start from the bottom to put the right structures in place. It needs the right seeds and grass to be sown, the water system to be understood and managed.’ If the NHS is an ecosystem in need of understanding and balance, the ethics of permaculture is a useful tool for much-needed ‘creative thinking’, Prof Cohen says.

Medicine’s culture is intertwined with the culture of the NHS and of medical education, she says. It makes as little sense to see them in isolation as to separate land, animals and trees

A DOG’S LIFE: Prof Cohen with labradoodle Bella (back) and Jack Russells Archie (left) and Alfie (right)

MATTHEW SAYWELL

about,’ she adds. ‘How we bring that back into medical culture, into any culture really?’

Her interest in caring for doctors came after the notorious Harold Shipman case, the GP from Hyde, Greater Manchester who murdered hundreds of his patients. Scrutiny and regulation inevitably intensified but without any extra help for doctors when things went wrong. ‘Back then, you only had the three wise men,’ Prof Cohen adds. ‘If you got into trouble you got tapped on the shoulder.’

But what’s this all got to do with smallholdings and husbandry?

It is really a way of thinking holistically about how people and less tangible elements of workplaces, such as ‘culture’, can work with and against each other in the NHS. ‘If you look at permaculture it’s a recognised and successful way of building sustainability into the land. It has three basic “ethics” guiding its practice,’ Prof Cohen says, on a crunch down a holloway, again in the rain, through her ancient woods and into the fields where rarebreed animals graze.

‘There’s earth care, people care, and fair share,’ she adds. ‘Look after your earth and soil: make sure you understand it, know how to drain and nourish it. Then there’s the people who live and work on the land and in the communities beyond. They have their own needs, they interact with the land, too. How do you care, nourish and address their needs and the land’s? How do we work as a group to manage and support each other? How are we fair about that?’

when seeking a sustainable, resilient land.

‘You have to look at how they can work together,’ she adds. ‘Next year’s conference is an opportunity to look at how we change things.’

In medical schools, students end up absorbing a ‘hidden curriculum’ from doctors claiming ‘invincibility’.

‘They hear people say, I never get ill. Let’s laugh it all off. They think, that’s what I’ve got to be like.’ And while universities may have reams of policy about mental illness, they can be unkind to students who miss lectures or exams.

‘They’re not very thoughtful in what they say, how they say it,’ she says.

‘All you need to do is say, Thank You,’ she adds, spelling out a more humane way. ‘For getting in contact with me. I’m sorry that you’re not well at the moment. I appreciate that you’re doing everything you can to get better. What can

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COHEN: Lessons can be learned from the land

I do to help? It’s not difficult is it?’

Her care of rare breeds, such as Soay and Boreray sheep from the isolated Scottish archipelago of St Kilda, links with a longheld interest in human behaviour and communication. ‘You can’t herd Soays with a dog,’ she says. ‘You learn how to manage them by understanding their behaviours.’

Prof Cohen has also studied doctors’ behaviour. In 2004, she studied GP behaviour when writing ‘sick notes’ (before they became ‘fit notes’) for her MD. Her interest now lies in helping doctors and medical students survive and thrive in the NHS. Such work informs her courses for medical students and junior doctors in communication and emotional intelligence, how to handle inevitable feelings of anger, frustration and upset which come with the job.

‘Trainees often feel vulnerable, their consultants forever assessing them,’ she says.

She helps them find strategies for managing these sometimes-difficult relationships.

‘One doctor told me, I thought I was a ninja, but actually, I’m a Buddha,’ she says. ‘Isn’t that lovely?’

There’s something from her childhood too which steers this interest in communication and behavioural change. As one of five children

(now, all doctors) of notable psychoanalyst and psychiatrist Norman Cohen, she spent years as a child in analysis herself until ‘I rebelled’.

‘My father was an amazing man,’ she says. ‘He was the one who said, follow your heart, be independent,’ she adds with a bang of the table.

She started her career at Charing Cross Medical School in the seventies and trained as a GP in Oxford. She followed her husband Professor Sir Michael Owen, a highly respected research psychiatrist, to Wales before a stint as an agony aunt for Practical Parenting magazine.

She retrained in occupational health after their son fell ill, working for Marks & Spencer, General Electric, and Greggs bakery.

‘It’s been a long journey,’ she says, back in the farmhouse, back at the table. ‘But we need to move on. What we’ve been doing hasn’t worked.

Doctors leaving in droves. People say, we’ve got the services, we’re OK. Well, no, we’re not,’ she adds. ‘Because why are people still killing themselves? Why are people still saying, where can I go to get help?’

The call for abstracts for the International Conference on Physician Health is now open until 31 January. Visit bma.org.uk/icph2020 to make your submission and for more information. thedoctor | November 2019 13

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ROYAL COLLEGE OF PSYCHIATRISTS

Consultant Kate Lovett received a pensions tax bill greater than her annual salary – a penalty for taking on wider work which benefits patients. She tells Jennifer Trueland it may force her to reduce her commitments

Annual pay: £-27,000 C onsultant psychiatrist Kate Lovett suspected she would be hit with a sizeable tax bill after receiving an increment and a bronze national clinical excellence award in the same year – but she didn’t expect that it would be some £27,000 more than her entire annual earnings.

Now she is faced with the prospect of remortgaging her house or raiding her pension fund to pay a likely bill in excess of £150,000 – and is also anticipating the gutting probability of having to cut back on her professional commitments to safeguard her financial future.

‘I’ve had a predicted tax bill from my accountant that is for £27,000 more than I earned in that tax year – 2018/19,’ explains Dr Lovett, who works in community psychiatry in Plymouth but is also dean at the Royal

College of Psychiatrists.

‘The reason that my pension growth was so big in that year was that I had the perfect storm in terms of receiving an increment, getting a bronze merit award, and I also have mental health officer status. But I do no private work and I don’t have any other streams of income.’

What makes it worse in a way is that Dr Lovett was encouraged to apply for the merit award – worth an annual (and pensionable) £36,000 – and decided to do so partly because she was aware of the gender pay gap and wanted to ensure women were better represented among those receiving this kind of recognition. It was her work on the national stage with the college that was the main driver for it, particularly her role in education and training and improving recruitment to the specialty.

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This role – on top of a busy day job – has naturally taken its toll on other parts of her life. ‘I’m away from home frequently and I work most evenings and Sundays. My free time is extremely limited. It’s a real privilege to be able to do what I do, and I wouldn’t choose to do anything different, but it does come at a cost.’

Like many of her female medical colleagues, Dr Lovett had taken the decision to work part-time while her children were growing up – taking the concomitant salary (and pension) hit for doing so. Now, as a direct result of the punitive pension tax charges, she is contemplating reducing her hours again, although it is the last thing she wants to do.

‘This is terrifying – here I am at 52 having thoughts about cutting down the work I’m doing. We simply can’t afford for people even beginning to think like that,’ she says.

Hearing that her tax bill was likely to be so huge was a shock, she admits, although she had been aware of the issue for some time.

‘I’m aware that there’s a great deal of anxiety among my colleagues, which has meant, for instance, that it’s very difficult to get people to take up extra sessions to do clinical work, but also to do important educational roles.’

It felt ‘unreal’ to be told of her own likely bill, she says. ‘There was a sense of disbelief. I was aware that people had had big tax bills, but I’d never heard of anybody having a tax bill as large as mine.’

Least worst option It’s a big thought to contemplate taking out a new mortgage or bank loan in her 50s, particularly with children still in education.

But the alternative – using ‘Scheme Pays’ to ‘borrow’ money from her pension fund – doesn’t appeal either.

‘Part of the difficulty is that it’s very hard to work out what the effect of that would be long term because there is interest payable on that, so I’m waiting to get good financial advice to find out what’s best for me to do.’

Ironically the large bill could in part be owing to her attempts to ‘catch up’ with colleagues who had been applying for clinical excellence awards over a longer period – which meant she had a large increase in pay in a short time, with a corresponding effect on her pension.

‘I worked part time earlier in my career. I’m very aware of the gender pay gap. So earlier in my career I had to focus on my core clinical job and family commitments. But since my children have grown older, I’ve moved to full time at work, and have worked considerably hard to contribute to the wider benefit to the NHS through my national roles.

‘I really don’t have a problem with paying tax,’ she stresses. ‘It’s really important that people like me do pay high rates of tax because that’s what funds the health service, our education system – I’ve no issue with that at all.‘ BMA lobbying ministers She, like many others, is weighing her own options carefully. ‘I don’t know what I’m going to do,’ she says. ‘Cutting down on work feels to me to be a morally reprehensible course of action given the service demand. But at the same time the debt that I accrued in this year is equivalent to the biggest debt I ever had in my life, which is my mortgage. I’ve worked hard to provide for my family over the years, and will be forced to make decisions that protect my assets and my income in my old age.’

The BMA has been leading the campaign against changes to pension legislation introduced in 2016, which have led to doctors facing large and often unexpected bills relating to their pensions. This has included writing to successive prime ministers and other senior policy makers laying bare the extent of the problem and calling for urgent action.

A BMA survey published in August found that thousands of GPs and hospital consultants have reduced their working hours, and thousands more are planning to cut back because of the changes.

The UK Government is reviewing the changes and has proposed some amendments, including allowing staff and employers to reduce the amount paid into pension pots.

But the BMA has said the proposed changes are just a ‘sticking plaster’ and would not solve the issue.

The association is also supporting its members to ensure they are aware of the tax implications of the annual pension allowance, and making available tools so that they can assess their own particular circumstances.

‘This is terrifying – here I am at 52 having thoughts about cutting down the work I’m doing’

‘I will be forced to make decisions that protect my assets and my income in my old age’

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11/11/2019 09:35

On the cusp of collapse Overcrowding and underfunding have left patients and doctors at risk and, as a demanding summer turns into a winter of alarming challenges, how will the NHS cope?

Peter Blackburn talks to doctors across the UK struggling on the front line

16

‘W

hen I left my shift at 2am there were 56 patients in the majors department – in a space with just 16 bays.

Each bay was split in half for two patients and we had to leave one bay free to be used for toileting and another as a drinks station owing to the sheer amount of people in the corridor.

‘It is a terrifying situation.’

Previous experience would suggest this southwest specialty trainee in emergency medicine, speaking to The Doctor anonymously, would be describing a hospital trust at the height of winter – with a flu epidemic and inclement weather driving rocketing demand in accident and emergency departments. But this is a mild autumn day, not a winter war zone.

‘I worked in finance during the 2008 crash before I came into medicine and what we are seeing now is not that dissimilar a story really, it’s all chaos. When you stop to think about winter pressures and

how demand is going to go in the next three months, I just don’t know what to think. It is not safe – I can hardly bear to think about it.’

Patients in the corridor It is a picture playing out in hospital trusts across the country.

One Midlands emergency medicine consultant tells The Doctor the summer was ‘absolutely brutal’.

He says: ‘It felt like winter from five or six years ago. It was just incredibly hard going.

We spent the summer with our patients in the corridor with very little space in the hospital and hitting October it felt like January of 2017 or 2018.

‘It is just horrible out there and it is incredibly difficult for people to do their jobs well.’

This is a three-fold crisis: this country’s most beloved national institution is bursting at the seams, patients are suffering and frontline staff have little more to give.

The consultant adds: ‘It’s really corrosive for staff because they are coming

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‘Trolley waits’ – projected number of patients waiting more than four hours for admission

Worst case 2019-20

297,271 Best case 2019-20

205,378 Winter 2018-19

213,877 into work with patients lining the corridor – we have been putting patients in bits of corridor we have never used before – we are actually expanding into new areas.

There have been cardiac arrests on the corridor in a number of places.

‘We are completely under the cosh and I don’t think there’s an emergency department in England or Wales that thinks that patient care isn’t going to suffer over winter. The truth is that it’s already suffering – and it’s not through lack of effort on the part of trusts. Trusts are doing all that they can do, they are engaged in the process of trying to free up beds but it feels a bit like the bottom has fallen out of the system – particularly social care.’

A Sussex nurse adds: ‘We don’t really have a time when we aren’t full to bursting point and are normally on black alert – where the need for beds is just overwhelming.’

But why was the summer so bad – and what might it tell us about the winter ahead?

During the three summer months the NHS in England averaged 17,536 emergency admissions per day – a 3.6 per cent increase from 2018.

Emergency admissions place a huge strain on resources as trusts can’t plan for them and a small increase can cause significant blockages in hospitals. On top of that attendances at emergency departments across England increased by 5.7 per cent and the NHS seems to have suffered a winter hangover, with four consecutive winters of at least 150,000 trolley waits leaving trusts on the back foot heading into spring, summer and autumn.

Pensions fuel problems The problems have been exacerbated by the pensions crisis – with consultants being prevented from picking up shifts for fear of dramatically increasing their tax bills. A recent Royal College of Emergency Medicine survey reveals that nearly 90 per cent of consultants who responded

said the rules would affect rota gaps at senior levels.

The pressure on NHS hospitals this summer carries a very significant health warning for the NHS this winter. This summer the NHS’s recovery was smaller than in any year since 2011, bar one – 2014, a year which saw an unprecedented fall in four-hour wait performance, dropping 5.4 percentage points between December 2013 and December 2014.

Documents released by trust boards from hospitals around the country do not make for pretty reading.

Several documents reference anxiety of staff looking ahead to winter, many raise concerns about the Australian flu season being the worst on record, one East Midlands trust is converting office space for beds and many trusts are launching new systems and pathways to try and cope with demand. In response the NHS has launched its biggest ever winter vaccinations programme and individual trusts are putting new

All forecasts refer to England, and cover the period from January to March. With thanks to Theo Chiles for his detailed work on the projections

‘We spent the summer with our patients in the corridor with very little space’

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17

11/11/2019 11:01

Emergency care attendances

Winter 2018-19

6,235,910

‘Patient care and staff mental health are going to take a real hit if we don’t improve this situation’

18

Best case 2019-20

6,372,258 + 136,348

practices in place across their hospitals.

Using national performance data and analysing trends the BMA has made projections for trolley waits, the four-hour wait and attendances and admissions this winter. The projections, which assume that recent trends continue and do not take any future interventions into account, do not make for pleasant reading.

The worst-case scenario is an NHS under much greater pressure than last winter in all the key measures identified.

But even the best-case scenario for emergency care attendances and emergency admissions is worse than the same period last year.

One Midlands emergency department consultant says: ‘It is absolutely daunting looking ahead to winter. I’m not a naturally negative person, I tend to believe we can manage but we didn’t a couple of years ago and we are in a worse place than we were then. There is genuine concern among colleagues about what this particular winter holds and

Worst case 2019-20

6,625,128 + 252,870

if we have the flu or a lack of medications through Brexit or a lack of people in care homes to look after patients then we are in serious trouble.

‘Emergency departments are the place with the light outside the door that never goes off, but that is playing out in a way that isn’t good for patients and that light can’t stay on forever. Patient care and staff mental health are going to take a real hit if we don’t improve this situation.’

London emergency department consultant Barbara Cleaver tells The Doctor that her trust is doing everything it can to put plans in place, and that wider systems are now recognising these issues are beyond the control of emergency departments, but that she anticipates a ‘difficult winter’.

She says: ‘None of us like to work in an overcrowded department – there is really good evidence that patients get a much worse outcome than if they came in and it wasn’t overcrowded. It’s difficult if you are a kind human being to think that is

acceptable. It’s upsetting to come to work and not deliver the care you would like to be delivering because you are overcrowded.’

Dr Cleaver says she is particularly concerned about homeless patients and patients with mental health issues this winter, with demand likely to soar and fewer resources available for appropriate treatment and support across the system.

Staff health concerns Doctors seem to be unanimous in accepting the horror of working conditions, and the expected decline in winter, are affecting patient care – ‘working conditions are actually dangerous and patients may come to harm’, one emergency department consultant says – but the health of staff is a genuine concern, too.

While trusts and NHS leaders might like to talk about resilience of staff during conferences and high-level meetings, the truth is that such consistent pressures take a toll on very many of them.

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11/11/2019 11:01

Emergency admissions

Winter 2018-19

1,625,214

Worst case 2019-20

Best case 2019-20

1,727,582

1,688,477

As the south-west specialty trainee says: ‘When people ask me what training programme I am on and I tell them, they suck through their teeth and they don’t envy me at all. Anyone who comes into any emergency department would wonder why on earth you would go into it because you are asking to be burned out in that environment.’

He adds: ‘It is just not feasible for someone to work that hard for that long in a system at breaking point.

The buzzword of resilience is great, but you don’t get through medical school and training without being a resilient individual. It is down to the system.’

The pensions crisis also represents a serious concern ahead of winter.

Last month, NHS Providers, which represents hospital, mental health, community and ambulance services, said patients would be at risk of unsafe care unless an ‘urgent solution’ to the problem – which is seeing consultants avoid working extra shifts due

to being hit with massive tax bills – is found.

With doctors already on the brink of burnout and the most pressurised winter in history on the horizon can anything be done to avert disaster?

The first answer is yes – with genuine political will and proper investment. The BMA has long campaigned for the NHS to increase its bed stock, and it is crucial this is done before winter begins.

Call for more beds BMA emergency medicine lead Simon Walsh says: ‘Last year the BMA called for a minimum of 10,000 additional hospital beds to be opened across the UK after an analysis of recent years’ performance and hospital occupancy left no doubt that there are insufficient beds to cope with the number of emergency admissions that are required over the winter months.

‘It is notable that even the chief executive of NHS England, Simon Stevens, has recently acknowledged that

we need to go into winter with more hospital beds than last year. The problem of course is that trusts don’t have the funding or staff to do that so what is required is for the Government to acknowledge the scale of the problem and to fund these additional beds and staff before it’s too late.’

And steps also must be taken to ensure doctors are not prevented from working by the pensions debacle.

Dr Walsh says there needs to be an immediate increase in funding to health and social care, and also a plan which can better meet the needs of an ageing population.

‘It is going to be too late to wait – the Government needs to take urgent action now before the worst of this winter fully arrives and we face a perfect storm undoubtedly resulting in the worst ever winter on record.

I’m afraid the staff cannot bend any more to absorb the pressure of this broken system – I fear for the consequences this winter if action is not taken immediately.’

‘The Government needs to take urgent action now before the worst of this winter fully arrives’

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11/11/2019 11:01

Under covered A lack of clarity in medical insurance policies can affect the quality and standard of care.

In response, the BMA has produced guidance to help patients pick a plan. Tim Tonkin reports

Lack of clarity Many private insurance policies do not, for example, cover costs associated with medical emergencies, chronic conditions, elective

surgery or even routine check-ups from GPs. This lack of clarity not only affects patients but potentially makes the job of the doctor looking to provide them with the best treatment that much more difficult.

‘Because there are so many different variations on the policies that are available, you’re not always aware what is covered and what isn’t – either as the doctor or as a patient,’ explains consultant in obs and gynae and BMA private practice committee chair Shree Datta.

‘An insurer might allow me to perform an operation as a treatment for my patient but when it comes to prescribing antibiotics post-operatively to prevent infection, these may not be covered by them so the patient is therefore left out of pocket. It’s a real dilemma for them at the time of greatest need.

‘Sometimes these decisions don’t really make sense, and yet they do have a direct impact on the quality and standard of care we’re able to provide.’

MATTHEW SAYWELL

T

ransparency and trust are the cornerstones of any relationship or transaction and are mutually valued by doctors and patients with regard to healthcare.

This is as true of those doctors and patients who choose to work in or receive treatment privately as those in the NHS. However, in the case of the former, there is a third party to the doctorpatient relationship: the medical insurer responsible for financing the care provided.

Practising or receiving healthcare privately is meant to be a matter of choice.

However, the complexity of the requirements and conditions set by different insurance policies determining what treatments are and are not covered is having an increasingly detrimental effect on doctors and patients.

Unlike staff working in the NHS, there is no contract of employment between a private doctor and a medical insurer, only a recognition of agreement which cannot be contested legally.

According to the PPC, this reality has enabled insurance

DATTA: Patients have to check they are covered constantly

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UNDER PRESSURE: Policies can limit the choice of doctor and lead to unexpected bills

firms to exert increasing levels of control over the way access to treatments and doctor-patient interactions take place.

This includes the use of ‘open referrals’ – a process which effectively allows insurers’ policies to pick and choose which consultant a patient can see, rather than allowing a GP to make this decision. Added to this is the fact that many insurers’ policies will only sanction treatment from a doctor included on their list of recognised clinicians.

This not only reduces patient choice but also serves as leverage on doctors who can face derecognition if they do not meet insurers’ wishes – whether this is reducing their fees or failing to agree to exclude patients from the treatment invoicing process.

In an effort to help inform and thus empower patients looking to take out private medical insurance, the PPC has created guidance, which has been reviewed by the BMA patient liaison group.

The guidance focuses on the information patients should consider prior to purchasing private medical insurance.

‘To a large extent, the treatment that they [patients] are able to access is wholeheartedly dependent on what their insurers are happy to cover and what they themselves can bear as a cost,’ says Miss Datta. ‘Often patients have to contact their insurer along every step [of their treatment] to clarify what parts of the treatment and investigations are covered.

‘Insurers are [also] very clear that patients can only have access to doctors who are recognised by them [the insurer] and are not able to top up their fees to see a clinician of their choice.’

Freedom of choice The undue influence being exerted on doctors and patients by medical insurers was roundly condemned at this year’s BMA annual representative meeting.

In a unanimously backed motion, the BMA criticised the restrictions on patients being able to access a consultant of their choice, the disempowerment of GPs in the referral process and the use of recognition and derecognition against doctors in the private sector.

The PPC has said that it will continue to meet with medical directors of the insurance industry to make their concerns known and push for a fairer deal for doctors and patients alike Responding to the concerns outlined by doctors, a spokesperson from the Association of British Insurers said that medical insurers would always seek to make policies as clear and transparent as possible They added that the open referrals process was designed to keep premiums competitive, while patient safety was part of the decision-making process for recognised clinician lists.

They said: ‘Private medical insurance is a competitive market, with various products available to cater to different needs and budgets of customers. Some policies may specify specialist consultants or hospitals in an area. This will depend on individual insurers, and sometimes different policies provided by the same insurer.

This can help keep premiums competitive while ensuring patients get the most appropriate and convenient treatment.

‘Insurers continually review the medical specialists they use, with patient safety and outcomes part of the decision process.

In occasions when the patient wants to use a medical specialist other than the one specified by their insurer, the patient should discuss this with their insurer.’ bma.org.uk/medical insurance

‘The treatment patients are able to access is dependent on what their insurers are happy to cover’

‘You’re not always aware what is covered and what isn’t – either as the doctor or as a patient’

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MARK HARVEY

In recovery Cuts to drug and alcohol services have become the norm – so how did doctors and other campaigners manage to win a reprieve? And will it last? Keith Cooper finds out

ON MESSAGE: Artwork hangs in a corridor of 3 Blossom Street

P

eople hoping to leave drugs or drink behind in York can seek help at 3 Blossom Street, a spiky red brick building situated between a Wetherspoon pub and Micklegate Bar, a medieval gateway made of stone.

Its reception leads on to a warren of clinic rooms, corridors and offices. A meeting room looks over a garden, a wilderness recently transformed by the generosity of a grateful family whose son sadly died.

It’s here where we meet Andy Ryan, operations manager at Changing Lives, and Helen Chidlow, a GP for Spectrum CIC, a social enterprise, which provides clinical support.

Together, they run the

substance misuse service on behalf of City of York Council.

This is now a fairly typical arrangement in England, some six years after councils took over the purse strings of these services from the NHS. Beefed up by investment by the last Labour government, charities have overtaken the NHS as the prime providers of substance misuse services, a shift further fuelled by austerity cuts.

Like many such services, the threat of cuts lingers still. But unlike most others, York’s has been spared another budget reduction, for this year at least, after an intervention by politicians, doctors, and the police.

So how does the service

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YORK: In a city famous for its number of pubs, campaigners battled with cuts to alcohol and drug services

‘If you’re using heavily, you can have pipe dreams of recovery, but if you’re not in a safe medical place, what chance have you got?’

work? How did the campaign to survive cuts succeed?

And what is the future for substance misuse services such as 3 Blossom Street?

Mr Ryan, a psychotherapist, says that his team of ‘asset coaches’ offers psycho-social support to those through their doors.

They get to know them, help them find out the ‘why’ of their dependency.

‘There’s a reason why someone takes substances.

It often lies outside the substance misuse,’ Mr Ryan says. ‘Is there a housing need? Another health need?

A social network need?

When someone has a problem with opiates and alcohol, the amount of people affected can be huge.’

Immediate needs This psycho-social approach takes time, regular contact with the coaches, and for people to stay engaged. They run an ‘abstinence-based’ programme in a separate building for those who can attend five days a week. ‘It’s been massively effective,’ Mr Ryan says.

But before getting into the challenging work of recovery, people’s immediate medical needs must be met.

This is where Dr Chidlow comes in.

‘While people are feeling really unwell, their ability to take part in meaningful recovery is limited,’ she says.

You can’t recover when you’re dead, is how one slogan doing the rounds puts it. ‘It’s

a strong message,’ Mr Ryan admits.

‘If you’re using heavily, you can have pipe dreams of recovery, but if you’re not in a safe medical place, what chance have you got?’

Dr Chidlow’s team screens for blood-borne infections, such as HIV virus and hepatitis. They manage detox for those who want to quit, an often intense process initially.

They step back when patients are stable.

‘We don’t want to overmedicalise it,’ says Dr Chidlow.

‘For some who present, the substance abuse is the whole problem. They’re like, please take it away. Please fix this. It’s to get them to a point where they can deal with what the issues really are.’ thedoctor | November 2019 23

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CHIDLOW: ‘We don’t want to overmedicalise it’

POLICE: Officers say thousands of crimes are linked to alcohol PAVLOVIC: Substance misusers need prompt access to services

‘The motivation to quit can be transitory’

Changing Lives and Spectrum CIC took over the service in 2017 on condition they would find £500,000 of ‘savings’ in five years.

The largest cut, of £213,000, was expected this year. But in an unusual reversal, the council agreed to a two-stage ‘release’ of funding – almost matching the planned ‘saving’ – after hearing evidence about its potential effect.

This evidence was gathered earlier this year by York’s health and adult social care policy and scrutiny committee, the council equivalent of the Parliamentary select committee. As a former probation officer in the city, its then chair, Labour councillor Michael Pavlovic, knows something about substance misuse services.

‘I would say to my clients, did you go to your appointment? They’d say,

oh no, I couldn’t get in,’ Cllr Pavlovic tells The Doctor.

‘That is what happens,’ he says. ‘The motivation to quit can be transitory. People might see someone overdose or overdose themselves. They see something has to change and go for help, go for an appointment, but are told to wait.’

Hazardous drinking The committee’s inquiry focused on York’s drinking problem. It’s a city well served. There’s a place to buy alcohol for every 200 adults. Some 7 per cent drink at ‘hazardous levels’, doctors told the committee, raising concerns of a ‘ticking time bomb’ of health problems.

York GPs are treating more and more patients with dementia, blood-pressure problems, and cancers from drinking.

Hazardous drinking

hits its hospitals too, says NHS Vale of York Clinical Commissioning Group, which funds them.

York Teaching Hospital NHS Foundation Trust sees ‘significant problems with stomach and liver ailments from high-functioning drinkers’, the scrutiny report says. Staff struggle with demand, despite their best efforts.

‘The situation is likely to worsen’ if budget cuts curb access, the committee heard. The evidence goes on: one in 10 people attend emergency departments, owing to alcohol. One in five arriving by ambulance are intoxicated. The cost? £2.6m to a trust already under financial pressure.

The police told of thousands of crimes each year linked to alcohol but also how detox helps rough sleepers and street drinkers get back

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‘The situation is likely to worsen if budget cuts curb access’

HARD ROAD: Detox services help rough sleepers get back on their feet

on their feet. While they still have trouble with one, named as KB in the report, ‘her more serious behaviour had been vastly reduced’ after help from drug and alcohol services, North Yorkshire Police chief inspector Rachel Wood said in a statement.

In its evidence, Changing Lives warned the cuts risked increased caseloads for its coaches and less frequent appointments, potentially moving from weekly to monthly.

Back at Blossom Street, Mr Ryan, a recovered addict himself, illustrates the effect of infrequent appointments with his hands. ‘If you see someone once a week, you’ll help them understand their problem and change. Then your funding’s reduced,’ he says, palms springing part. ‘You get one appointment every two weeks, it reduces again. You get one every three, every four,’ he adds, pulling them apart.

‘Success drops off. Touching base every three to four weeks is not going to work in drug and alcohol treatment.’

RYAN: ’Touching base every three to four weeks is not going to work’

Dr Chidlow says she worries about growing caseloads.

Deaths from drugs in York are high and rising, a trend under investigation by the authority.

‘Unlike many other health services we have a long-term continual relationship with people who are dying in their forties,’ Dr Chidlow adds.

‘That’s really sad, a tragedy. We have to absorb that and there’s often a critical eye on us.’

Mr Ryan says the scrutiny report was ‘a gift’. ‘We haven’t waited for this to happen,’ he adds. ‘The report was: this is going to happen. It was open and honest, not about blame and shame or papering over the cracks. We have untouchables in our budget.

We can’t stop prescribing.

We don’t want to affect needle exchange because of blood-borne viruses. These are fixed costs, so savings, unfortunately, sit with staff.

If you reduce the numbers, you reduce capacity, and frequency.’

York Council’s Liberal Democrat executive member for health Carol Runciman says it’s forced to ‘pick up the pieces’ of Government austerity cuts. ‘All the concerns are important. It would be very unwise to ignore

them.’ Changing Lives does a ‘tremendous job’, she says.

She insists the money would have been put back without the scrutiny. ‘The most vulnerable are really important to us,’ she adds.

Cllr Runciman, however, refuses to comment on the planned big cut, or ‘saving’ as it’s so called, due next year.

Council papers last month call this year’s financial reprieve an ‘emergency’ measure.

‘If you can’t give adequate support to people in the grip of addictions, those addictions will kill them’ The fight for the service will continue in the political arena in York, Labour’s Cllr Pavlovic pledges. He now chairs the council’s audit committee, keeping track of its finances.

‘I recognise that efficiencies have to be made,’ he says.

‘But if you can’t give adequate support to people in the grip of addictions, those addictions will kill them.’

The evidence is all in.

The fate of those who make it through the door of 3 Blossom Street, with the hope of giving up drugs or drink, now lays in the hands of York’s council. thedoctor | November 2019 25

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

A consultant’s decision to change employer went awry when his job offer was withdrawn and he was unable to annul his notice.

Left with nowhere to turn, he contacted the BMA who drew on a recent similar case to reach a resolution Like moving house, but the removal van disappearing into thin air between old home and new, the idea of something going wrong while changing jobs is the stuff of nightmares.

It happened to one consultant, who having handed in his notice with one employer, and passed all pre-employment checks with another, was suddenly told he didn’t have a new job after all.

It left him in limbo. He could not withdraw his notice with his previous employer. The new one told him that information had come to light which made him unsuitable for the post, but wouldn’t share what it had found out. It was an invidious situation.

The BMA wrote to the chief executive of the NHS organisation which had changed its mind about employing the consultant.

The letter asserted that it had breached its own recruitment policy and the General Data Protection Regulation which obliged it to meet the doctor and explain what information had come to light and from whom. There were also strong legal considerations.

It was difficult for the employer to deny that it had caused severe detriment to the consultant by taking

away his immediate ability to work and earn money. The issue was more the payment it would make to him – and of course the information on which it had based the decision, to which he was legally entitled.

The BMA argued that he deserved at least six months’ salary. The trust only offered three, and was reluctant to offer more without asking the approval of central government.

This made the process drag, and, because of the time limits imposed by employment tribunals, the BMA initiated proceedings through the legal firm Gateley.

Shortly after Gateley became involved, the BMA employment adviser learned of Amar Alwitry, a consultant ophthalmologist who had also had a job offer rescinded. Mr Alwitry, in a case supported by the BMA, took the Jersey States Employment Board to court, and was likely to be awarded extensive damages beyond the contractual notice pay.

Gateley took the advice of counsel, who found there were similarities in the cases. Neither had fulfilled the grounds upon which a consultant contract could be terminated, which must, according to the English and Jersey consultant contracts, be followed when

ALWITRY: Entitlement to future loss of earnings gave a useful guide

consultants are dismissed, regardless of a consultant’s length of service.

In the Alwitry case it was ruled that there was an entitlement to claim for future loss of earnings, and not just the notice period of the contract. The court had not at that point determined the extent of losses that could be claimed

by Mr Alwitry, but counsel recommended that, in this case, a claim of six months’ pay would not be unreasonable.

This gave our doctor a stronger case, and he received six months’ pay and the information which had triggered the termination.

He sent the employment adviser his ‘sincere thanks’ and said he had been given clear direction and support.

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the secret doctor

DREADED DEVELOPMENT: Mention of the word ‘sepsis’ can turn concern into blind panic

The ‘s’ word The situation was, frankly, a little hairy. The infant was grey and shut down, breathing rapidly but scarcely whimpering a protest at the needle.

Cannulation had failed, and our first attempt at intraosseous access had just dislodged. The emergency care consultant was there with me, both of us started to feel things could go either way. The patient’s mother was holding herself together with an obvious effort, pale but dry-eyed, stroking her child’s head.

Half an hour later, things were looking up. We finally had access and 20ml/kg of crystalloid were working their magic. The baby still didn’t look ready to star in a Pampers advert any time soon but her colour had improved and her blood pressure was finally creeping up. It was only then that I had a chance to speak properly to the mother, to explain what we had been doing, and why, and what we expected to happen next. I believed, I said, that her baby had sepsis.

And that was when she lost it. Previously impressively composed, her face crumpled in dismay and she burst into tears. I was startled – it took me a moment to realise which bit of what I had said had alarmed her. She had held it together through the oxygen mask, the intraosseous needle, the scalp cannula – but the ‘s’ word was a step too far.

That was my first encounter with the new public awareness of sepsis. Sixty years ago, I’m told, cancer occupied the same place in the collective imagination: an almost

supernaturally horrific fate, to be whispered about in dark corners. Thirty years ago it was AIDS. I’m sure, at other times and in other places, there have been other illnesses which evoked that shudder, that hushed voice.

For now, however, it’s sepsis. As with cancer and AIDS, its fearsome reputation is not unfounded – it’s a serious, potentially life-threatening condition. Through an entirely well-intentioned campaign, we have been taught to look for sepsis in every patient, to suspect it even where the evidence is limited, and sometimes to treat it even at the expense of another equally dangerous but less well-publicised diagnosis.

There are clearly some benefits to our heightened alertness but the public terror of sepsis now goes well beyond the rational.

That young mother already knew her child was very ill, but the word ‘sepsis’ evoked an almost superstitious level of dread.

We all know words are important. A ‘chest infection’ conveys different associations from ‘pneumonia’, and a diagnosis of Hodgkin’s disease doesn’t necessarily tell patients they have cancer. ‘Sepsis’ should be a useful label for a cluster of symptoms that remind us to look promptly and carefully for infection, not a bogeyman to frighten medical students.

Whatever went wrong?

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

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the consultation The Doctor will see you now

Rugby doctor Charlotte Fairweather achieved her childhood dream with absolute precision but it was a difficult journey. She talks to Keith Cooper My waters broke when I was on call.

I was moved quickly to the obstetric ward. I still had the bleep on me.

I felt panicked. I was only 22 weeks.

They told me the baby wouldn’t survive or be severely disabled.

They tried everything. I was home in three days.

Samuel was born two weeks later.

He made a little cry. I glimpsed his minute little body before he was taken away. He weighed 792 grams.

On his third day he bled into his lungs and brain. The outcome looked bleak.

They asked if I wanted the chaplain, to take him outside. But after surgery he improved. Six months later we were home.

You might never work again as a doctor, they said. I’d walked through those hospital doors for three years as a doctor then every day for six months to see my poorly child. How was I going to manage? I’d wanted to be a doctor for the England rugby team, my grandma reminds me. Now my confidence was knocked.

Samuel defied all the odds. He met milestones, started to smile, mobilise, to bum-shuffle, then walk. He’s a stubborn child. I started working locum shifts. I hadn’t forgotten everything. I did an MSc in sports medicine, trained as a GP. I took leave to work for the Welsh Football Association, before taking a job as lead medic for the RFU (Rugby Football Union) Red Roses [the England women’s national rugby team].

SWING LOW: Dr Fairweather and son Samuel (inset) who leads England rugby team captain Owen Farrell (above) out to a game against Scotland

I missed the first two games of the Six Nations. Samuel was very unwell.

My boss in the RFU told me to go home and be mum. I returned to work for the rest. Samuel, dressed in full England kit, led the England men’s team out, three months after his emergency surgery. I still don’t know what he whispered to make Owen Farrell laugh.

It has been a rocky old road but I’ve got to go somewhere where I want to be.

Charlotte Fairweather is a Marlow GP and lead medic for the RFU Red Roses

28 thedoctor | November 2019

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it happened to me Doctors’ experiences in their working lives

STUCK INSIDE: Paramedics could not open the shower cubicle door so kicked it down

The day I joined the paramedic cavalry He was really big. Naked. Not breathing. And wedged fast inside a tiny shower cubicle at the gym.

They had heard him fall, and one of the staff had gone to investigate, squeezed over the top of the partition and was in there with him, calling for help. He couldn’t budge him, and we couldn’t get the door open. The young chap said he had been groaning, so it hadn’t been put through as an arrest. Agonal breathing can be so confusing.

By the time I had run back to the truck for the red bag, the crew had used their paramedic kick-boxer training to destroy the cubicle walls and had started CPR. There was water everywhere. Towels had appeared, loads of them, and in between chest compressions, intubating, calling for the back-up crew and getting the chest pads on, we were mopping frantically. The hazard remained theoretical, however, as we never got a shockable rhythm. An hour and six paramedics later, we called it and went to talk to his family.

It was on my PDP (personal development plan): improve my confidence with pre-hospital care. I’ve long had this admiration – OK, hero worship – of the cavalry who come galloping over the hillside with lights and sirens, swooping in and saving the day when it’s all going to pot in our surgery.

So, when I got invited by one crew to spend a day with them as an observer, I was thrilled. We had had a few fairly low-key calls.

The confused hypertensive older lady on blood thinners, hosing impressively from a nosebleed. The faint in early pregnancy. The allergic reaction (we got biscuits and a juice at that one, while we monitored the response to Piriton. Very nice). We heard amazing stories of patients’ lives, and back on the truck shared horror stories of our own.

It was a good day. I’m so grateful to the lovely crew that took me out. I achieved my PDP and improved my emergency-care skills. But, as they say, be careful what you wish for…

We covered our patient decently with towels and trundled him out past the now-deserted rowing machines and exercise bikes, and the staff holding doors open. The young chap who had been wedged in the cubicle with him was there, looking shaken and miserable.

I patted him on the arm as we went by.

I wanted to stop and hug him, to say – look, you did your best, you were good, you stayed with him, you tried. Sometimes these things just happen, no matter what you do. But we had to keep moving. We had other places to be in.

Beatrice Duck is a GP. She writes under a pseudonym thedoctor | November 2019 29

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and finally...

Two cheers for a great diagnosis Did you save any lives today?

So goes the usual banter, but how many of us actually save lives on an daily basis?

Perhaps, like me, you spend most of your time managing chronic disease, listening to people’s concerns and trying to manage expectations.

OK, no lives saved. Did you make any diagnoses today?

– after all, we spent years at medical school learning to diagnose. Many of us make many diagnoses but typically, we are trying to look after people with pre-existing diagnoses. Some of us work in areas where making a diagnosis is commonplace. I’d expect someone working in a memory clinic to diagnose dementia but sometimes I meet patients who don’t even want diagnoses.

So, when did you last make a cracking diagnosis? I made one recently: central cord syndrome.

However, as I would find out, there are a number of

associated problems: It’s often bad news for the patient; there is a risk of feeling smug or proud. And we know that pride comes before a fall; once you have made a cracking diagnosis, you are then trying to deal with a patient who needs specialist management and is now in the wrong place; you need to get someone who is an expert in the field (because you certainly aren’t) to review and look after the patient; and the specialist you speak to expects you and everyone else to be an expert in managing this condition.

I was delighted with my clinical skills in history taking and physical examination, and the MRI spine confirmed the diagnosis.

We assessed a man who had walked into a lamp post.

The neurosurgeon had been and gone, and had written an instruction in the notes: ‘Hard cervical collar.’

The trouble was, we didn’t have any collars and I hadn’t

had any recent experience in sizing or fitting them. I decided to call again for help.

The response I received: ‘Well, every nurse in the hospital should know how to fit a hard cervical collar.’

In this age of superspecialisation, it got me thinking. What should every nurse know how to do? What should every doctor know how to do?

We’ve got GMC guidance for that: – Recognise and work within the limits of your competence – Work with colleagues in the ways that best serve patients’ interests.

My simple guide would be: – Ask for help when you need it – Help someone when they need it.

I don’t think the neurosurgeon had read that guide.

Joan Forrest is a consultant.

She writes under a pseudonym

S RRY…

thebma writing competition 2020

‘Sorry’ has been called the most over-used word in the English language. It can seem like a verbal tic. We say it for the smallest reason, or for no reason at all.

#writeBMA Terms and conditions online

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For this year’s writing competition, we’d like you to reflect on this word.

When do you most remember saying it, hearing it or needing it?

It might have been when you made or witnessed a mistake. Or when you had a disagreement with a patient or colleague. It might be something that happened last week or many years ago. This is inherently sensitive, and you might find it necessary to

change some identifiable details. As with our previous competitions, what matters most is that the piece is vivid and engaging. Our webpage bma.org. uk/writingcompetition has last year’s winner and runners-up to give you some inspiration. We need 700 words, and the deadline is 25 January 2020.

Email your entry to thedoctor@bma. org.uk with ‘Writing competition’ in the subject line.

11/11/2019 10:29

Time is running out…

Following the outcome of a recent court case, if you worked on a rota that was monitored using Allocate/Zircadian, you may have had your rota banded incorrectly and may have been underpaid.

If you are a BMA member we can check the eligibility of your claim and support you in bringing forward a case. But you need to be quick – there is a six year limit.

what’s on

For more information, visit bma.org.uk/monitoringbreach

November

BMA resolution panel members

29 Planning for retirement – delivered by the BMA, Oxford, 9am to 4pm

Doctors who would like to help strengthen the BMA culture and to support its behaviour principles (be professional, be accountable, be representative, be kind and respect others) are urged to put themselves forward to take part in BMA resolution panels. The BMA is looking for grassroots members with the skills and experience to support its work in this area.

Resolution panels hear complaints that have been made against BMA members under the BMA code of conduct and that have been investigated by external independent investigators. Panel members consider the complaints and the evidence put to them, before determining whether there has been a breach of the code and whether a sanction would be appropriate.

Candidates will need to be able to have strong analytical, interpersonal and decision-making skills.

They will need to be able to commit to attending panel meetings, to completing preparatory work and to undertaking training for the role. Candidates must not be part of the BMA’s democratic structures (ie, committees, councils etc.)

For more information on the role, and an expression of interest form, please contact Daira Moynihan, corporate support and resolution manager, at dmoynihan@bma.org.uk. The deadline for submitting an expression of interest is 27 November 2019.

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

January 2020 24 Planning for retirement – delivered by the BMA, York, 9am to 4pm

February 1-2 BMA junior members forum 2020, London, 9am to 7pm 7 Planning for retirement – delivered by the BMA, Edinburgh, 9am to 4pm

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

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