The Doctor – issues 19, March 2020

The magazine for BMA members

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Issue 19 | March 2020

In good faith Why the clothes you wear should not limit the doctor you become

CEAs – blessing or curse?

How the pensions crisis has turned recognition into rebuke

When partnerships go wrong The mediation service helping GPs back from the brink

Failing the test of fairness

Why do some doctors fare worse in royal college exams?

06/03/2020 14:37

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

Email thedoctor@bma.org.uk

Editor Neil Hallows (020) 7383 6321

Call a BMA adviser

Chief sub-editor Chris Patterson (020) 7383 6978

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

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

The Doctor is a supplement of BMJ vol: 368 no: 8237 ISSN 2631-6412

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In this issue 4-5

Briefing

Much needed improvements to the GP contract in England, and 20 years of campaigning on organ donation pays off

Welcome Chaand Nagpaul, BMA council chair Our NHS relies on the care and compassion, hard work and innovation of people from all different backgrounds, and from all walks of life.

It is a national institution built on principles of fairness and equality – a response to need wherever it arises and regardless of individual circumstances. Yet those principles of equality and fairness often do not extend to those working and training in the health service. And in this month’s issue of The Doctor we shine a light on differential attainment – an issue which I, and the BMA, have campaigned on for some time, but which desperately needs addressing.

It cannot be right that BAME (black, Asian and minority ethnic) doctors trained in the UK still have significantly lower specialty examination pass rates than their white counterparts. We know from research this is not related to a lack of ability – we know BAME students are a great success in other fields. The harsh reality is that these students find themselves in an unsupported learning and working environment. We must get to the bottom of these issues and take steps to address them urgently.

This month we also look at the pensions crisis and, in particular, the effect of clinical excellence awards. We speak to doctors whose supposed ‘awards’ have turned into tax liabilities, which could run, in some cases, into six figures. The irony of senior clinicians seeing the value of their CEAs wiped out by the punitive pension tax won’t be lost on anyone. These are the doctors whose innovative and expert practice drives so much improvement in the NHS. One consultant, Rick Body, won his award for his part in developing a decision aid for diagnosing heart attacks. It could save our service £100m a year yet he now understandably regrets his ‘successful’ application.

The BMA has for more than 18 months been demanding the Treasury fix this fiasco, one harmful to patients, staff, and public finances, another obvious irony. We will be ready to respond when the chancellor announces plans to solve this appalling problem in his budget statement.

Features looking at dress codes and a BMA mediation service for GP partners – a free benefit of BMA membership unknown to many – are also included in this edition.

8-13

One step forward...

Why do doctors from ethnic minorities fare less well in royal college exams?

14-17

CEAs – blessing or curse?

Doctors recognised for making outstanding contributions to patient care have been among the most penalised by the pensions crisis

18-21

Unfairness laid bare

Restrictive NHS dress codes have left Muslim women doctors feeling harassed

22-25

Pulling together

Disputes between GP partners can cause enormous stress and disruption.

The BMA’s mediation service provides impartial support

26-30

Life experience

Life in the snot factory – why it’s so hard to limit the spread of infections in a GP surgery. Plus, a doctor feels bullied on return to work and why DNR should never mean ‘do not respond’

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What’s on Keep on top of events

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briefing Current issues facing doctors

VAUTREY: ‘The Government must build on these foundations if it is to deliver on its promises’

A step in the right direction for GPs ‘People talk about “hands off our NHS”, [but] the thing they forget is primary care in the UK is delivered by 220,000 entrepreneurs called GPs.’ When you hear a statement such as this go unchallenged, on Radio 4’s Today programme, with its seven million listeners, it’s hard to know where to start.

Despite the private outsourcing company Serco having millions of pounds of business interests in the NHS, its chief executive Rupert Soames in his interview last month overstated the number of GPs in the UK by a factor of six.

There are, in fact, around 35,000 FTE (full-time equivalent) qualified GPs in the UK. And ‘entrepreneurs’? They may often be entrepreneurial, including the way in which they improve care, but there is a bit more to GPs than that. You might mention the 335 million consultations per year in England alone or the ability to manage risk, which prevents the rest of the NHS from collapsing.

Finally, what about drawing equivalence between a private company bidding for parts of the NHS, and people who, with their colleagues in primary and secondary care, are the NHS? This is what general practice has to put up with. Not just the intense pressure caused by surging workload, growing complexity, and a workforce which has fallen relative to the size of the population for the first time since the 1960s but also a basic ignorance of its role and capacity (clue: not infinite).

This ignorance is a malady that especially

Keep in touch with the BMA online at 04

affects politicians and will often flare up at times of intense pressure when the answer to virtually every question is that primary care can handle it.

It’s not 220,000 sharp-suited entrepreneurs taking on this work but an insufficient number of GPs and practice staff spread far too thinly.

There’s no shortage of actual facts about huge pressures and their effect on primary care.

Eight out of 10 GPs work more than their regular hours, according to a BMA survey last year, while the GMC found many are cutting their official hours, owing to increasingly onerous workloads.

The effects on their mental health of such pressure is obvious. ‘If you take time off, your colleagues have to pick up the slack and it just makes everyone else’s job even more difficult,’ one GP told the association’s survey on mental health and wellbeing in the medical profession.

The context is important when it comes to examining the new contract deal the BMA has negotiated with NHS England. BMA GPs committee chair Richard Vautrey said it was a ‘step in the right direction’. It’s also clear it’s a desperately needed one.

GPC England voted in favour of a contract last month, which was the culmination of many months of negotiations between the BMA, NHS England and NHS Improvement, and after the committee rejected an earlier version of the deal. Among the core agreements in the contract is a £94m fund dedicated to alleviating GP recruitment and retention pressures by providing financial incentives for GPs to become

instagram.com/thebma

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‘ENTREPRENEURS’?: There’s more to general practice than that

practice partners or to go to work in underdoctored areas.

The contract also includes a £173m investment designed to support PCNs (primary care networks) to bring in allied health professionals such as clinical pharmacists and physiotherapists to help support doctors with their workloads. Reimbursement for these staff has been resolved and will now be at 100 per cent (up to a set limit).

It seeks to introduce enhanced sharedparental leave arrangements for salaried GPs and increase the proportion of time GP trainees spend in general practice from 18 to 24 months of their three-year programme.

Dr Vautrey said: ‘After months of challenging and tough negotiations we’re pleased to have secured this package of changes that have the potential to make a real difference to GPs, the practices they work in and the patients they treat. These changes won’t fix the crisis gripping general practice overnight and we recognise there is much more work to do to address the real concerns GPs and local medical committees have expressed in recent weeks.

‘However, they are a significant step in the right direction. Alongside NHS England and NHS Improvement, the Government must now build on these foundations if it is to deliver on its promises to boost GP numbers, improve patient access and ultimately guarantee the future of general practice.’ bma.org.uk/gpcontract

Two decades of campaigning pay off There will be a life-saving change to the law in May, for which the BMA has spent the first 20 years of this century campaigning.

The Government has announced the new ‘opt-out’ organ donation system will be introduced in England in May. Wales already has such a system and one will be introduced in Scotland in autumn this year. The BMA continues to press for action in Northern Ireland.

The development in England is a hugely positive step for the BMA and its many members who took part in the campaign, and an even better one for the hundreds of people every year who would otherwise die waiting for a transplant.

The BMA pledged its support for an opt-out system for organ donation at the annual representative meeting in 1999.

It brought together 18 medical and patients’ organisations into a Transplant Partnership to campaign for improvements to the organ donation system. A BMA document in 2000 made a cogent case for a change in the law.

Campaigns are rarely won by evidence alone, however strong that evidence is. Tactics included sending Valentine’s cards to every MP, urging them to ‘have a heart’.

Over the years, momentum gathered. An organ donation taskforce was established to identify barriers to donation and improve the existing system. Unfortunately, in 2008, it opposed the introduction of an opt out but said it was a ‘finely balanced question’. The former chief medical officer, Professor Sir Liam Donaldson, expressed his support for an opt-out system.

Political support grew, with the BMA backing a private member’s bill and Scotland and Wales moving to introduce their own systems. And if there is one thing you can say about former prime minister Theresa May’s otherwise calamitous party conference speech in October 2017 (remember the cough, the prankster and the falling letters) it is that it contained plans for a new opt-out system in England.

BMA medical ethics committee chair John Chisholm said: ‘Last year more than 400 people died waiting for a transplant.

The BMA wholeheartedly believes the opt-out model is the best way to address the serious organ shortage in England and will save many lives.

‘With the change to the system now set to go ahead in the spring, it is essential that it is widely publicised and communicated to patients and the public, so people are fully aware of the changes and can choose to opt out of organ donation if they wish to do so.

‘It is also vital the NHS is given the proper resources and is fully staffed to ensure patients reap the full benefit of the new system and the potential increase in donations.’ bma.org.uk/organdonation

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What do you think of The Doctor ?

The magazine for BMA members

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We want to know more about what our members think of their membership magazine.

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Issue 19

|

March 2020

In good faith Why the clothes you wear should not limit the doctor you become

CEAs – blessing or curse?

How the pensions crisis has turned recognition into rebuke

When partnerships go wrong The mediation service helping GPs back from the brink

Failing the test of fairness

Why do some doctors fare worse in royal college exams?

06/03/2020 14:37

The Doctor readership survey 2020 gives you the opportunity to share your views and opinions on The Doctor magazine. It should take around 5 minutes to complete.

Please complete and return the survey which is enclosed in this month’s issue.

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06/03/2020 14:40

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

Taking exception

The doctors leading the way in reporting unsafe working conditions

LOLs and trolls

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

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11/03/2019 10:46

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When fresh air or company is the best treatment available

Glaring oversight Eye surgeons angry at a rationing ruse

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August 2019

Going viral

20190418 thedoctor p1 v2.indd 1

The magazine for BMA members

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

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The magazine for BMA members

05/08/2019 10:08

thedoctor

The pressures threatening to overwhelm the NHS this winter

How a fragmented health service is failing patients with asthma

Fake news costs lives – the rise of anti-vaxxers

08/07/2019 09:47

Issue 15 | November 2019 Issue 15 | November 2019

A neglected killer

08/04/2019 10:39

An interview with the Apollo 11 doctor

The magazine for BMAfor members The magazine BMA members

Singing on prescription

Issue 12

My patients went to the Moon

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April 2019

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July 2019

The magazine for BMA members

The magazine for BMA members

Issue 11

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09/12/2019 12:11

How does it feel?

A job’s worth

Asking what managers with funny sounding titles actually do

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Have confidence Fresh hopes for SAS doctors to win the recognition and opportunities they deserve

14/01/2019 10:39

Issue 9

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May 2019

Off and on again

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

Seven sisters

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

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

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13/05/2019 10:50

Issue 13

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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

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11/02/2019 11:11

Issue 10

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June 2019

Would you pay to work?

Doctors driven out of the NHS by punitive pension tax rules BIL

L

s 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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RK

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Double standards

NHS England subjects GPs to lengthy checks – but is secretive about its own performance

Streets ahead

Good care for the homeless – why is it so rare?

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10/06/2019 10:09

Issue 14

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October 2019

Belittling

Be listening

Speaking up How David Nicholl braved a politician’s insults to warn about a no-deal Brexit

A plan or a wish list?

Can the Government keep its pledge to improve mental healthcare?

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February 2019

A junior doctor’s working life told through seven emotions

Homelessness – the victims, the politics that fuel it, and those working to tackle the human cost.

The Doctor investigates a needless epidemic

07/12/2018 09:27

Issue 8

Doctors confront the European refugee crisis which politicians have ignored

The cutting edge

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A spectre calls

Your NHS ghost stories

Facing up

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

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The winning entries in this year’s BMA writing competition

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Can the NHS Long Term Plan really make a difference?

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March 2019

If you could change one thing ...

Issue 6

Promises, promises

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05/11/2018 11:45

Issue 7 |

The overseas doctor who overcame early setbacks to become a leading consultant

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Told to go home

January 2019

09/09/2019 11:25

Issue 17

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January 2020

Our loss Doctors driven out of the UK by callous visa rules which separate families

‘Be resilient’ Are these the most patronising words you hear?

Big data Its uses and abuses

Hollow promises The strain felt by mental health staff and the broken pledges for new recruits

What kind of culture do you work in?

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The magazine for BMA members

‘Why am I here?’

The surgeon who gave up a ‘useful job’ to become an MP, on finding a role in Westminster

|

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The GP practice left on the brink of collapse by an NHS England investigation

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A cause for complaint

Revealed: The consultancy companies chewing up NHS resources

Issue 5

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A doctor’s baby was removed at birth – we go to court to uncover concerns about her care

Taking the biscuit

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Born of injustice

Issue 4 | December 2018

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Why is the Home Office trying to deport doctors in the midst of a recruitment crisis?

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Right to remain

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Issue 3 | November 2018

07/10/2019 11:14

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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One step forward...

Black, Asian and minority ethnic doctors achieve lower pass rates in royal college exams – a ‘stark’ difference in attainment, with environmental causes, which must be urgently addressed, say doctors.

Peter Blackburn reports

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having to fight for an extension is the option suggested by the powers that be.

‘A

NAGPAUL: ‘BAME students are more likely to feel bullied’

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s a doctor from an Asian background nothing is ever adapted for you – you always have to make 200 per cent effort just to survive and you are never given any leeway.’

Dr S Agrawal has chosen to raise her voice about an issue few people – understandably – feel able to discuss. Most trainees do not think they can ‘stick their heads above the parapet’, but the GP trainee is not staying silent.

Training for specialty exams has been a draining experience, Dr Agrawal says.

She has found herself being castigated for mistakes and made to feel incompetent while white, male colleagues, ‘from the right side of the line’, are given extra practice and encouragement.

She spent six months in a GP surgery where she worked to the early hours of the morning just trying to keep up – with no time for revision or attention given to mentoring or training. And she has seen colleagues from Asian backgrounds trying to fit in and fearing that being themselves would bring judgement or discrimination.

Despite months of difficulties, her perception that she has had a lack of proper training or supervision, and a constant feeling of stress and worry – Dr Agrawal says she has received little to no support and is not being given any extra time or leeway for her exams.

Instead, if she is unable to pass, the stigma of

Crushed hopes Dr Agrawal feels these experiences would be very different for a doctor from a different background. It is all weighing heavily. Dr Agrawal, whose family comes from northern India and who went to a UK medical school, says: ‘I feel I am somebody brave enough to voice my concerns with a loud voice – what about those people who don’t have the courage to stand up and say those things?

They are crushed and buried without a teardrop being shed and easily forgotten.

‘I am tired and feel very stressed about whether I can achieve it. They need to take the pressure off my head and give me a safety net to allow me to complete my training fairly.’

Dr Agrawal is far from alone in feeling discriminated against and lacking proper support during training. And the statistics suggest there is an issue, too.

Latest figures, for 2018, show that 90.2 per cent of white graduates of UK medical schools passed the Royal College of GPs membership examinations, compared with 75.5 per cent of UK medical school graduates from BAME (black, Asian and minority ethnic) backgrounds.

The figures are even lower for students whose primary medical qualifications were obtained outside the UK – as low as 41.2 per cent for BAME international medical graduate trainees.

The MRCP(UK) equality and diversity report for 2018 found that for the Part 1 examinations, the pass rate was 64.5 per cent for white UK graduates, 50.8 per cent for BAME UK graduates, and 36.9 per cent for BAME

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A BMA report published in 2017 suggests a number of areas of concern which can put BAME students and trainees at a disadvantage.

It says relationships with seniors can be more international medical graduates. There are problematic for trainees who feel they don’t similar disparities in the Part 2 examinations fit in and can struggle to access support and PACES (Practical Assessment of Clinical Examination Skills) component. when under pressure.

And figures from the Intercollegiate In addition, trainers may feel unease in Committee for Basic Surgical Examinations, giving feedback to students who are from which covers the surgical different backgrounds, medical royal colleges, show and there are perceptions 59.1 per cent of white UK of bias in workplace‘There is something medical graduates passed about the environment based assessments and MRCS, compared with recruitment. which is failing to bring 47.5 per cent of UK medical Dr Nagpaul says: out the best in them’ ‘Throughout medical school graduates from BAME backgrounds. training and thereafter, BAME Dr Agrawal can understand students are less likely to why the figures are this way. She says: ‘After feel included and therefore more isolated. a while you get really disheartened and it Learning itself depends on having interaction becomes a cycle, you stop putting in the extra with your peers and your tutors and educators effort and ultimately you end up fulfilling the and being isolated means you are denied that prophecy. Even the most resilient people are softer, more interactive, way of learning. That affected. People do make it through but it will impact on your educational development. needs to be a whole culture change from the ‘We also know BAME students and doctors very core to support more people to succeed.’ are more likely to feel bullied and harassed.

BMA council chair Chaand Nagpaul says They feel more worried about raising concerns the statistics are ‘stark’ – particularly when and that they are more likely to be blamed for comparing the differential attainment medical errors. between doctors from BAME backgrounds ‘They are also fearful of – and are at educated and trained in the UK and their disproportionate risk of – being referred for white counterparts. disciplinary action and complaints.

‘That does not make sense,’ he says.

‘Clearly these factors can affect wellbeing.

‘These are students who were educated in BAME doctors are suffering from a lack of this country, understand the system and are wellbeing and that impacts on performance. hard-working, diligent and capable. We know It is not down to any inherent lack of capability.’ from research that this is not related to a lack Care suffers of ability.

The 2017 report suggests a number of ‘There is clearly something about the potential solutions, all of which seem to be as environment they are experiencing which is relevant today. It suggests diversity is better failing to bring out the best in them. That is a recognised, cultural competence is improved, detriment to patients and to the NHS. It is a data throughout the student journey is better moral problem – and it has a service impact.’ monitored and early intervention and support Isolated students put in place.

So, alongside Dr Agrawal’s experiences, what The UK medical workforce is remarkably are the major issues driving this inherent diverse. The GMC’s 2019 report, The state of unfairness? medical education and practice in the UK,

‘Education and training should be fair for all’

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PATEL: Early support needed for struggling trainees

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says: ‘For the first time, more non-UK medical graduates took up a licence to practise than UK medical graduates. And, UK medical graduates were more ethnically diverse than ever before.’

But it seems unclear whether the culture of medicine fully takes into account such diversity.

BMA representative body deputy chair Latifa Patel wants action to be taken immediately.

Dr Patel says the system needs to be overhauled because it is not only affecting doctors but also having an effect on the NHS, with doctors who do not get through training often ending up in staff grades without any continuing care or supervision rather than supported through their careers.

Among a host of possible solutions to this problem, Dr Patel suggests the removal of arbitrary time limits for passing exams, a questioning of the evidence base for the number of attempts allowed and the period of time offered, a greater degree of national oversight, and more effective tailored and early support for trainees who may be struggling.

Ultimately, what Dr Patel is suggesting is simply investment in people. And if the NHS can’t get that right, what can it be expected to get right?

She says: ‘Why are we throwing trainees out

of programmes? We have a lack of consultants and a lack of doctors. What is the benefit of throwing a trainee out of a programme to have them work as a staff grade in that specialty being self-led? What is better about that?’

Dr Patel adds: ‘Maybe some people are just going to take longer to go through specialty training – that’s fine. Why not support them along the way? Some people are less likely to pass first time and they are more at risk of failing – they may also max out of time.

‘These people are more at risk. If we know they are less likely to pass an exam how can you throw them out – we should be supporting them earlier. Why not give them longer but say you will always be supervised by a national training programme – you will never be on your own.’

The BMA remains committed to tackling this issue and launched Equality Matters last year – a project which aims to promote fair treatment for all doctors working in the NHS. The association recently sent a letter asking the RCGP what it had done to address differential attainment in its exam and progress in implementing measures to make things fairer.

BAPIO (the British Association of Physicians of Indian Origin) president Ramesh Mehta says: ‘I do have a little bit of optimism for two reasons – since we challenged the RCGP, all the colleges and the whole establishment, people have realised this is a big problem and everybody is trying to see how things can improve. The second is that the Department of Health and NHS England have realised and NHS England has appointed a director for people [Prerana Issar] understanding this is a huge issue.’

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The Intercollegiate Committee for Basic Surgical Examinations says the organisation has taken a number of actions The Doctor contacted three educational to understand and address differential bodies for comment after analysing the pass attainment in exams, including ‘the rates from their specialty exams. identification of fair access measures in all assessment content and the production Safe practice of a mandatory examinations-specific RCGP council chair Martin Marshall says: equality and diversity training module ‘[My] organisation has for all examiners’. already taken a number of The GMC says it believes steps to address differential assessment pass rates are ‘Differential attainment a ‘useful tool’ to measure attainment – including touches on social and differences but are not the developing resources and educational events to ‘primary cause of difference’ cultural factors’ support trainers and trainees, and that more research introducing an “exceptional” into the issue is required fifth exam attempt, recruiting to understand the ‘true examiners from an international medical causative factors’. graduate or BAME background and investing A spokesperson says: ‘Education and in research around the topic.’ training should be fair for all but we know He adds: ‘The purpose of the MRCGP a complex range of factors can cause assessment is patient safety and to ensure GPs disadvantage. We’re working with others meet the highest standards to deliver this. We to understand the intricacies are confident it is a robust assessment of a GP at the heart of this issue trainee’s clinical knowledge and communication and share learning that skills – both of which are essential to practise could help bridge the gap independently and safely as a GP in the UK. faced by doctors from ‘The college has always been transparent different backgrounds. about differential pass rates between We ask educators to keep candidates taking the MRCGP and is differentials front of mind committed to identifying and addressing the and make efforts to minimise underlying issues for them.’ or eliminate challenges A spokesperson for the Federation of wherever possible.’ the Royal Colleges of Physicians of the UK Whatever the causes says: ‘Differential attainment is an extremely for differential attainment, complex issue and touches on social, cultural, while trainees are left feeling educational and other factors. dispirited or even defeated ‘We have been at the forefront of research they are being failed. And into differential attainment in examinations for every brave trainee like Dr Agrawal, who since the issue was first identified. We stands up to speak out about this problem, measure it as part of our exam quality many others may be suffering in silence. assurance processes and report it as part of As Dr Agrawal says: ‘It just needs to be our governance arrangements. We undertake so much fairer and the same opportunities our own, and contribute to, research on and judgements need to be given. It is about differential attainment.’ the enthusiasm for reaching people of all He says the federation is ‘fully engaged backgrounds being equal.’ with stakeholders’. bma.org.uk/equalitymatters

‘Why are we throwing trainees out of programmes?

We have a lack of consultants and a lack of doctors’

MARSHALL: ‘Committed to identifying underlying issues’

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E IV L CE SA RE OS LL L BI CO X TA £

CONGRATULATIONS! YOU’VE WON A CEA

O R IMPPAT

E V SA E NHS NS TH ILLIO M

CEAs – blessing or curse?

Doctors recognised for making outstanding contributions to patient care are among the most penalised in the pensions crisis. Jennifer Trueland hears why some clinical excellence awards may no longer be worth having

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E V O T R N P M ATIE RE P CA

Y

BODY: ‘There is a limit to the cost that anyone is prepared to incur’

‘No one is going to want to apply for a national CEA’

ou work really hard, go over and above your job plan, and even find solutions to the problems besetting the NHS. This is recognised at the highest level – you win a national CEA (clinical excellence award), which represents not only a pay rise but also a sense someone appreciates the sacrifices you have made. And then you get hit by a whopping pensions tax bill.

Today, senior doctors across the UK are coming to terms with the fact that their supposed ‘rewards’ have translated into tax liabilities, which in some cases could reach six figures.

If – as most doctors will have to do, given few have a spare £90,000 or so kicking around – you elect to ‘borrow’ from your pension pot via Scheme Pays, you will then have the added injury of paying interest on the loan. If you’ve been ‘lucky’ enough to win an award early in your career, you could be talking about paying interest of 4 or 5 per cent for a 25-year term – essentially a mortgage with no house to show for it.

What is even worse is that if you don’t actually hold on to the award until close to retirement – and you have to reapply every five years – you might not even get the pension benefit that should accrue from the higher salary; and

no, you don’t get a tax rebate if that happens.

No wonder, then, that doctors who have already been stung are warning others to think carefully before applying for the awards. No wonder BMA pensions committee chair Vishal Sharma expects applications for the once sought-after awards to ‘fall off a cliff’ as fears spread.

Success penalised Rick Body is one consultant who regrets his ‘successful’ application. As The Doctor reported last year, he won a CEA, in part for developing a decision-aid for diagnosing heart attacks that could save the NHS £100m a year. His pension tax bill (still unresolved at the time of writing) is likely to cost much more than the £36,000 salary boost carried by the bronze award and, with interest, will probably cost him around a quarter of a million to pay off through Scheme Pays.

‘No one is going to want to apply for a national CEA, and even with the provision that’s apparently been made this year [the UK governments have announced plans to mitigate the issue] people are still reluctant to take on extra work, which has wider implications for the NHS,’ says Professor Body, who is a consultant in emergency medicine at Central Manchester University Hospitals NHS Trust, and professor of emergency medicine at the University of Manchester.

‘You want people to take ownership of the problems that

we have in the health service, and to be actively trying to solve them, not just going in and doing a shift and come home and not really think about solving the problems and how to improve services for patients. So we’ve got to be very careful of that.’

The work which led to his national CEA was certainly not covered in what you might call a normal working day, he concedes. ‘Most of that is totally outside of work – programming, spreadsheets, emails – producing a bespoke pathway for every trust in Greater Manchester. That’s not part of my job plan. That’s really why you get a CEA – it’s for going above and beyond the day job.

‘I don’t mind doing that – and I won’t stop, to be honest – but there is a limit to the cost that anyone is prepared to incur. My wife’s asking if we should cancel the holiday.

We’ve got an unfinished house extension because we don’t know what we can afford. I know we’re lucky – most of the population are much less well off than us. But when this is the result of working so hard, you do think: why do it, at this cost to your family? I’d have been much better off if I hadn’t done that.’

This situation, and that of Plymouth consultant Kate Lovett (see page 17) makes Dr Sharma shake his head in despair.

‘Professor Body has got a big award for doing something really valuable for the NHS. And basically because of that he’s had a big pensions rise. But the worst thing about it is that he’ll get that big pension rise this year, and he’ll have to pay the tax on it, but these awards are thedoctor | March 2020 15

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SHARMA: The number of people applying for excellence awards has ‘dropped off a cliff’

temporary. You have to reapply for them every five years. And if he doesn’t hold the award until retirement, a lot of the pension growth that he’s paid tax on doesn’t actually give him a pension; it just disappears.

‘This is a good example of why this form of tax simply doesn’t work for the NHS pension scheme, and that’s what the BMA has been campaigning to try and fix for the last few years.’

Budget hopes

‘When this is the result of working so hard, you do think why do it?’

Other people who have temporary pay increases are also hard hit, he says.

‘If someone takes on a management role, or a leadership role, they can get a temporary rise in pensionable pay, so again they get a big tax bill. For those positions, it’s very common that you take them for two or three years. So you get your pay rise initially, you get your big tax bill on that, and then you give that all up.

‘You pay the tax, but you don’t get the tax back that you paid when you got the pay rise.

It’s very unusual to keep those roles until you retire because management roles in particular are very onerous, and as you get older, they are more and more difficult to do. But unless you keep that role until within three years of when you retire, all that pension growth that you paid tax on disappears; it just drops down again.’

The UK Government – whose responsibility this is – has indicated that it will introduce measures to address some of the pension tax problems in the next budget (expected, at the time of writing, to be in March). But that will provide little comfort to those who have already been hit.

‘What’s likely is that any reform that is announced will apply from April – from the next tax year,’ says Dr Sharma.

‘We’re not expecting there to be any compensation for people who have already paid tax, unfortunately. That’s not been offered in any way, shape or form.’

Put off excelling Dr Sharma believes the threat of punitive tax bills puts people off applying for national CEAs and roles with additional responsibility. Naturally, this could have an effect on doctors’ willingness to put in the extraordinary effort these awards are set up to recognise.

‘We’ve got good data from around the country that the local excellence awards used to be very competitive: people would apply for these awards, they were doing huge amounts of great things for the NHS, such as redesigning services, great teaching, research and so on. But the number of people applying has just dropped off a cliff.

‘In some places they’ve got more awards to give out than people that have applied, whereas in the past there were three or four applicants for every point. I don’t know the figures for the national awards – the report on last year’s round hasn’t been published yet – but again there

used to be roughly a thousand applications each year for them [for 300 awards], but these numbers certainly will drop off,’ he says.

Although new local points awarded in England have been non-pensionable since April 2018, pre-existing ones are still pensionable. Scottish discretionary points and Welsh commitment awards remain pensionable.

If people lose the awards (or the increased pay for increased commitment) then it is possible in some cases to apply for pension pay protection, but this is complex, only applies to those in the 1995 scheme, and there are limits.

In any case, the pay protection safeguard would probably not be of use to a younger doctor who would expect basic salary to increase incrementally as they become more senior.

‘If they lost their awards, they may still see their pay rises above the level of protection in time,’ explains Dr Sharma.

The ACCEA (Advisory Council on Clinical Excellence Awards) has not yet published figures of numbers of people who applied for them last year.

Last month it published its 2019 annual report, covering the 2018 round.

This showed that applications continued to fall slightly (this has been the trajectory since 2011), but this was before concerns about pension tax became widely known.

This year’s application round was supposed to open on 13 February but ACCEA announced at the eleventh hour that this was being put back a month. bma.org.uk/pensions

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Doctors will be taxed out of a job One of the UK’s leading psychiatrists warns doctors are being pushed out of the workforce owing to punitive pension taxes.

Kate Lovett (pictured), dean at the Royal College of Psychiatrists, and a consultant community psychiatrist in Plymouth, told The Doctor she does not want to cut her commitment to the NHS but fears she will have no choice.

As with Dr Body (see page 15), Dr Lovett faced a huge tax bill for 2018/19, largely because she received a bronze national CEA, partly in recognition of her work in promoting psychiatry as a career choice.

Ironically, her own tax situation means that if she does not retire aged 55, the risks of further financial loss could be high. This is because she would lose the pension benefits of the award if she did not still hold it close to retirement, but also because she would be paying interest on Scheme Pays over a longer period, costing more money.

‘You want to make sure that if you’ve got one of these [CEAs] that you’re retiring on it because otherwise you don’t get the benefits of it,’ she says. ‘In my situation, because I have mental health officer status, I’ll be able to draw my pension in two and a half years; I’m in a relatively fortunate position because I’ll likely still have the award, but also my Scheme Pays interest is over the short term. But people in their 40s who are getting awards and having to take out Scheme Pays for a 20year period will have to pay back an awful lot of interest.’

This situation has ‘absolutely’ led her to consider taking pension at age 55, unless the situation changes, she confirms. ‘I don’t know what I would do after that – I might well continue to work in some capacity in the health service. However, I wouldn’t be able to work fulltime if I’ve drawn my pension. My clinical commitment would have to be greatly reduced. But I simply can’t afford to go on year on year having big tax bills that I can’t afford to pay.’

When The Doctor wrote about Dr Lovett’s situation

last year, her accountant and financial adviser had confirmed she faces a tax bill in excess of £150,000 for 2018/19. After highlighting her situation on Twitter, however, she was contacted by a specialist financial adviser who offered to look at the figures again.

‘He did a lot of real attention-to-detail forensic accounting on it, and found that my trust hadn’t paid out CEAs for a couple of years, so when I applied for them they were backdated over two years. So that money that was paid in one big chunk made it look as though I was paid an awful lot in one year, and that made me liable for a lot of pensions tax, [and] should actually have been paid in other tax years.’

This potentially means a huge reduction in her total bill – trimming a massive £83,000 off the sum owed, although she will, of course, now have an additional tax liability for the other years when the money ought to have been paid.

Although she is still faced with a bill running into tens of thousands of pounds, it is not as bad as she had originally been told. ‘It’s not altogether brilliant, but it’s less than it was,’ she says. ‘It’s made my overall tax bill less, but it’s also made it more complicated as there’s a question over whether I can retrospectively apply for Scheme Pays because you normally have to elect to pay it within the year. We’re quite hopeful that it will be OK because it wasn’t my fault, but there’s a risk that it won’t be which, in the short term, puts me in a worrying position.

‘So there’s some good news, but had I not been vocal about it on Twitter and had somebody offering to give me a second opinion, I wouldn’t have discovered that my bill was several tens of thousands of pounds lower and I would have just paid.

‘My advice to others is to get a second opinion; I had a financial adviser, I had an accountant, but they had taken it at face value. It took someone else going through it forensically to see that it wasn’t right.’ thedoctor | March 2020 17

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Unfairness laid bare The NHS has committed to changing dress codes which have left Muslim women doctors feeling harassed. Jennifer Trueland reports

W ‘People told me they wanted to change career paths because of it’

hen Emma Wiley asked Muslim women to share their experiences of bullying and harassment in the NHS, she did not expect their top concerns would turn out to be dress codes.

Yet the stories women shared about their discomfort, about being rudely challenged, about changing their careers, being subjected to racist ‘jokes’ – and even, in one case, having a heart attack – made her realise how serious the issue was.

‘I thought they would talk about things like appraisals and line management,’ says Dr Wiley, a consultant microbiologist in south London. ‘But they actually started talking about dress codes and it was a surprise to me that this was the main theme that came out.

‘People were saying they wanted to leave the hospitals where they were working

because of difficult experiences with dress codes, such as feeling they were constantly under scrutiny. People told me they wanted to change career paths because of it – moving towards general practice [rather than hospital medicine], and they told me how they felt – that they were uncomfortable coming to work because they felt that somebody was always watching them to see if they were compliant and so on.’

This reaction had a particular resonance for Dr Wiley – both as a microbiologist with a strong interest in infection control, and as a Muslim woman (who wears a hijab) who wants more discussion of, and sensitivity to issues related to faith in the health service. So she decided to do something about it, campaigning for more inclusive dress-code policies.

Uniform policy SIMPLE ALTERNATIVE: Dr Wiley calls for sterile disposable sleeves to be available

Four years after that initial inquiry – and with help from the BMA – NHS England has committed to producing updated dress-code guidelines. Dr Wiley hopes it will help raise awareness about the issues and potential consequences of ill-thought-out or ‘blanket’ dress codes, and the need to apply them sensitively.

A spokesperson for NHS England confirmed to The Doctor that updated information had been developed after a range of stakeholders (including the BMA) requested a revision of the 2010 Department of Health Uniforms and Workwear Guidance, especially relating to ‘bare below the elbows’ and ‘hand hygiene’ policies.

‘NHS England and Improvement have worked with a range of stakeholders and medical providers to revise the voluntary

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EMMA BROWN

EMMA WILEY: The requirements of faith and hygiene can both be met with more sensitive NHS clothing guidance

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EMMA BROWN

WILEY: Trainees were left feeling isolated

bare below the elbows for faith reasons [as a guidelines around uniforms and dress policy Muslim]. Her line manager, who was the senior for NHS Employers including medical staff,’ chaplain, was really unhelpful – things really a spokesperson says. ‘This is expected to be escalated and she felt physically threatened finalised before the end of the financial year.’ by him. She was an older lady and she went The new dress policy will be aimed at all home that evening and had a heart attack.’

NHS employers and employees working with patients in the NHS, and aims to be inclusive In addition, Dr Wiley reports that students ‘I hope it’s the and meet the needs of a diverse workforce. told her they had missed out on placements, particularly in surgical theatres, because there For Dr Wiley, it’s a welcome step forward beginning of was no accommodation of in a campaign which has Muslim women their faith. occupied much of her time being able to ‘They were being told that for several years. After the speak out’ ‘They felt somebody nobody had ever asked for initial feedback about dress was always watching this before, and everybody codes, she and colleagues them to see if they else was OK with it. So they conducted some formal were left feeling isolated, and research (with the help of were compliant’ that’s really difficult when the British Islamic Medical you’re young.’

Association) which was The bare below the elbows policy, although published in BMJ Open in 2017. This found that there was a lack of consistency on dress well-known, is not based on evidence and is codes and how they were applied, particularly often applied inflexibly. regarding the wearing of the hijab and ‘bare ‘Once the policy had been written and below the elbows’. the ink had dried, it was almost as if there It notes that although NHS Employers was no coming back,’ she says. ‘The critical advocates careful consideration of religious thing should be having engagement with belief and avoiding discrimination for those policy makers at an early stage so that key who wear hijabs, in practice, many staff stakeholder groups are consulted. Because ‘For doctors members reported bad experiences. Some once it’s in the system, it’s very hard to tackle, women reported being challenged by staff, certainly at an individual level.’ with faith-based She would like to see a range of options clothing practices, while others felt they had no choice but to available both to organisations and individual it shouldn’t be the avoid working in surgical specialties. healthcare workers. This might include luck of the draw’ Placements missed specific products such as disposable sterile Dr Wiley has heard many stories from staff, sleeves to wear on arms, or disposable hijabs, including doctors, who have felt discriminated which some employers have introduced. But against. ‘The worst case was a lady who was a it should also include recognition that while chaplain – she didn’t have much direct patient there is strong evidence that good hand contact in that she wasn’t doing procedures washing prevents infection, this is not the or anything like that. She didn’t want to be case for bare below the elbows.

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NAGPAUL: Updated guidelines are desperately needed

Feedback on disposable hijabs, for example, from those who work in theatres, is that many actually want the breathability and feel of a cloth fabric. ‘[The hijab] is fine in terms of infection control as long as it’s washed at 60 degrees,’ she stresses. ‘But we need to have a range of options. It’s important that we allow trusts options, and women options too.’

Long campaign She is delighted that the guidance will soon be published. ‘It’s been a long campaign and has taken many woman hours,’ she laughs.

‘For me, I hope that it’s the beginning of something. I hope that it’s the beginning of Muslim women being at the table and being able to speak out, and have their voices heard as equal to everybody else.

‘I want to thank the BMA for putting its weight behind this – the team has been fantastic over what’s been a very long journey.’

BMA council chair Chaand Nagpaul says the updated guidelines are desperately needed to ensure consistent and inclusive policies.

‘For doctors with faith-based clothing practices, it shouldn’t be the luck of the draw whether their employer has a supportive policy. Doctors of all faiths must feel welcomed at work,’ says Dr Nagpaul.

‘We have lobbied for the publication of this guidance for over two years, but our work won’t stop here – we need to ensure that every trust has a dress-code policy that adheres with the guidance.’

‘Blunt and tactless’ Doctors share their experiences with Dr Wiley of how they have been made to feel uncomfortable in the clothes they wear to work As a junior doctor working in a hospital placement, Zeinab Ahmed was surprised and upset to be challenged for having covered arms – when she was nowhere near a patient. Infection control and patient safety is a priority for her, but so is her faith as a practising Muslim.

‘One day at work a health professional asked me to “roll up my sleeves” and remain bare below elbows although I was not in direct contact with a patient and was in a hallway on the ward. Despite explaining this, I was told bluntly and tactlessly that keeping my arms covered was not a religious commitment and I must adhere to being bare below elbows at all times even if not involved in direct patient care.’

Dr Ahmed, who is now training to be a GP, spoke to her clinical supervisor, explaining that she wanted to adhere to infection control guidelines, but also to express her faith.

‘I am fortunate that he was understanding and supported me in a fair way with safe patient care in mind, where I was allowed to cover my arms when I am not involved in direct patient care,’ she adds.

Another doctor, who wants to remain anonymous, describes how she was made to feel in the wrong for raising concerns.

‘I used to quite regularly wear shalwar kameez to work, but around the time of the London bombing, I came into work to have a colleague say to me “you could be hiding a bomb under that thing”. I do try not to be oversensitive to clumsy comments but I mentioned this to my consultant. He was quite annoyed [with me] and told me that “this department isn’t racist”, even though I hadn’t even made that accusation. I have never worn Indian clothes to work again.’ thedoctor | March 2020 21

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Pulling together Conflict between GP partners can cause enormous stress and disruption and threaten the survival of a practice. The BMA offers free and impartial support through its mediation service.

Tim Tonkin reports

G

HERMISTON: Being a doctor and running a business can pile on the pressure

P partnerships have often been compared with marriage.

They each require qualities such as trust, honesty and good communication if they are to be successful and can go through difficult periods, with partners disagreeing or even falling out with each other.

While some clashes are a natural part of any business relationship, there are some disputes which, if left unresolved, can become intractable and ultimately undermine the effectiveness and stability of a practice.

In a worst-case scenario, workplace conflict can lead to the breakdown of a partnership and even jeopardise the continuation of the practice itself.

Mediation offers an alternative and constructive

method of resolving conflict, focusing on the needs and priorities of the parties.

‘Conflict, in its full throes, can be so detrimental it really can threaten a practice’s survival, often for no good reason,’ says BMA mediator Niall Hermiston.

‘Practices that really don’t need to fall apart have been on the verge of it because unresolved conflict has such an impact on partners’ and staff wellbeing and work.’

As an ACAS-qualified mediator Mr Hermiston has been part of the BMA’s GP partner interpersonal mediation service since it was relaunched two years ago.

The service, which is free to access, seeks to provide impartial and confidential support to partners experiencing interpersonal conflict in the workplace by

bringing them together to discuss challenges and agree a way forward.

The potential for conflict in general practice is high.

Practices are under huge service and resource pressures which are well documented. Conflict can arise in any number of forms and for many, sometimes complex, reasons.

‘GP practices can be difficult workplaces. A lot of the pressures result when people leave practices and the fact that, as well as being a doctor, partners also have to run a business,’ says Mr Hermiston.

‘Conflict can arise because of disagreements about the business model and what the practice should be aspiring to be or what work it takes on.

It is often challenging when senior partners, who have been there a long time, take

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on newer GPs, bringing with them new ideas and ways of approaching things.’

Undermined This is certainly a scenario GP partner Simon Bywater* can relate to.

After joining a practice as its newest partner, he says he went on to endure several years of bullying and undermining behaviour from a senior partner, which gradually took a toll on his mental and physical wellbeing.

‘What I had been naïve to was how threatened existing partners can be when new partners come in,’ he says.

‘He used to watch what I did clinically and would mention the GMC from time to time. He would even go out and visit patients after I had seen them without telling me,

particularly when he thought something had gone wrong or that a patient might want to complain.’

Dr Bywater says that, when he first joined the practice, he had felt unsure of himself in his new position, which was not helped by the fact his fellow partners never sought to encourage or offer feedback on his abilities.

The situation eventually escalated to the point where he ended up having to take time off work.

‘Nobody ever told me why I’d been appointed, so I wasn’t given any positive feedback,’ he says.

‘It didn’t fill me with confidence by not telling me why they had appointed me and then allowing a senior partner to undermine my confidence clinically and block just about every new

idea that I tried to bring in.

‘The main thing was the fear,’ he adds.

‘There was always a threat that [the senior partner] was going to do something to make me lose my partnership, either by referring me to the GMC or undermining me in the eyes of my partners.’

Goal of reconciliation Doctors looking to access mediation can approach the team directly, although many are referred from BMA FPC (first point of contact) staff.

Mediators act with the utmost impartiality and aim to treat all those involved in the process equally whether they were the ones to initiate mediation or not.

An initial assessment is carried out to judge if

‘Conflict can threaten a practice’s survival, often for no good reason’

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Image posed for by models

DEFUSING CONFLICT: The BMA GP partner mediation service tries to get doctors to see each other’s perspectives

VAUTREY: ‘General practice can place strain on the closest relationships’

mediation is appropriate and a mediator takes charge at that stage. A team of mediators work across the four nations and travel to support GP partners going through the process.

After speaking one-to-one with each partner, mediators will then bring everyone together for a joint session of dialogue, truth and, hopefully, reconciliation.

Ultimately, the aim is to encourage partners to devise the solutions and agree the next steps to resolving their workplace impasse, with mediators serving as honest brokers to this process.

‘Mediation is really about bringing together the people who are in conflict and trying to get them to understand each other’s perspective,’ says Mr Hermiston.

‘It differs from conciliation and arbitration [processes] in that it doesn’t judge, give or impose solutions, it’s about getting them [the partners] to come up with the solutions themselves. By doing that they’re much more likely

to own the outcomes and that’s the bit that makes it so successful.’

Confronting and attempting to deal with conflict, particularly if it is a long-standing issue, might be a daunting prospect.

However, the potential benefits of using the BMA’s mediation team cannot be overstated.

First and foremost are the financial benefits of avoiding the potentially onerous costs associated with private mediation firms or from the even more expensive and lengthy route of using the courts.

It has been successful in improving working relationships, creating a renewed opportunity for the successful practice to grow, improving partners’ welfare and job satisfaction.

One doctor recently commented: ‘I just wanted to thank you for everything you did to support us. You were fantastic. It was a really difficult process for me, but you made it bearable and

productive. I feel a change in the surgery. It is not going to be easy, but I think we are able now to move in the right direction for us all.’

Another partner, at a different practice also said: ‘[The mediator] was professional, sensitive and fair, which is fundamental in such conversations.

She helped us establish communication bridges between partners by looking at the shared aims rather than at the personal emotions, that were left outside the room.’

While there are no guarantees mediation will lead to a resolution, the process has undoubtedly helped many partners to overcome their differences and help to keep a practice together and get it back on the right track.

Workplace disputes Dr Bywater only became aware of the option of mediation through the BMA while taking part in a leadership programme,

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and after speaking to a BMA adviser began the process of taking action to bring an end to how he was being treated.

Although the process was not an easy one, it ultimately led to a change in the behaviour of his colleagues and his role at the practice is now ‘in a very good place’.

‘It is essential doctors are given support to address difficulties they might be experiencing’ ‘When I first approached the BMA and revealed what was going on, they seemed to have a complete understanding of what I was experiencing,’ he says. ‘[The BMA] was brilliant as was the person I was referred to.’

Dr Bywater says while he thinks BMA members are aware the association provides support in workplace disputes, many might assume this only applies to situations where doctors are in conflict with their employers.

‘Mediation is about bringing together the people who are in conflict’ He strongly recommends efforts to raise awareness of the mediation support available to GP partners.

‘What BMA members want from their trade union is support in their time of need,’ he says.

‘I wanted a good resolution and the BMA seemed to be the best way to do that because it’s a professional body and trade union that represents all doctors and is therefore less adversarial

[a mediator] than an independent firm or lawyer.’

Best outcome BMA GPs committee chair Richard Vautrey says the partnership model is the foundation of his branch of practice, and ensuring GPs have the support they need during periods of disagreement or conflict is vital.

‘GP partnerships are at the heart of general practice,’ he says.

‘A good partnership, in which all members feel valued, listened to and engaged in decision making and the running of the practice, can lead to not just a good place to work but also a positive outcome for patients.

‘Like all parts of our health service, however, general practice can be a demanding and challenging environment in which to work, something that can place strain on even the closest partnerships.

‘Where these difficulties arise, it is essential to practices and their patients that doctors be given the support they need to address and attempt to work through whatever difficulties they might be experiencing.

‘Being able to speak to a source of expert and impartial advice, be it from the local medical committee or the BMA’s interpersonal mediation service, can make all the difference to a practice’s future and help to resolve issues that may otherwise lead to a costly and painful partnership split.’ *Names have been changed

bma.org.uk/mediation

A pathway to peace – how mediation works

–– BMA mediators carried out around 12 cases since the service was relaunched –– The service is run by six ACAS-trained and NOCN-accredited* mediators working across all four nations –– There is no charge for interpersonal mediation as it is a benefit of BMA membership for GP partners, although partners accessing the service may incur costs such as arranging locum cover during the mediation process –– The process begins with the mediator having a one-to-one conversation with each partner, before moving to a full day of mediation –– The process is designed to be confidential, independent, neutral and voluntary; no one can be forced to partake in mediation –– Mediators aim to provide an honestbroker role in bringing partners together, discussing the issues and then suggesting a framework for going forward –– There is also the facility for separate commercial mediation in some cases, where BMA members are eligible for access to this service at a preferential rate * NOCN formerly known as the National Open College Network

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

A doctor feels bullied on returning to work, and junior doctors challenge their rotas – issues the BMA has resolved No room for recovery Doctors taking time off sick would be supported and treated fairly. At least that’s what the employer promised.

A consultant, who was unwell having had an accident on holiday, was rushed through the sickness absence process, made to feel bullied and victimised, and even given a date for clearing her desk.

Without the BMA’s help, she may have been out of a job, and the health service could have needlessly lost a talented and experienced doctor.

In common with many hospitals, the employer had a three-stage process for dealing with sickness absence. The BMA became involved at the second stage, and the employment adviser made a strong case that the doctor was still undergoing treatment, and her health was improving.

However, the employer was determined to escalate the doctor to the third and final stage. This gives a number of options, such as further support or redeployment. If – and this is important – all other options have been considered, then the employee could be dismissed on the grounds of incapacity.

The stage-three meeting gave no sense the employer had even considered the options. A letter followed, saying there would

Rota evidence pays off You don’t get very far in medicine without evidence, and the same applies when you’re trying to win back pay owed to doctors.

A group of more than 20 trainees were working on a 1C rota under the previous junior doctor contract. The local negotiating committee representative for trainees thought they should be on 1B. She raised it with the trust, informally at first, with a BMA industrial relations officer. The trust was initially sceptical but what followed were months of emails and phone calls from the

be no attempt to enable a phased return or implement reasonable adjustments.

While her managers never reached the stage of formally telling the consultant she was being dismissed, it had achieved much the same effect by writing to her, telling her to clear her desk by a given date and return her lease car. Most of her belongings were disposed of.

The BMA decided to do some escalating of its own and took the matter up with the hospital’s deputy director of workforce.

The employment adviser highlighted the failure of the employer to follow its own procedure in properly exploring the available options, and the intimidating and discriminatory approach it had taken. None of the reasonable adjustments required by the Equality Act had been made or attempted.

The stage-three hearing was reheard, this time with the ears of the corporate NHS a little more open. The doctor was allowed a phased return, and in her words, ‘very well supported during a difficult time’ by the BMA. Doctors in a similar situation are well advised to contact the BMA at the earliest stage – especially if their employers, like this one, are keen to fast-track them to misery.

BMA and an investigation involving rota software. The doctors gathered significant evidence themselves, about the volume of work and how the nature of it had changed over time to include more intensive on-call.

One thing the case shows is the importance of having a junior doctor representative on the LNC, who had the legitimacy to raise the issue with the trust and to speak on behalf of colleagues to the BMA. Their efforts paid off – the trainees were awarded almost £500,000 in back pay divided between them.

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the secret doctor

FLAT OUT: Mundane tasks such as fixing the printer are acquired – then lost – by junior doctors

Skills learnt and forgotten Throughout the marathon of medical training, we’re meant to get better and better at doctoring.

You get to do bigger and more elaborate operations, or prescribe more obscure and dangerous drugs, or put tubes into tinier and tinier orifices.

That’s how it works, right?

Why, then, a few weeks into my first registrar job, did I begin to feel an uneasy sense that there were things I couldn’t do quite so well as before?

That my finger was no longer quite so firmly on the pulse of my ward? That, to put it bluntly, I was losing my touch? It wasn’t that my clinical skills were atrophying – fresh from the latest set of postgraduate exams, I felt quite up to date with my knowledge. My procedural abilities and diagnostic skills were developing slowly but steadily.

No, what was slipping away was the mysterious art of how to get things done.

As a senior house officer, your consultant or registrar may make the big decisions but it’s up to you to make things actually happen.

If your patient needs a scan – or a transfer, or a specialist review, or an abstruse blood product that can only be sourced from Aberdeen, or a leaflet about syphilis translated into Pashtun – you’re the one who is expected to see to it.

This is when you learn the things that aren’t in any textbook. By the end of your SHO years you are your unit’s leading

authority on where to find that strange, blue blood vial you need for serum selenium, on how to fix the printer, on where to send a videofluoroscopy request form, on what to do if a hungry vegan is admitted at 11pm and all the sandwiches are ham, and on a thousand other mundane, niche but collectively vital matters.

These were the skills I could feel fading during my first registrar post. My ST1 knew the back way into the lab to drop off an urgent sample after hours, so I never had to find it.

My house officer fixed the automatic updates on the handover list, so I never had to learn how. Once I became aware of the change in myself, I noticed it in others too; ask your consultants how to arrange respiratory physio on a bank holiday, and watch them look blank.

I dare say it’s a necessary trade-off.

Probably no one can effectively take overarching responsibility for the successful running of a clinical service while simultaneously knowing how to replace the photocopier toner or the one place in the hospital you can get hold of Vaseline.

I don’t really regret that my attention these days is mostly given to ‘more important’ things – but undoubtedly, something is lost along the way.

By the Secret Doctor bma.org.uk/secretdoctor @TheSecretDr thedoctor | March 2020 27

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It happened to me Doctors’ experiences in their working lives

DNR doesn’t mean ‘do not respond’ ‘I saved a life yesterday,’ was my colleague’s opening gambit as she arrived in the office on Wednesday.

As this is not something you hear very often in the hospice, she had our immediate attention; we all work part time, so this is the one day we are all in together and can catch up on the events of the preceding few days.

Anyway, it transpired that one of our patients, toothless after a lifetime of minimal dental care and many years of sugary methadone linctus, had choked on a piece of seafood.

Hearty slaps on the back as prescribed would not move it, and our colleague had ended up performing the Heimlich manoeuvre numerous times on the patient – now blue and unconscious – before dislodging the offending item. Not easy on a patient semi-prone in bed, with an ileostomy and an abdominal wound.

We bowed down and worshipped but I was particularly chuffed. When I am having the conversation about why we will not be offering resuscitation to patients with advanced disease (‘If your heart stops it is because your body is worn out, not that there is something wrong with your heart that we can change.

The chance of restarting your heart is very small, and if we do, the chance of you suffering is very great’) I am at pains to reassure them that ‘do not resuscitate’ does not mean ‘do not treat’.

We will always be looking to reverse the reversible, whether it is treating people’s hypercalcaemia, or giving them antibiotics for chest infections, for example.

Every so often I can be seen galloping around the hospice crying, ‘you’re allowed to die of your cancer, but nobody dies of constipation on my watch’, and this is something I’ll say directly to patients and families.

The example I always use is that of course we won’t walk past you if you’re choking on your lunch. So now there’s proof this is indeed

CHOKED: A life-saving intervention brought particular joy

the case. Patients and their families are comforted that we will always be trying to do what is in their best interests.

And the patient? She came round with no memory of the event, and was heartily displeased we wouldn’t let her have any more crab sticks.

She deteriorated during the next few days and died shortly after, but we were all comfortable with that.

Becky Hirst is a consultant in palliative medicine in Barnsley

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the consultation

JEAN-MICHELLE

The Doctor will see you now

OAR-SOME YEAR: Dr Doyle gears up for the Olympics

Philip Doyle has taken a year out of medicine to represent Ireland at rowing at this year’s Olympic Games in Tokyo.

He talks to Tim Tonkin Rowing was originally a hobby that kind of got out of hand. I only started rowing while in my second year at university but it was just something that took my mind off studying. I don’t see the Olympics defining me as a successful person and I don’t want to be remembered as the rower who did medicine on the side. I want to be remembered as the guy who had a long, good career and was known to be a really good doctor who happened to go to the Olympics.

Back in the day I used to play hockey for Ireland. When I went to university I gave up on sport for a few years. However, it was the 2012 Olympics, and watching rowers Helen Glover and Heather Stanning do so well, that got me interested. It was 2014 when I really took it up.

The main similarity between medicine and rowing is the mental tenacity that is needed. As a student I was already used to being on the water by 6am and then again at 5pm. I would be out of the house from 5.30am to 10pm every day and would need all my food, supplements and training kits packed and organised for an entire day, so in some ways going to work felt like a bit of a break.

Going to the Olympics means more to me than winning a medal. When we qualified for Tokyo at the semi-finals of the 2019 World Rowing Championships in Austria it was probably more of an elation than when we won a silver in the following finals race.

A little bit of me was always worried that, if I went back to work having not accomplished what I wanted to in rowing, I would forever be ‘the guy who left medicine to not go to the Olympics’. Thankfully all the hard work paid off in the end.

I’m having to consume 7,500 calories a day as part of my training regime. The best part is never having to restrict or limit myself in terms of what I eat; I just go ahead without having to think about my waistline, cholesterol or fat, as I know my metabolism and body need the calories. My dentist, however, is having to work overtime as the amount of sugar I’m putting into my mouth for such prolonged periods does have a detrimental effect on tooth enamel.

Philip Doyle is a foundation doctor 1 from County Down thedoctor | March 2020 29

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and finally...

30

Working in the snot factory A patient hit me in the face yesterday. Accidentally, I should add.

She was obediently raising her arms above her head for a breast exam, and just whacked me straight in the eye. Powerful woman, sent me flying. How we laughed.

There are times when I think this job will be the death of me but this is my first actual bodily harm. And it really wasn’t the worst harm I’ve encountered in my several decades at the coalface.

We have the standard zero-tolerance policy neatly displayed on reception but in reality we tolerate an awful lot.

Such as snot, for example.

I’m fed up of tolerating snot.

We have it coughed, sneezed and gratuitously sprayed in our faces on a regular basis, and it’s not OK. I’m thinking of declaring a war on snot.

My timing would appear to be quite good, what with the latest viral menace arriving in our surgeries, no matter how politely we ask it to stay at home.

I fear it may cause me an

acute sense of humour failure, which is an occupational hazard I’ve mostly managed to avoid till now.

I’m already a shameless squirter of alcohol gel at my patients. When they sit in front of me picking at their cold sores and rubbing their impetigo, I’m ruthless at demanding they stick their hands out for decontamination and a lecture about infection transmission.

I feel more like a nursery teacher than a doctor half my life. But all the alcohol gel in the world isn’t going to keep this one away.

The waiting room troubles me. It’s already a wall-to-wall snot factory over the winter, standing room only, febrile tots cosying up to fragile grannies, the odd puddle of vomit and other bodily fluids, and fluorescent rashes boldly ignoring our sign directing them to the isolation room.

The ‘Keep Calm and Carry On’ voluntary self-isolation policy is a spectacular failure, at least in our neck of the woods.

They just keep rolling up.

Now, I see about 130

patients a week. Say I catch this new lurgy. I could be infectious before I even start to snuffle.

I’ll probably pull through, being pretty robust; but how many of the fragile might I unwittingly infect?

I could make Typhoid Mary look like an amateur. I’ve had at least six colds already this winter, generously donated by one sneeze-in-your-face tot or another. We can’t stay home every time we feel a little ropey; the NHS would literally grind to a halt.

No, it will have to be a pragmatic approach. I’m thinking it won’t be long before patients grow used to seeing their doctors through the muffling veil of a blue mask.

At least it will provide a little protection against wallops in the face.

Felicitas Woodhouse is a GP in Warwickshire Read BMA guidance on COVID-19 infection control at bma.org.uk/coronavirus (This column is unrelated to the coronavirus outbreak)

thedoctor | March 2020

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what’s on

May 01-02 Junior doctors conference, London, day one 12 noon to 5pm, day two 10am to 5pm 13 Practical skills... leadership and management for doctors, London, 9am to 5pm 20 Critical appraisal workshop – part 1, Manchester, 9am to 4pm

March

April

17 BMA joint regional council (Eastern, London, South East Coast and South Central) on climate change, London, 6.30pm to 8.30pm

02-03 Train the trainer, London, day one 9am to 5pm, day two 9am to 4.45pm

20 Retired members conference, London, 9.30am to 4.45pm 23 CESR seminar for SAS grade doctors, London, 1.30pm to 4.45pm 25 Armed forces conference, London, 9.30am to 4.45pm 26 Critical appraisal workshop – part 2, London, 9am to 4pm 27 Medico-legal conference, London, 9.15am to 4.45pm

03-04 Medical students conference, London, day one 11.45am to 5.45pm, day two 9.30am to 4.45pm 20 LNC chairs conference, London, 10am to 4.30pm 23 Practical skills for improving personal leadership, London, 9am to 5pm 24 Private practice conference, London, 9.30am to 5.30pm

2020 BMA annual representative meeting The agenda for the ARM will be published on the BMA website at beta.bma.org.uk/ arm2020 on 22 May 2020.

If any member would like a paper copy, this can be obtained by emailing ARMmotions@bma.org.uk

The ARM will be held from 22 to 25 June 2020 at the Edinburgh International Conference Centre, 150 Morrison Street, Edinburgh, EH3 8EE. Information on how to submit motions to the ARM can be found at beta.bma.org.uk/ writingamotion

Visit bma.org.uk/events for full details Download the BMA events app at bma.org.uk/eventsapp thedoctor | March 2020 31

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