The Doctor – issue 66, April 2024

Why stop this?

The visa rules keeping families apart and forcing doctors to leave the NHS

Right to strike New threats and restrictions

The advocates GPs fighting for the most disadvantaged

Poison or stab?

Life as a TV medical adviser

In this issue

3

At a glance

Consultants approve a pay deal but say there is much still to be done

4-9

Social insecurity

The GPs advocating for the most disadvantaged in society

8-9

Survival plan

A GP practice takes an unexpected step in a bid to stay viable

10-11

Forced apart

Doctors needing to care for relatives overseas put in a dreadful dilemma by visa rules

12-15

Failed by the system?

A young artist’s death, and what it reveals about mental healthcare in Britain

16-19

Dying to be on TV

Where to stab? How best to poison? The life of a TV medical adviser

20-21

Rights under threat

When excessive restrictions are put on the right to strike

22

Welcome

I have had the pleasure of knowing Tom Black, a GP from Northern Ireland who is absolutely devoted to his patients, for many years. This issue of The Doctor reveals the almost impossible pressure he and thousands of other GPs face.

Dr Black’s practice was losing thousands of pounds a month, with the prospect of he and his partners having to hand back their GP contract. In his case, he hopes taking on some private consultations – for which the doctors are not being paid (and which is not barred in their contracts) – might keep the practice afloat. An experiment or a necessity? Other practices in Northern Ireland and across the Irish Sea are observing with interest and concern.

GPs across the UK are working under unsustainable pressure, struggling to stay fi nancially viable; they see secondary care generally protected –those same protections have been consciously denied them by the political choices and decisions of respective governments in each nation.

As we report, a staggering 99 per cent of GPs taking part in a BMA referendum have rejected the changes to the English contract for 2024/25. Enough is enough and the fight for general practice enters a fresh epoch of utilising collective organised action.

The background to this is the appallingly prolonged austerity which has done so much to damage communities and their health. As Glasgow GP David Blane puts it, in the second part of our feature about the ‘Deep End’ practices in Scotland, ‘it is the communities already struggling the most whose services have been cut the most’. His empathy is palpable.

Evie Wilson was a talented young artist, whose pictures recounted her experiences of mental healthcare. One of them was captioned ‘not sick enough’ but ‘too sick for help’, encapsulating the perceptions many patients have of falling through the cracks of a broken, bewildering system. Her father, a GP, tells us it was clear to him from an early stage local mental health services were not meeting Evie’s needs. Tragically, she died aged 24.

Bevan

As the prospect of industrial action continues in many parts of the health service, BMA council deputy chair Emma Runswick, who is working on our industrial relations strategy, continues her examination of the Government’s counter-productive and damaging legislative move to impose minimum service levels on public services during strikes.

Phil Banfield, BMA council chair

AT A GLANCE

‘We will not back down’

‘The fight is not yet over.’

As consultants in England approved a hardwon deal to begin the process of restoring pay earlier this month, BMA consultants committee chair Vish Sharma, while welcoming the outcome, made clear he was in no mood for triumphalism.

Consultants in England voted to endorse new terms, which will see a flattening in pay scales and a £3,000 uplift granted to those with four to seven years of service, on 5 April following months of unprecedented industrial action.

Dr Sharma’s reaction to the deal, which also includes important reforms to the DDRB (Review Body on Doctors’ and Dentists’ Remuneration), illustrates the vigilant mindset doctors everywhere have adopted in the profession’s collective and continuing fight for fair pay and conditions.

‘We’ve reached this point not just through our tough negotiations with the Government, but thanks to the resolve of consultants, who took the difficult decision to strike, and did so safely and effectively, on multiple occasions, sending a clear message that they would not back down,’ said Dr Sharma. ‘This is only the end of the beginning, and we have some way to go before the pay consultants have lost over the last 15 years has been restored. Therefore, all eyes will be on this year’s pay review round, recommendations from the DDRB and response from the Government.’

With industrial action continuing for junior doctors in England, and temporarily suspended for consultants and specialist, associate specialist and specialty doctors in Wales, the possibility of strikes also remains in contention for SAS doctors in England, and consultants and SAS doctors in Northern Ireland.

Meanwhile, GPs in England are preparing themselves for what could be a long struggle over

fiercely disputed changes to the general medical services contract.

Despite close to 100 per cent of the more than 19,000 GPs in a BMA referendum last month voting to reject the 2024/25 contract, which included a 70 per cent plus turnout of all GP contractor/partner members, the Government has, for the third time in as many years, imposed the terms, which will see a below-inflation 1.9 per cent uplift to national contract baseline funding for general practices in England.

The parlous state of general practice was laid bare in February this year, when a BMA snapshot survey of just 10 per cent of practices in England revealed 57 per cent had battled with cashflow issues in the previous 12 months, with one in four practices forced to consider cutting staff to remain open.

BMA GPs committee England chair Katie Bramall-Stainer warned the decision to force through the contract with its grossly inadequate funding settlement meant many GP practices, already struggling financially and with understaffing and patient demand, faced the real risk of closure in the next six to 12 months.

She added, while the resounding referendum vote had not been a formal ballot on industrial action but rather a ‘temperature check’, the result demonstrated clearly that GPs were at ‘boiling point’, and her committee would soon be reaching out to GPs to inform them of next steps.

‘This contract, which the Government is choosing to impose upon us, is not safe,’ warned Dr Bramall-Stainer. ‘General practice has been demeaned, diminished, diluted, bullied and gaslit long enough. We are the bedrock upon which the rest of the NHS stands [and] the battle to save general practice has begun.’

By Tim Tonkin

SHARMA: This is only the end of the beginning

General practice has been ‘demeaned and diminished’

BRAMALLSTAINER:

SOCIAL INSECURITY

BLANE: Inspired to work with patients with complex needs

SOCIAL INSECURITY

‘I can’t imagine how hard it must be to trust anyone given what my patients have been through’

In Scotland, 100 ‘Deep End’ surgeries are based in the most socio-economically deprived communities. The Scottish Deep End Project calls for more resources in a bid to redress the Inverse Care Law. In the second of a two-part series, Peter Blackburn reports from the front line of the Deep End – this time shadowing a Glasgow GP inspired to advocate for the most disadvantaged in society

The first word that comes to mind after a morning spent in the surgery of Glasgow GP David Blane is complexity.

The first patient of the day has mild learning difficulties and is struggling with pain in his arm and low mood. He has recently had a stroke. And now it has been suggested by a hospital consultant that he should be prescribed pregabalin. His consultation requires conversation about all of these issues and advice and guidance around this new, strong, treatment.

Our second patient is an Eastern European man with a history of heroin addiction and HIV in his 40s presenting with chest pain, abdomen pain and cirrhosis – he candidly describes this as ‘my fucked liver’.

Then Dr Blane ponders the case of a woman with type-one diabetes in her 30s who has depression, suicidal ideation and a host of adverse childhood experiences – and the means to take her own life with insulin. The local mental health team isn’t able to support her because their services are so stretched they struggle to deal with anything but the most catastrophic crisis.

Dr Blane also looks after an Iranian Christian forced to flee his home country owing to being at serious risk of persecution whose life has fallen apart after a marriage breakdown and a serious accident, a man from Pakistan who has had liver problems and also presented at the emergency department with chest pain, a three-yearold with croup and a mum desperate for help in the form of antibiotics, another patient with a street Valium addiction, and a woman in her 80s whose blood pressure plummets when she gets out of bed.

Finally, we see a young man who comes to

DOUGLAS ROBERTSON

Dr Blane with fears around what his likely diagnosis of Ehlers-Danlos syndrome might mean for his future life chances and who is also struggling to stay in employment owing to severe back and knee pain on top of major difficulties with anxiety, depression and suicidal ideation.

‘Even just observing for a morning can be quite tiring, can’t it?’ Dr Blane says when the first eight patients have been dealt with, reflecting on the dizzying array of need we have seen in the space of just an hour and a half.

Empathy

For Dr Blane, who is primarily a medical academic but works clinically one day a week here in the Pollokshaws medical centre, this is a quiet day. There is even time for a rare tea break. For a tired observer, this seems anything but quiet – and a 10-minute tea break hardly feels like presenting the headspace needed to cope with the scale of people’s need for help in this community. Is that sense of overwhelming need – and particularly the trauma that rests in the past and present of so many patients’ lives, often defining much of their future – something that rests heavily on Dr Blane?

me it’s a helpful lens to understand why people don’t necessarily behave the way I would in any given situation.

‘My parents got divorced, but they were decent people and good parents. They didn’t beat me up or sexually abuse me but there are many people here who can’t say that. And often it’s not spoken about. Lots of things are swept under the carpet and go unspoken because they can be deeply shameful or people internalise those things. It manifests at some point and often that will be with mental health or physical health symptoms.’

‘My parents didn’t beat me up or sexually abuse me but there are many people here who can’t say that’

Dr Blane adds: ‘The things that maybe keep me awake at night are where I feel that there is real suicide risk, and there was one case that wasn’t a patient of mine but was at the practice and did kill herself. When that sort of thing happens it really sticks with you. You are always going to think, is there anything we could have done to prevent that?

‘For me, I think working clinically just one day a week is protective. I think that sets up automatic boundaries in terms of coping.’

‘I don’t feel like it affects me as such,’ he says. ‘I just sometimes think I cannot imagine what that would be like. I know I’m not personally impacted by the trauma but I feel for them. I can’t imagine how hard it must be to trust anyone given what they’ve been through. For

The practice sits three or four miles south of the city centre on the Eastern flank of the massive Pollok country park. This – like so many parts of the UK’s most populous and significant cities – is a place of great contradiction. It is an area with pockets of striking, grand, Victorian housing, occupied by young professionals and affluent families on streets marked

DOUGLAS ROBERTSON

BLANE:

Some patients are lost to or ignored by the system

by independent bakeries and coffee shops. But there is also significant deprivation, poverty and need here – tower blocks and high-rise housing still loom large over local skylines. Here, the inequality and inequity rife across the UK is up close.

This deprivation and, particularly, the effect of economic and social policy on areas such as this are a huge driver of health need.

Dr Blane says: ‘The context for this practice and these patients is a decade-plus of austerity. If you look at the way services have been cut during this period it is the communities already struggling the most whose services have been cut the most. The notion that we were all carrying an equal burden on our shoulders was just fanciful. Food insecurity and fuel insecurity have increased. All these issues are more common.’

these communities need.

It is likely the difficulties faced by doctors and patients in communities such as these are only going to become more entrenched, with such a strong sense of economic and political perma-crisis engulfing domestic and international narratives – from the effects of Brexit and the pandemic to austerity, the cost-of-living crisis and war breaking out in Europe.

‘Levels of anxiety in particular are really high’

Dr Blane adds that ‘missingness’ – patients just lost and ignored by the system – is a real problem in this area and has an interest in improving access to care. ‘We have patients who report that they very rarely leave the house,’ he says. ‘Levels of anxiety in particular are really high.’

It is working with patients of complexity – who most need general practice and anticipatory care – that inspired Dr Blane to follow the career path he has, working in one of the practices which serve Scotland’s 100 most deprived communities, and pursuing academic work in crucial areas such as food insecurity, social risk factors on health, access to healthcare and the organisation and delivery of care for people with multiple long-term conditions.

Skipping meals

Last year, Deep End practices published a series of stories from the front line – outlining the effect of the cost-of-living crisis on patients’ lives every day. They tell of parents skipping meals so their children can eat but who still feel like they are failing, housing without basic washing facilities, people with diabetes swirling out of control and unable to eat nutritious food owing to relying on food-bank basics, lives blighted by panic attacks, two-year waiting lists for vital trauma psychotherapy and an overwhelming sense of hopelessness.

‘The context for this practice and these patients is a decade-plus of austerity’

Dr Blane is also the academic lead for the Scottish Deep End project, which sees GPs serving the most socio-economically deprived communities working together to advocate for greater resources where needed the most. It is a project which advocates for general-practice hubs providing answers to healthcare challenges such as multimorbidity, fragmentation, increased pressure on emergency services and static (or worsening) inequalities in health. The project aims to improve the care of patients and make general practice an attractive career option to recruit and retain sufficient numbers to provide the services

In 2022, Deep End GPs from across Scotland –alongside charities and community organisations – met, in a round-table meeting, to discuss the challenges of the cost-of-living crisis and how general practice can support patients experiencing financial hardship, with the link between poverty and poor health and widening health inequalities well established. Participants covered fuel poverty, inadequate housing, food insecurity and access to health and care services amid rising transport costs – discussing how to build teams and community hubs to challenge all these issues. But those present at the meeting also noted the effects working in these environments – with ever-increasing workloads amid so much trauma and suffering – was having on staff and agreed morale was ‘as low as it has ever been’.

In the face of all the evidence, the case for increased investment in, and focus on, general practice and anticipatory care in the most marginalised and disadvantaged communities is tough to ignore.

As former BMA president Sir Harry Burns once wrote: ‘What we need is a compassion that stands in awe at the burdens the poor have to carry, rather than stands in judgement at the way they carry it.’

Advocates such as Dr Blane will continue to make exactly that case.

Tom Black’s GP practice in a deprived area was losing thousands of pounds a month, so the partners took an unexpected step to try and save it. Jennifer

Trueland reports

SURVIVAL PLAN

Tom Black loves Derry, the Northern Ireland city where he has lived and worked since he was a child.

‘To be blunt, the contract was going back in June this year at the latest’

‘One of the reasons we need this is that the health service has collapsed –we had to do something’

As we drive towards his practice in the Bogside –an area high in deprivation and redolent with political history – he proudly gestures towards a building which used to house his widowed mother’s clothes shop. As a boy during the Troubles he would be on duty, he says, making sure there were no bombs. ‘There were none on my watch,’ he adds.

The family shop – latterly run by his wife – has changed recently. COVID was hard on retail with so much going online, so now his daughter runs a beautician’s business from the premises; it has flexed to survive.

It’s a similar story at Dr Black’s surgery. From the start of the year, Abbey

Medical Practice has moved to a hybrid model, continuing to care for HSC (Health and Social Care service, essentially similar to the NHS) patients on its list as usual, but also seeing private patients after hours. Patients pay £75 for a 15-minute consultation with one of the practice’s GPs. The doctors themselves are not paid for this extra work – all the money is ploughed into keeping the practice doors open and lights on for its own patients.

No choice

Nobody could sound more surprised by this turn of events than Dr Black himself – private healthcare is not normally the go-to solution for GPs who chose to make a career among deprived communities – but he says the practice had no choice: it was either take this radical step or go bankrupt.

‘To be blunt, the contract was going back in June this year at the latest,’ he says. ‘We were losing thousands of pounds a month – it simply wasn’t sustainable.’

When The Doctor visited Dr Black’s surgery in February, the Northern Ireland Assembly had just started sitting again after a gap of two years. The suspension of devolution has had a huge effect on healthcare in Northern Ireland, and many, Dr Black among them, fear the restoration of government has happened too late to save public services. General practice is no exception. The lack of a health minister has had practical consequences which have hastened the demise of many practices (see box on p9), not least because even the belowinflation 6 per cent financial uplift recommended by the

BLACK: Staff and utility costs could barely be met

Review Body on Doctors’ and Dentists’ Remuneration had still to be paid, almost a year after it was agreed.

‘To give you an insight into the impact that has had, in my own practice we didn’t get the 6 per cent and we were already overdrawn.

‘We then lost three reception staff in six months – because our pay was lower than Lidl’s. We took a second overdraft from the bank and we gave all our staff an 8 per cent pay rise, because we need someone to answer the phones.

‘At the same time, our heating and lighting costs had doubled in the last 12 months, and our workload is phenomenal, partly because of the huge problem we have with long waiting lists in Northern Ireland. One of the reasons we need this is that the health service has collapsed – we had to do something.’

The private patients are paying for the convenience of an appointment without waiting, and for extra time –there are no fancy consulting rooms with comfy sofas at the practice. ‘They get a 15-minute appointment – they’re getting the appointment I used to be able to give them 10 years ago,’ he says. ‘You know, I’m really annoyed I’m having to do this, because I never thought I would. But all confidence and hope and trust has gone out of the system.’

Debt relief Regulations mean they can only offer the service to patients from other practices, not their own, and it remains

a small part of the overall workload. Nevertheless, it’s making a financial difference, and the practice is now paying off its debts.

Patients appreciate the private service, says Dr Black, who ends his six-year term as chair of BMA Northern Ireland council this summer. He describes one man, an IT consultant with an upperrespiratory tract infection.

‘It would have cost him an awful lot of work time to sit on the phone, talk to the receptionist, make his case [for an appointment], wait for the GP to call back, then go down for an appointment at the convenience of the practice. He said: “I’m selfemployed, I make £85 per hour, and you saw me at 5.30pm – you’ve saved me a fortune today.”’

Another typical patient was someone who attended with three or four small problems which were worrying them, but they felt they were not worth ‘bothering their GP’ with. ‘We gradually worked through her non-urgent problems – it did take longer than 15 minutes – but the patient was really delighted.’

Setting up the service has been challenging with many regulatory hurdles to cross, says Dr Black. But patients in his own practice have been very understanding.

‘There have been so many practice closures in Northern Ireland and they worried that we would be next in line.

‘So, I said to them: “I’ll work harder, I’ll maintain your service, and I’ll use this private money to keep the practice going.” They believe me – after 35 years, there’s a relationship of real trust.’

‘Extreme pressure’

Dire warnings on workforce and financial pressures in audit report

General practice in Northern Ireland is under extreme pressure, with one in three practices seeking crisis-support services in the last four years, according to a public-services watchdog.

A report from the Northern Ireland Audit Office on access to general practice, published last month, warns extreme pressure continues to build on primary care, with challenges including funding and workforce. Auditor General Dorinnia Carville called for the development of ‘sustainable long-term plans’ to address the situation.

The report shows that, between March 2022 and March 2023, 13 practices either handed back or gave notice to hand back their contracts. The need to attract locums to these practices has led to trusts (who took over five of the contracts) paying rates of up to £1,000 per day.

Workforce issues, including a shortage of GPs, and the failure to roll out multidisciplinary teams are also challenges, as is demand resulting from growing waiting lists in secondary care, the report warns.

BMA Northern Ireland GPs committee chair Alan Stout says the report reiterated and validated what the BMA has been warning about for some time.

‘Escalating workload, workforce and financial pressures, coupled with a failure to tackle these issues with sustainable long-term and properly funded solutions, has brought general practice to the state it is in today. This is the latest in a long line of reports published over the past decade which have outlined what needs to happen to save general practice. We can only hope its recommendations do not also fall on deaf ears and that properly funded, long-term, sustainable interventions to save primary care are actioned before it is too late.’

FORCED APART

Doctors needing to care for relatives living overseas have been left with an agonising dilemma because of highly restrictive visa rules. Many are being forced to cut their NHS hours – costing them, and the health service, dearly. Tim Tonkin reports

Consultant Aniya Kumar’s* life used to be a happy and straightforward one.

Having trained in the UK and worked in the NHS almost continuously since 2002, Dr Kumar lives in north London roughly a mile from the hospital that, until three years ago, she worked at full-time.

In the summer of 2021, however, Dr Kumar’s life was turned upside down when six members of her extended family in India lost their lives to the COVID-19 delta variant which was then sweeping the country.

Aside from the tragedy of losing so many relatives, the deaths meant Dr Kumar’s older widowed mother, who herself has been left physically debilitated as a result of COVID infection, was now alone and

without support.

As the eldest child in her family, Dr Kumar’s first instinct was to try to bring her mum to the UK to live with her so she could be financially supported and cared for.

Unfortunately, this wish has so far proved impossible owing to rules imposed by the Home Office on those applying for visas for ADRs (adult dependent relatives).

Immigration rules were greatly tightened in 2012, and those wishing to bring adult family members to the UK must be able to demonstrate their relatives’ health is sufficiently poor that they require long-term care, and that the requisite level of care cannot be obtained in their home country. In practice it has meant very few have gained permanent entry.

As a result, Dr Kumar was

forced to take the difficult decision to leave her job and work instead as a locum, a decision which has reduced her hours in the NHS and affected her finances and career, so that she is able to spend up to half of each year in India looking after her mum.

‘I think this is the height of discrimination, that’s how I feel,’ says Dr Kumar.

‘Just because I was not born here and my family is not from here, I can’t care for my mother. At the same time, the NHS and the Department of Health and Home Office want me to care for other people of her age by working in the health service.’

Many affected

As extreme as Dr Kumar’s situation is, her experience is sadly far from unique

‘I can’t leave my mum by herself, because if something happens there is no support’

FAMILY BONDS: Visa rules are keeping doctors apart from their relatives

for many doctors with dependent relatives overseas working in the NHS.

A recent BMA survey into the effect of UK immigration rules around visas for ADRs, exposed just how significant a personal and professional effect restrictions on bringing family members to be cared for in the UK is having on many doctors.

Garnering more than 3,300 responses and with 90 per cent of those participating stating they had dependent adult relatives overseas, 76 per cent of doctors told the BMA they had been forced to take time off work in the past five years to travel abroad to provide care to relatives.

Eighty-four per cent told the survey they knew of at least one colleague who had quit the NHS owing to carer responsibilities, with 94 per cent warning immigration rules made it less likely they would remain in the UK in the long term.

Occupational health physician Shailesh Katyal is facing a similar dilemma with regards to continuing his career in the UK owing to the obligations he feels towards his parents in India.

Dr Katyal says he has so far not sought to engage with the process for applying for ADR visas, owing to the sheer hopelessness he feels he and others are faced with when attempting to meet the almost impossible set of criteria the Home Office sets out.

‘When I first came to this country [in 2003], doctors were allowed to bring their parents to come and live with us without any of these criteria recently set out by the Home Office,’ he says.

‘Learning that this was no longer the case came as a shock to me as I had no idea it had been changed. There was no consultation with the BMA in this regard as far as I am aware. Both my parents are old and infirm and not in good health any more, and to be able to bring them here, to look after them and just be with them for whatever time they have left, would mean so much.’

Dr Katyal says he understands how many doctors in his position might consider leaving the UK altogether if forced to choose between their career and looking after their parents.

‘Having been a part of this country, having lived here and served in the country for several years, one feels let down by the UK. If it was conducive, I would have brought my parents here as soon as possible. Events like the pandemic really bring things to the fore: one is always thinking, are you even going to be seeing your parents again. Living here under the circumstances is a continuous dilemma.’

Urging change

Dr Kumar says that, while her former clinical director had been understanding and tried to accommodate her needs, it simply hadn’t been feasible to continue to balance work, international travel and looking after her mum.

She says that, while her mother had been granted a visitor visa to the UK, this did not allow her to remain for the extended periods needed.

She adds that, were her mother to relocate to the UK, she was fully able and

prepared to support her financially and pay for private medical care, so there was zero burden on the NHS.

‘I can’t leave my mum by herself, because if something happens to her in India there is just no support available there for her,’ she says.

‘I go to India for three to four months of the year and then I come back to the UK and locum for three months and then go back again to India.’

She says that if the Home Office was reluctant to grant dependant visas for people such as her mum, the introduction of a longterm visitor visa could be an acceptable compromise.

The BMA has official policy calling for the Government to relax the requirements for ADR visas and following its latest survey, association council chair Philip Banfield wrote to home secretary James Cleverly imploring him to take action.

The letter said: ‘Our survey shows that if unaddressed, [this] issue risks doctors leaving the UK, further exacerbating the existing workforce crisis in the NHS. [It] also demonstrates how the rules are already disrupting patient care with doctors being forced to take leave to provide care for their relatives overseas.’

Home Office minister Tom Pursglove wrote in response to Dr Banfield’s letter that the ADR rules were fair and that there was no evidence they were deterring overseas doctors from coming to the UK – despite the evidence to the contrary in the BMA’s survey.

*

Dr Kumar’s name has been changed

‘I think this is the height of discrimination’

A self-portrait of Evie, ‘bright, vivacious, interesting, sharply funny, with a wicked sense of humour’

FAILED BY THE SYSTEM?

Evie Wilson was a promising young artist. Her death at the age of 24 shows, in the words of her GP father, a lack of ‘shared understanding’ between the parts of the health service meant to serve vulnerable patients. By Ben Ireland

‘N

ot sick enough ... but too sick for help.’

‘Her parents say her death was “entirely avoidable”’

Evie Wilson describes her experiences of adult mental healthcare in one of her many powerful paintings. The talented young artist had been accepted on to a fine-art degree at Goldsmith’s months before she died in July 2022, aged 24.

Much of the ‘joyful’ and ‘mischievous’ young woman’s artwork, cherished by her grieving family, spoke to her six-year experience of NHS adult mental healthcare.

As a complex patient with multiple diagnoses, she was passed around services and, as her parents tell The Doctor, ‘never felt recognised’.

The coroner at Evie’s inquest concluded she died as a result of morphine toxicity, and her intent was unknown. Her parents say her death was ‘entirely avoidable’.

Evangeline May Wilson, known as Evie, had been diagnosed with bulimia, post-traumatic stress disorder, depression and borderline personality disorder.

She had been passed around local adult mental health services by AWP (Avon and Wiltshire Partnership Foundation Trust) over six years and had a history of severe self-harm and suicide attempts.

Her GP had been aware of her eating disorder from her teenage years, after which her condition escalated following a traumatic event. She was admitted to hospital more than 50 times between 2016 and 2022, with some detentions under the Mental Health Act.

On 22 June 2022 she was admitted to Cassel Hospital, London, for what was intended to be a nine-month stay at the inpatient facility,

which offers a ‘living and learning environment’ – where patients discuss their conditions and treatment plans with each other as well as clinicians in a ‘therapeutic community’.

Less than three weeks into her stay, Evie was placed on short leave after breaching Cassel’s no-alcohol rule, despite drinking being a relapse indicator in Evie’s AWP safety plan. She had told nurses she felt as though other patients ‘hated’ her and had had a seizure the previous weekend. On Friday 8 July she was released with a return train ticket to Bristol and her next therapeutic session planned for 12 July.

The leave was to give her extra time to ‘reflect’. But she never returned. Evie was found dead at her Bristol flat by police on 10 July 2022 with a toxicology report showing acute morphine toxicity. Evie’s parents say she was ‘naïve to opiates’.

Welfare calls

The inquest focused on the welfare calls which were supposed to have been made to Evie during her short leave – and whether she should have been allowed to return home to an empty flat at all.

It was agreed that, as her home trust, AWP was responsible for making welfare calls while Evie was on leave from Cassel. The inquest heard messages were sent by a doctor and nurse at Cassel to AWP’s consultant psychiatrist who had treated Evie previously. On the Friday evening, he had forwarded a plan for her weekend’s care to AWP’s duty team – which consisted of two unregistered practitioners employed by a mental health charity commissioned by AWP. One responded to say making such calls was out of their scope and could ‘pit us against’ nurses.

The psychiatrist followed up to reiterate his

plan should be followed, but those welfare calls were not made by the duty team, which at the time worked 9am to 5pm on weekends. The staff member who questioned the scope was off sick on the Saturday and the inquest heard the system relied on staff proactively checking emails to know about welfare call requests.

It was only on Sunday 10 July a call was made to Evie. This was made by the crisis team after a concerned call from Evie’s mother – not by the duty team which was supposed to call her. She was found dead by police that night.

During questioning of the systems in place at the time, and which have since been updated, coroner Peter Harrowing said: ‘Those calls were never going to be made.’

Dr Harrowing, however, found Evie’s short leave period was ‘appropriate’ given she was a voluntary, informal patient and safeguarding plans had been made. Although Evie’s family contended Evie faced a heightened risk at the time, he concluded the missed welfare calls were deemed ‘precautionary’ and therefore them not taking place was not ‘causative’ in her death.

AWP has since changed its welfare call practices following an internal investigation and Cassel Hospital has updated its assessment processes for new patients and when short leave is granted following a serious incident review. Both trusts offered their condolences. With the changes in mind, the coroner made no preventing future death statement.

In his summing up, Dr Harrowing said: ‘That a system can be improved does not in itself mean there has been a system failure.’

Evie’s father, GP Nick Wilson, told the inquest that her ‘complex difficulties’ got to a point where they were ‘out of our depth as parents’. Her

‘It was clear to us early on that the local mental health services were not meeting her needs’

Artwork by Evie Wilson

EVIE: ‘Life is a paler colour without her’

Evie’s

what seemed a contradictory and confusing care system

‘She knew she was falling between two stools, constantly waiting for someone to wake up and smell the coffee. It was exhausting’

mother, Sally Watson, has also worked in healthcare roles.

‘It was clear to us early on that the local mental health services were not meeting her needs,’ said Dr Wilson, who had asked for Evie to be referred to inpatient care locally – but the family’s funding request was declined in 2017. ‘There seemed to be an insurmountable hurdle for Evie to climb.’

Dr Wilson says his daughter’s mental health treatment at AWP involved ‘a lack of leadership’ and was ‘focused almost exclusively on medication’.

After deferring her degree for a year, Evie was finally referred to Cassel in September 2021. That was the last time her parents, who say it was ‘extremely difficult’ to work with AWP’s mental health team for six years, were directly involved in her care. They say there was ‘no contact whatsoever’ after that point despite several crises before her death.

While Evie had limited how much information could be shared with her parents, she had given consent for them to receive non-personal details. When in crisis, Evie would engage with mental health services but not her family. After Evie’s death, her parents found out that a psychiatrist had written, in capital letters on a review, that Evie did not have a personality disorder. A subsequent letter had supported this, yet Evie was still referred as an inpatient to Cassel, where having a personality disorder is a pre-requisite of being accepted.

When Evie was sent on short leave, her parents received ‘radio silence’ from Cassel Hospital. They only knew because her mum, Ms Watson received a text from Evie saying ‘glad to be home’.

‘She was very vulnerable,’ Dr Wilson, who was on a camping trip in Cumbria with Evie’s two brothers when he received news of her death, recalled at the inquest. ‘Had we known she was home, and at high risk, we would have made ourselves available.’

Evie’s parents’ concerns about her care speak to some of the issues raised in a recent BMA report into the failures of the ‘broken’ and ‘dysfunctional’ mental healthcare system in England, published the week of the inquest.

The report found growing levels of complexity

among mental health patients and limited opportunities for psychological therapies in stretched services. As a result, patients are increasingly ‘falling through the gaps’, ‘leaving a significant group of patients with nowhere to turn’. Patients with suicidal ideation find it particularly difficult to access talking therapies, the report found. One psychiatrist said when a patient becomes suicidal, it ‘becomes like an exclusion’ from treatment such as CBT through NHS England’s flagship Talking Therapies programme.

Sense of isolation

Speaking to The Doctor, Evie’s parents say her level of complexity was ‘absolutely central’ to the substandard care they say she received; being considered too complex for treatment in primary care, self-harming behaviour preventing eating disorder treatment, question marks over her personality disorder diagnosis being ignored, and ‘light-touch’ involvement from consultant psychiatrists.

‘They didn’t know what to do with her,’ says Evie’s mother, Ms Watson. ‘They kept saying you can’t run more than one therapy at a time.’

The frustration was evident in Evie’s artwork. She expressed feelings of isolation, of a beastly, intimidating system towering over her. ‘Why can’t you see me?’, she asked in one piece.

Evie had multiple care coordinators during her care: her family estimates about 10. They have no complaint with the individuals but say the system – and high staff turnover – affected Evie’s care, losing vital continuity.

As her father puts it: ‘There wasn’t ever a shared understanding between her and the people looking after her. She died thinking that no one really got her.’

The BMA report recommends that NHS England expands opportunities for talking therapy to address the gap in provision. It also calls for more dedicated care coordinators and says different parts of the health and care system often find it difficult to work together. This, it says, is often ‘impossible’ because of the ‘extreme pressure’ those working in the system are under, but also because of ‘siloed services’ and ‘tension between different parts of the system’.

Doctors told the BMA this could be frustration from GPs at refused referrals, or pressures on secondary care teams to ‘bounce back’ patients because they don’t have the resources to meet demand.

summing up of

Evie’s parents say her hospital admissions were treated as isolated incidents with notes ‘just filed’ with ‘no follow-up’, primary care ‘assuming the mental health team are on it’ and mental health teams saying she was not suitable for their services.

‘Someone needs to stand back and take a holistic view,’ says Dr Wilson, who believes mental health teams should ‘empower’ patients’ families and friends, ‘especially if the service is overstretched’.

Long waiting lists, and higher thresholds for receiving care, are also issues identified in the BMA report which align with Evie’s experiences.

‘It was a bit Alice in Wonderland,’ says Dr Wilson, explaining how Evie was expected to attend a tier 3 service before being admitted to tier 4 – when no tier 3 service existed locally.

‘It was Cassel or nothing,’ he says of the centrally-funded tier 4 service that obviated the need for local funding.

‘She was told she was too ill for the eating disorder service, but not ill enough for an inpatient setting,’ recalls Ms Watson. ‘Her maladaptive coping strategies became more entrenched. She became unrecognisable.

‘She knew she was falling between two stools, constantly waiting for someone to wake up and smell the coffee. It was exhausting.’

Disjointed system

Frustration at this led to pursuing the out-of-area specialist admission at Cassel Hospital, which her parents now describe as a ‘fatal’ decision. While the inquest heard of multiple assessments Evie undertook before admission to Cassel, and that the hospital deemed her ‘suitable’, her parents say acute admissions in the months before her referral should have raised alarm bells.

The BMA report says the issues it has identified, including those experienced by Evie, have been exacerbated by the lack of sufficient funding or staffing for mental healthcare.

The Government has pledged to increase mental health funding by £2.3bn a year in real terms by 2023/24 compared with 2018/19, but the BMA recommends restoration of the public health grant to 2015/16 levels, which would mean an additional £1bn a year. Mental ill health has been estimated to cost the UK economy £118bn annually.

Without adequate funding, the report says, ‘the NHS will continue to haemorrhage staff, patients will receive worse care, and we will be a

poorer society for it’.

Targets, it adds, are often ‘unambitious’, and – coupled with a lack of consistent data to show the prevalence of mental illness – it is difficult to know how much funding and staff is needed.

It is a sentiment Evie’s parents agree with. And while the coroner concluded that no systemic failures caused their daughter’s death, they say the disjointed mental healthcare system manifests itself as ‘complacency’ and a ‘lack of professional curiosity’.

In a statement released after the inquest’s conclusion, they said: ‘Our faith in a professional, caring and effective healthcare system has been shattered.’

Evie’s parents keep her artwork displayed on their walls. For Dr Wilson, a collage she made as a 10-year-old hangs in his consulting room; a reminder of her ‘lovely, naïve’ childhood – before her mental health challenges set in.

‘Life is a paler colour without her,’ says Ms Watson as she describes her daughter as ‘bright, vivacious, interesting, sharply funny with a wicked sense of humour’.

Those characteristics are so vividly and poignantly present in Evie’s artwork – artwork that tells the first-hand story of a complex mental health patient who felt ignored in a broken system.

‘There wasn’t ever a shared understanding between her and the people looking after her. She died thinking that no one really got her’

Artwork by Evie Wilson

Need a stabbing or poisoning done well?

Not an advert for a hit man, but a typical task for TV medical adviser

Christopher Peters. Seren Boyd reports

DYING TO BE ON TV

If CID were ever to investigate Christopher Peters’ internet browsing history, there could well be questions to answer. Those poisonings, lingering deaths, carefully timed comas in his searches all look highly suspicious.

These are nothing to do with his work as a consultant surgeon at Imperial College Healthcare NHS Trust, it is important to stress.

For a decade now, Mr Peters has been a medical adviser for several of the UK’s best-loved TV shows

‘I’m constantly coming up with new places to be stabbed’

and some award-winning storylines.

If there is a particularly complex murder in the BBC’s Death in Paradise or a prolonged illness in EastEnders, there is a strong chance Mr Peters is behind it. He has been involved in countless (fictional) stabbings too, taking a certain pride in avoiding more clichéd areas of the body.

‘I’m constantly having to come up with new places to be stabbed,’ says Mr Peters, with disconcerting cheeriness.

‘If the police looked at my computer, there’s an awful lot of web searches they would probably think are highly suspicious. How long does this poison take to work? Do hospital tox screens include this poison? I do sometimes worry I’m setting myself up for a problem down the line.’

Solving the plot

It all started 10 years ago with an invitation out of the blue to advise on a neurosurgical case in the BBC’s Holby City, through a family connection.

SET ADRIFT: Actor Ralf Little plays Detective Inspector Neville Carter in the BBC drama Death in Paradise

He became a regular on the Holby advisory team for the rest of its run.

Since then, TV writers have moved on to other shows and taken Mr Peters with them: an adviser who can provide guidance on strokes as well as stabbings in Albert Square is highly prized.

At the most basic level, he provides veracity: advice on standard treatment and procedures for common conditions and injuries; How long should a cast stay on a broken ankle?

Or he might help ‘flesh out the story’ around a more complex scenario such as a heart attack: What might the symptoms be leading up to it? What might happen in hospital?

But far more exciting for Mr Peters are the invitations to work with writers to help shape storylines, to suggest medical conditions which

fit the narrative arc and dramatic themes.

‘Some actors, when they’re being written out, killed off, are desperate for their deaths to be brilliant’

So, in Death in Paradise, for example, ‘they wanted a character to think that they had killed someone immediately but the victim had to be able to walk a couple of miles and then die. I had to think: What poison can I give them? How would they find it?

‘Or I have to come up with a stabbing that incapacitates someone for exactly the right amount of time: for example, we want them to be in hospital, to think they’re going to die, to have an operation, and be pretty much back to normal in three months.’

This creative problemsolving is what Mr Peters loves and part of the ‘intellectual challenge’ is avoiding medical clichés.

‘Conditions like head injuries and comas lend

themselves well to drama: often they want the person who is injured to not be able to say anything for a few days. Or they want lots of family interactions and dialogue across someone in a coma. So I will often try to look for alternatives.

‘The classic in-joke in Holby City was “damaging the spleen”, which was a kind of shorthand for something going wrong in an operation. It was always a case of: What can we do instead? Making a hole in the aorta is a nice dramatic alternative.’

The final cut

The advisory role has become ‘a nice diversion’ from clinical work and one he can generally confine to evenings and weekends, emails and internet calls.

Occasionally, however, he is called to work on set. Here, the role is particularly

BATTLE WITH ALCOHOL: Actor Steve McFadden portrays a struggle with addiction

PETERS: Medical adviser for much-loved British TV shows SURGERY TIPS: Actor Mark Strong in Temple

exciting as he is collaborating with ‘people at the top of their game’: advising and coaching actors, proposing props or suggesting activities for extras.

‘Some actors, when they’re being written out, killed off, are desperate for their death to be brilliant, to do it justice. A few times an actor has said: “Can we talk to the doctor about what it would feel like to be stabbed?” Which is an interesting question, because I don’t really know, not having been stabbed, but I’ve seen patients who have been, so I can infer what it would be like.’

He often trains actors to give credible impersonations of surgical techniques –notably Mark Strong who plays a surgeon in Sky One’s Temple.

‘I’m quite pernickety about making it realistic,’ says Mr

‘A lot of doctors watch these series, and it would break my heart if the actor was holding the scalpel wrong’

Peters, ‘because a lot of doctors watch these series, and it would break my heart if the actor was holding the scalpel wrong.’

But where close-up shots involve complex procedures, there is no substitute for the real thing: Mr Peters’ own hands.

While the procedures are familiar, and the body parts prosthetics, ‘hand doubling’ can be stressful work.

‘In most TV work, only one or two cameras are used, so you have to think of a way of doing it that looks good on camera, and you have to do it over and over again in the same way, so that it works in the edit.’

For the mini-series Trauma, in which Adrian Lester plays a surgeon accused of a fatal error, Mr Peters worked closely with screenwriter Mike Bartlett to design the surgical

procedure at issue – and was Mr Lester’s hand double.

‘In one shot, they panned from the patient’s head to his feet,’ recalls Mr Peters. ‘And as the camera crossed the torso, my hand was making the incision in the opposite direction.

‘I can only cut a prosthetic once, and we only had three. And when I made the cut with the knife, which had blood tubing up the sleeve, the blood had to come out. The director was surprised I was so stressed about it, but when I make an incision in real life, I don’t have to time it with a camera.’

These are the shots Mr Peters will tend to watch back, with forensic scrutiny. But sadly, as for all actors, Mr Peters’ hands are at the mercy of the editing suite. The surgical closeup scenes in Trauma were considered too graphic and didn’t make the final cut.

He would be delighted to be summoned to the set of Death in Paradise in Guadeloupe, he says, but that’s not happened yet. ‘I keep on making up very complicated storylines and saying, “You really need a medical adviser on set”. And they say, “Yeah, we’re not flying you to the Caribbean”.’

Medicine with a message

One of the longer-running plots of which Mr Peters is particularly proud involved EastEnders’ Phil Mitchell in 2016.

The writers wanted to reinvent Steve McFadden’s character – a predictably belligerent alcoholic – and

DIGNITY: Actor Danielle Harold portrays Lola Pearce who suffers with a brain tumour

find a medical condition which might help redeem him.

Alcoholic liver disease and the health consequences portrayed in Mitchell’s decline provided lively dramatic interest: the possibility of a liver transplant also gave a strong publichealth message about organ donation.

The storyline was intended to counter ‘the George Best effect’ – the direct, negative impact on the number of livers donated for transplant each time the footballer started drinking again after his own transplant.

‘[The George Best story] sat in people’s minds, the idea that the livers were going to alcoholics who were still drinking, which is just not true. So we were able to show how much effort Phil Mitchell had to put in to prove he was dry, how he was tested, to

reassure the public there is a robust process for organ donation.’

Mr Peters recognises soaps such as EastEnders ‘are not public-health broadcasts’. But he is pleased when he is given the opportunity to spotlight little-discussed conditions or NHS issues, from Alfie Moon’s prostate cancer and Lola Pearce’s palliative care last year, to long waiting lists for CBT (cognitive behavioural therapy).

‘It makes me sound like a psychopath but I’m determined to give a character oesophageal cancer at some point, because that’s the cancer I treat,’ says Mr Peters, who is perfectly personable.

‘But the writers haven’t bought it yet. Even the word oesophagus isn’t very accessible, and treatment for that type of cancer would probably be too long an arc for them. I’ll keep trying.’

Stranger than fiction

The real art and challenge in being a medical adviser lie in navigating a course between medical truth and dramatic pace, and being true to both.

A certain amount of dramatic licence is essential: current waiting lists don’t make for racy plotlines so residents of Albert Square tend to get far faster treatment than your average NHS patient. Diagnosis and treatment are often condensed too. ‘We can’t have three weeks’ worth of someone with cancer going for CT, MRI and PET scans, so we present it differently.’

But there are some red lines Mr Peters refuses

to cross. He swiftly and routinely dismisses tropes such as unkind GPs and stereotypical portrayals of schizophrenia. He will not permit characters to defibrillate patients in asystole (who have flatlined), despite Hollywood’s insistence on doing so.

Nor will he allow characters to ignore grave medical warning signs without consequence – and often challenges the 100 per cent success rate of chest compressions in some programmes.

Interestingly, the TV show he feels best reflects the kind of dialogue and relationships real doctors have with one another is Green Wing , Channel 4’s surreal medical sitcom, which he wasn’t involved in.

‘We don’t walk around being deeply respectful of colleagues all the time. We joke with each other, we mock each other. In some of the American dramas like Grey’s Anatomy, everyone is very serious and worthy all the time and it’s not a world I recognise.’

As a seasoned adviser, he is sometimes asked to suggest dialogue and takes pride in finding turns of phrase which fit with the rhythms of speech and narrative beats.

One day, he would like to write his own show. It may be more Green Wing than Grey’s ‘I always joke with my trainees: “Don’t mistake me for being arrogant. If anything, I am even better than I think I am.” I’ve tried to get that line included in shows and they’ve said: “That’s a bit over the top! No one would ever say that.”

I say it all the time.’

Actor Tyler Luke Cunningham played nurse Louis McGerry in Holby City

BBC/KIERON MCCARRON

RIGHTS UNDER THREAT

The Strikes (Minimum Service Levels) Act is provoking questions. Would compliance make action ineffective? What might defiance look like? What risks would that carry? How can such legislation be defeated? Those of us facing such questions can learn from industries hardest hit by previous anti-strike laws.

Many countries legally protect the ‘right to strike’ but Britain never has. From 1906, unions held ‘immunity’ from being sued for inciting workers to break their employment contracts in connection with a trade dispute. Since 1980 that immunity has been successively restricted by complex strike rules. If an employer can show that there is ‘a serious question to be tried’ – an astonishingly low burden of proof – they can obtain a court injunction ordering a union to stop a strike. Breaking an injunction is contempt of court, which can mean a union facing unlimited fines or sequestration (seizure) of assets.

Modern anti-strike laws

HIGH-LEVEL VIEW:

The construction industry gives insights into how workers can operate when lawful strike action is impossible and, below, Ian Allinson’s book

Workplace activist Ian Allinson

looks at what can happen when excessive restrictions are put on the right to strike

threaten union finances to put pressure on union leaders to police their own members. Margaret Thatcher adopted this new approach after mass protests and strikes forced the release of the ‘Pentonville Five’ dockers from prison and defeated Edward Heath’s Industrial Relations Act 1971.

A strike is ‘unofficial’ if not backed by a union, and ‘unlawful’ if the law doesn’t permit it. The anti-strike laws don’t make striking ‘illegal’ or criminal. If workers take part in unlawful strikes they are more vulnerable to discipline or dismissal by their employers. Until 2000 the law didn’t make it automatically unfair for employers to sack lawful strikers either. Workers relied on sticking together to protect themselves.

‘Making bad laws unenforceable through mass defiance can win repeal’

Power imbalance

Since 1980, each Act has given bosses yet more power against workers. Slow postal ballots help employers impose changes – even redundancies – before workers can lawfully strike. Only strikes over a

‘trade dispute’ with your own employer are lawful, but employers can divide themselves into multiple legal entities, subcontract work and use agency workers. Ballot turnout thresholds have prevented many workers who voted to strike doing so lawfully, including many NHS staff last year. In the 1980s, workers in the engineering industry struck lawfully to demand better pay for NHS staff. Now strikes in solidarity or over issues such as climate change or war are generally unlawful.

Construction is an industry where lawful strike action has been impractical for most workers for many years. Workers are often employed through subcontractors or are notionally self-employed. The workforce changes constantly as different trades come on and off a site. With lawful action rarely an option, construction workers take unlawful action and are often successful despite the industry being notorious for victimisation and blacklisting.

With unions unwilling to call

unlawful strikes, workers built a network called the National Construction Rank and File, which includes non-unionmembers alongside members of different unions. The rankand-file plan and call action themselves – independently of the unions.

The attitude of the unions to this has varied a lot. When bosses tried to impose a 35 per cent pay cut on electricians in 2011, a union national officer described the rank and file as a ‘cancer’ in UNITE. Undeterred, workers staged protests and occupations at sites across the country and staged some unofficial unlawful (‘wildcat’) strikes. As the campaign grew, so did pressure on unions to back it. Increasing numbers of UNITE executive council members joined protests, a mass picket and a brief site occupation. Eventually UNITE balloted workers at the Grangemouth oil refinery, a rare site with a stable enough workforce to make this possible. This combination of wildcat action and the threat of official lawful action was

enough to defeat seven major construction companies. UNITE has become supportive of the National Construction Rank and File, but both parties keep at arm’s length and value their independence.

Most wildcat strikes are short. There are sometimes longer strikes, particularly if the employer sacks strikers, when workers typically refuse to return to work until all are reinstated. The involvement of workers in more than one union, or no union, helps unions fight off injunctions. It is many years since UNITE ‘repudiated’ a strike (telling members to return to work) to avoid an injunction despite frequent unofficial action.

Unlawful action is a scary prospect for workers. But, as the law is tightened to make lawful action impractical or ineffective, more are bound to see unlawful action as the best option. From the 1971 Act to the Poll Tax, making bad laws unenforceable through mass defiance can win repeal too.

Ian Allinson is a workplace activist and author

How the new law might be used

Emma Runswick considers the likely effect of minimum service levels legislation on doctors’ industrial action

We expect MSL (minimum service levels) regulations for hospitals to be published imminently. The levels set so far have varied from 40% of journeys in passenger rail to 100% in fire and rescue, and border security.

No employer has yet issued a work notice forcing somebody into work. In some cases, for example on the railways, this is because the strategies adopted by trade unions have scared the employer. ASLEF called more days of strike action on LNER when the rail company began the MSL process.

Our strike action so far has been highly effective. Consultants in England have achieved a deal after strikes. If NHS Employers use MSL to prevent our current short periods of action being effective, additional periods of strike action may be needed to generate a similar effect.

Now junior doctors have gained a mandate for action short of strike, this can also be in our arsenal when employers seek to issue work notices. As our campaigns develop, we can expect other tactics to be used to prevent safe industrial action, such as accusations that doctors have breached their professional duties.

If there is unofficial action, the BMA will be legally required to repudiate unofficial industrial action in specific and exacting terms or face fines and sequestration of assets.

Given the safety fears involved in use of MSL, explained in the last issue of The Doctor, we advise medical managers and consultants to plan for industrial action as you always have done. It will continue to be necessary to ensure cover for urgent, emergency and critical care without the presence of junior or SAS doctors.

Emma

Runswick is BMA deputy council chair

and finally…

‘LOOK WHAT WE BUILT’

The National Theatre’s Nye is a moving insight into the creation of the NHS, ‘a huge and slightly miraculous achievement’, writes GP Sassa Calthrop-Owen

‘Did I look after everyone?’

Michael Sheen’s last words as a dying Aneurin Bevan in his NHS hospital bed.

The bed features pretty heavily in Nye. As do the curtains. In Rufus Norris’s surreal and exuberant production, with Vicky Mortimer’s clever set design, the ward becomes furniture and backdrop in a feverdream of the life of Nye Bevan and the formation of the NHS. Tim Price uses a little artistic licence here, as Bevan actually died at home some five months after the surgery that revealed his stomach cancer; but the device works. ‘The morphine’s doing its trick.’

Nye in his post-op, drug-fuelled delirium wanders in permanently bewildered pyjamas, as beds become a classroom, a library, a podium, even the ‘Aye’ and ‘No’ lobbies. Curtains are the House of Commons benches, and the backdrop for projections – X-rays, ECGs, even the serried rows of furious doctors.

His surgeon becomes Winston Churchill (an imposing Tony Jayawardena), Matron becomes Clement Attlee (Stephanie Jacob in a bald wig driving a motorised desk with remarkable gravitas), and a nurse in full regalia serves gin and tonic on the Commons’ balcony while he romances his wife-to-be (Jenny Lee, a formidable politician in her own right, perfectly played by Sharon Small).

Sheen is, of course, a brilliant Bevan. Charismatic, charming, passionate, vulnerable, full of mischief and machinations. Very funny. ‘You can’t get whisky on the NHS.’ ‘Well, that was a bloody oversight!’

A large cast brings the production to glorious life, even breaking into a song-and-dance routine (Get happy, bizarrely perfect). And they keep our attention through the complex and sometimes

choppy narrative – ‘my whole life was jumbled up’.

Getting the NHS Bill over the line, he fights his greatest opponents – the medical profession, possibly not in our finest hour – as they oppose nationalisation of their livelihoods right down to the wire. Amid threats of strikes and boycotts, he obstinately sets the date, and a tense three-month countdown sees concession after concession – GPs to keep their independence, consultants their private practices. But he gets it through. And on 5 July 1948, the NHS comes into being. Universal, comprehensive, free at the point of need.

At the very end, as the cast leaves the stage, Michael Sheen pauses and looks up. Projected across the NHS curtain is this: ‘Within 10 years of the creation of the NHS, infant mortality decreased by 50%. Since its founding, life expectancy has increased by 12 years. Every day, 1.3 million people are treated, based on clinical need, not the ability to pay.’

Did he look after everyone? It’s not often I feel pride in my work these days; for those of us at the coalface of the NHS, it’s easy to lose sight of what a huge and slightly miraculous achievement the whole thing is. And Bevan never had any illusions –‘expectation must always exceed capacity; it must always appear imperfect’.

But there’s a moment at the very start of the play when a post-op Bevan is wheeled in his bed on to the serene Nightingale ward, and in his scared and confused state he’s comforted: ‘Look what we built!’

Sassa Calthrop-Owen is a GP in London. Nye is at the National Theatre in London until 11 May, then the Wales Millennium Centre in Cardiff from 18 May until 1 June, and in selected cinemas on 23 April

Michael Sheen and members of the cast during rehearsals JOHAN PERSSON

Your BMA

My role has become increasingly challenging as views have become more polarised

On the way home from the BMA annual representative meeting in 2019 where I was elected deputy representative body chair, I was approached by a BMA rep at Belfast Airport.

‘I voted for you,’ he said. But he swiftly went on to add he had immediately begun wondering, ‘Oh gosh, what am I putting this poor person through? What am I putting this junior doctor through? Is this the right thing for her?’

It stuck with me. My election had been a bit of a shock. I stood at the last minute because I felt I was the best candidate – the most qualified from an ARM perspective having been involved with the agenda committee for years and knowing the processes and the conference very well. I thought I could do a good job and it wasn’t lost on me that I was in a number of under-represented minority groups in the BMA and across medical leadership. I was a woman, from an ethnic-minority background, and I was a junior doctor. It surprised me that I was elected but it clearly worried the kind colleague who voted for me.

It was a tumultuous experience – and has remained so. In 2021, in the midst of a global pandemic, my predecessor and the RB chair stepped down unexpectedly. I was in a position where our articles and bye-laws offered no provision other than for me to step up and do both jobs. So I did.

It was a worry for me, though. This hadn’t been a career goal for me. But, as a colleague from the GMC where I was working in 2019 told me: ‘Sometimes the best leaders are those who don’t aspire to power.’ On my part, I saw inequalities in medical school, in the NHS and in society and I wanted to make a difference. At that time – and still now – the BMA was the best tool to do that.

But, the person who approached me at Belfast Airport

was right to be worried. This job can be brutal. And in recent weeks and months I have found myself increasingly at the centre of dispute, on the receiving end of judgement or poor behaviour.

When I was elected I stood, as I have repeated in this column for clarity, on a manifesto of challenge, change and communication. I’ve delivered on those things. I’ve made significant, consistent improvement to the ARM for the benefit of the association and members. I’ve constantly challenged and been challenged by individual grassroots members. And I’ve done my best to communicate and be visible. I try to reach out to people, I write this regular blog and I respond to people wherever I possibly can.

But the role has become increasingly challenging as views become more polarised, members’ positions become more entrenched and discourse becomes more difficult. I have been pulled in many directions at the same time and it is not easy. Often, policy gives a structure and a backbone that governs my work but when issues outside policy come up my remit is governed by BMA articles and bye-laws.

These rules and processes often lead to questions about fairness, and to criticism. Sometimes it ends in people questioning me and my role. But fairness is so often subjective and I cannot campaign for one member’s fairness over another’s. With more than 192,000 members, representation on an individual level isn’t possible. My role is neutral. Sometimes, unfortunately, members won’t get the answer they want even though I truly am listening.

On most days this role has been a pleasure and a privilege – on fewer days, however, it has been difficult and unpleasant. I always welcome challenges – I’m happy for people to ask me to do things differently and better –but I have had increasingly unpleasant experiences and I would ask people who are challenging to be mindful of the way they are doing that, especially if your request is not a possible one. To leaders – what do you do when you can’t meet expectations?

If you have any views on my reflections about leadership, or want to speak or challenge, you can contact me on RBChair@bma.org.uk or @DrLatifaPatel

Dr Latifa Patel is chair of the BMA representative body

Including a spectacular range of excursions: Days 1 – 7: 4-star cultural tour

• Rhodes Old Town: UNESCO World Heritage Site, one of the oldest and largest medieval cities in Europe, with Mandraki Harbour, imposing city wall & one of the wonders of the world, the Colossus of Rhodes.

• Lindos: considered the pearl of Rhodes. With its revered acropolis and magnificent bays, it has earned its place as the most popular attraction on the whole island.

• Marmaris: dreamlike landscape with beautiful islands, forests and bays.

• Traditional artisanry in the fashioning of jewellery and leather

• Pamukkale & Hierapolis (World Heritage): Together with the adjacent „Holy City“ of Hierapolis (admission included), the famous travertine terraces with their thermal springs form a UNESCO World Natural & Cultural Heritage Site.

• Aphrodisias (World Heritage): Capital city Caria, home of artists and sculptors and one of the best-preserved ancient cities in the world, and quite rightly a UNESCO World Heritage Site.

• Kuşadası: magnificent seaside resort and cruise port on the Turkish Aegean Sea.

• Arts and crafts in traditional carpet weaving

• Ephesus (Word Heritage): in ancient times, one of the oldest, largest and most important cities in Asia Minor with many preserved buildings (UNESCO World Heritage Site). With its impressive Temple of Artemis (admission included), one of the Seven Wonders of the Ancient World.

Day 8 – 15: Free extended holiday in an exclusive 4-star hotel in Rhodes

Relax in your modern 4-star hotel on the sunny island of Rhodes. The comfortable rooms are luxurious and modern. Take time out down by the hotel‘s outdoor or indoor pool, or go for a leisurely stroll along the beach.

* In Greece, a climate protection fee of up to €10 (£ 8.55) per room per night applies from 1 March to 31 October for 4- and 5-star hotels. Outside of this period, the state spa and city tax of up to €4 (£ 3.40) per room per night applies (as of January 2024). A deposit of 20% of the tour price is payable on receipt of written booking confirmation. The balance must be paid 80 days before departure. The price applies on 11 February 2025 for flights from Manchester. For other travel periods the prices in the flight schedule on page 6 apply. This offer and any booking only applies to the recipient and accompanying adults and is subject to the booking conditions and privacy policy of RSD Travel Ltd which can be found online at www.rsd-travel.co.uk or made available on request. Note: minimum number of participants 15 people for each travel date. Cancellation no later than 20 days before the start of the trip, if this is not achieved. Estimated group size is 35 people and RSD advises that this tour is not suitable for people with reduced mobility. Subject to misprints and changes. Photographs appearing in this advertisement are illustrative examples of what you may expect from the hotels we use. The 8-day extension can only be used when booked with and in conjunction with the cultural tour and not separately.

Package includes:

(Price when booking the following separately)1

Return flights with a reputable airline2 £3201 to and from Rhodes, incl. hotel transfers

7-day cultural tour of Rhodes & the £6301 Aegean with 2 Ancient Wonders of the World and the 4 most famous UNESCO World Heritage Sites

- 7 nights in a double room in selected 4- and 5-star hotels (national category)

- 7× tasty breakfast

- Round trip in our modern and air-conditioned travel coach with qualified, English-speaking cultural tour guide

- Panoramic catamaran crossing from Rhodes to the Turkish Aegean and back

- Spectacular range of excursions + admissions (as per itinerary)

OUR GIFT: FREE 8 days of relaxation £2501 in an exclusive 4-star hotel in Rhodes

- 7 nights in a double room in an exclusive 4-star hotel (national category)

- Free use of hotel facilities: attractive outdoor pool, heated indoor pool and much more

- Qualified, English-speaking tour guide

Combined price per person £1,2001

Price difference per person – £1,0001

Your rate per person from only £200* £630 £250

Optional services at attractive conditions:

2 e.g. charter flights with Aegean Airlines (Best European Regional Airline 2014-2019 according to the Sky Trax World Airline Award)

3 Feedback provided by customers of RSD Travel Ltd and RSD Reise Service Deutschland GmbH, a European group of companies travelling in 2021/22.

Gourmet package: The package includes a delicious buffet every evening with international specialities during the 7-day cultural tour: only £149 per person instead of £1591

Single room surcharge: £200 per person (subject to availability) £159

1 The combined price of individual components if booked separately was calculated on 14 March 2024 for the travel dates 11 February 2025 to 25 February 2025. Flight from Manchester to Rhodes and Rhodes to Manchester on www.opodo.co.uk (cheapest, cancellable available flight including luggage), transfers airport – hotel – airport on www.suntransfers.com. Best Western Plus hotel, Venus Suite hotel, Charisma Deluxe hotel and Rhodes Skyline suites on www.booking.com. Excursions on www.viator.com and www.getyourguide.co.uk. Between the date of the price comparison and the date of travel, these prices may go up as well as down. The comparative price for the gourmet package is based on the standard prices of our Turkish partner (www.nbktouristic.com).

All the flights and flight-inclusive holidays in this brochure are financially protected by the ATOL scheme. When you pay you will be supplied with an ATOL Certificate. Please ask for it and check to ensure that everything you booked (flights, hotels and other services) is listed on it. Please see our booking conditions for further information or for more information about financial protection and the ATOL Certificate go to: www.caa.co.uk.