The Doctor – issue 8, April 2019

The magazine for BMA members

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Facing up Doctors confront the European refugee crisis which politicians have ignored

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Issue 8 | April 2019

Singing on prescription

When fresh air or company is the best treatment available

A neglected killer

How a fragmented health service is failing patients with asthma

Glaring oversight Eye surgeons angry at a rationing ruse

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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

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

The Doctor is a supplement of BMJ vol: 365 no: 8195 ISSN 2631-6412

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Senior staff writers Peter Blackburn (020) 7874 7398 Keith Cooper (020) 7383 6390 Staff writer Tim Tonkin (020) 7383 6753 Northern Ireland news email news@bma.org.uk Scotland correspondent Jennifer Trueland 07775 803 795 Wales correspondent Richard Gurner 07786 035 874 Senior production editor Lisa Bott-Hansson Designer Andy Bainbridge Cover photograph Anna Pantelia / MSF

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In this issue 4-5

Briefing An agreement on shared parental leave, the pensions tax crisis, and why Brexit lacks informed consent

Welcome Chaand Nagpaul, BMA council chair As doctors we are professionally compassionate as well as professionally caring. We are part of a global community – united by that sense of compassion – and I believe we have a responsibility to speak up for all human life on these shores and beyond.

In this issue of The Doctor we feature a report from the refugee camp Moria, on the Greek isle of Lesvos. There we found some of the families hit hardest by a political crisis around immigration – stranded in a facility bursting at the seams where babies stop growing and children have panic attacks. Doctors provide remarkable care in trying circumstances in Moria. They tend to mothers and babies in temporary buildings, which make the crumbling NHS estate look luxurious and they showcase the best of our profession on an hourly basis: compassion as well as care.

As we move into spring and summer the immigration crisis will become a major news story once more, with the numbers crossing the sea growing exponentially. It is crucial the experiences and perspectives of doctors, advocates for our patients wherever in the world, are heard in the debate.

Also in this issue of The Doctor we tell the shocking story of asthma deaths among children in the UK, which highlights the stark consequences of the failures of successive governments to provide adequate funding for the NHS – creating a fragmented service providing piecemeal, reactive care.

It is a problem highlighted in our landmark, all-member survey as part of the Caring, supportive, collaborative project, which revealed stark concerns about the state of the health service: eight in 10 doctors said underfunding was seriously affecting quality and safety of services and six in 10 said care was compromised by barriers between primary and secondary care.

But as an association we cannot just be there to highlight the problems – we are also an advocate for the solutions – and our project will help to provide workable solutions for a better NHS. At the highest level it is crucial that additional funding promised by the Government finds its way to the front line quickly – and that it is the beginning of a new package of support for services based on collaborative systems and timely access to specialist services.

But when it comes to detail it is critical that doctors and patients are at the forefront of efforts to redesign care locally. The lessons highlighted in these tragic cases must be learned and acted on.

6-11

A neglected killer Patients are dying needlessly of asthma, in a fragmented health service where warnings go unheeded

12-13

Glaring oversight A rationing ruse deems cataract surgery of ‘limited clinical value’

14-19

A place of refuge?

A deal to keep migrants fleeing wartorn countries from entering Europe has left thousands in squalid, overcrowded camps where their health deteriorates further

20-23

Prescribing hope Walking, singing, fishing – soon to be widely available on prescription

24-25

Practice makes perfect Scotland’s GPs, a year into a new contract aiming to transform primary care

26-30

Life experience Thank-you gifts, a Good Samaritan rebuffed, and is personalised healthcare just for the rich?

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What’s on Keep on top of events

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The chancellor must now listen

briefing

SHARE THE LOVE: Parents will benefit from workplace equality gains

Current issues facing doctors

WIJESURIYA: The situation has contributed to the gender pay gap

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Fair deal for parental leave Shared parental leave was introduced in the UK in 2015, but take-up has been relatively low.

For junior doctors, the rotational nature of their work meant that many were unable to accumulate the 26 weeks of continuous employment that would entitle them to it.

Even if they did qualify, the low statutory pay (£145 a week), acted as a financial barrier, because unlike maternity or adoption leave in the NHS occupational pay did not apply for shared parental leave.

So, many couples who might have otherwise wanted to share caring responsibilities had to revert to the previous situation of just the mother or primary adopter taking leave.

Now, a landmark agreement, resulting from campaigning by the BMA junior doctors committee, between NHS trade unions, NHS Employers and the Department of Health and Social Care means that junior doctors in England will be able to qualify for the higher rate of occupational pay. It is one of a series of important gains on workplace rights and equality.

JDC chair Jeeves Wijesuriya said the situation previously meant ‘parents wishing to take time away from work to share in child care have been unable to, which in turn has compelled one parent to take most of the leave and time out of their career, a situation that has contributed to the gender pay gap within medicine’.

He added: ‘Junior doctors will also receive the equivalent to statutory pay for maternity, adoption and shared parental leave as well, which they have missed out on previously due to their rotational contracts.

‘Also, any time on an approved out-of-programme experience will now not affect your continuity of service and entitlement to leave.’

There is also a right to a day in lieu if junior doctors work on a paid keeping-in-touch day.

The efforts to extend these rights to other doctors and those in the devolved nations, and thus ensure equality across branches of practice as well as gender, is one that the BMA is determined to continue to fight for. bma.org.uk/spl

UK pension rules fuel NHS staffing crisis. Consultants turn down shifts over pension fears. NHS chiefs hold emergency talks over pensions tax crisis.

They’re all headlines from the sober-headed Financial Times.

Enough to make the chancellor, Philip Hammond, sit up and take notice you’d think?

Well, think again.

Despite repeated warnings since last summer, the Treasury has stubbornly refused to meet the BMA consultants committee to discuss the issue.

The crisis is being caused by ‘a taper’ on pension allowances, which came in the year Mr Hammond became chancellor, that’s 2016. It’s landing consultants and other senior doctors, such as GP partners, with tax bills of four, five and even six figures. No wonder they’re retiring early or being forced to decline extra work which would relieve NHS pressures.

In one case, reported on BBC Radio 4’s Moneybox, a doctor was hit with a £13,000 tax bill for earning an extra £10,000.

Doctors have already shown their feelings in force. In just four days, more than 1,000 have dispatched letters to their local MPs with a template prepared by the BMA.

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MPs in the know are similarly concerned by the crisis. Conservative MP for East Renfrewshire and former pensions solicitor Paul Masterton held a debate on the issue in Parliament’s Westminster Hall this month.

The Treasury was invited but ducked it. We know how Mr Masterton must feel. The Government sent the Department of Health and Social Care minister Jackie Doyle-Price instead.

The BMA is calling on Mr Hammond to rethink the allowance to prevent the NHS further haemorrhaging senior doctors.

He’s recognised our health service as ‘precious’ and a number-one priority for the public in Parliament.

So when will he recognise the crisis about to engulf it? We won’t stop until he tells us and finds ways to fix it. You’ll be hearing from the BMA again soon, Mr Hammond.

HAMMOND: Refusing to acknowledge the pensions tax crisis

Keep in touch with the BMA online at

REMAIN SOLID: Dr Nagpaul (third from left ) and colleagues attend the people’s vote march

No Brexit without informed consent When the economist John Maynard Keynes was accused of altering his view on an issue, he is said to have replied: ‘When the facts change, I change my mind. What do you do?’

Since the EU referendum in June 2016, the facts have not only changed, but many things presented as facts – ‘the easiest trade deal in history’, £350m a week for the NHS – have turned out not to be facts at all.

The BMA thinks the public should be able to have a say on whether to accept whichever deal politicians agree. Its support for a people’s vote, and its opposition to Brexit, received overwhelming backing at the association’s annual representative meeting last summer.

An estimated million protesters took to the streets to support a people’s vote last month, and among the speakers was the BMA council chair Chaand Nagpaul.

He outlined the many harms which have already been wrought upon the health service, such as the 35 per cent of doctors who qualified in other EU countries and who told a BMA survey they were thinking of leaving. And he warned of the dire consequences of leaving the EU without any deal at all, including the threat to membership of Euratom and the European Rare Disease Network, which could delay diagnoses and treatment.

Fundamentally, the call for a people’s vote is about consent.

Dr Nagpaul told those at the rally

instagram.com/thebma

that a refusal would be like a doctor failing to inform a patient of a change in their medical circumstances in the period between consent and an operation taking place.

‘We wouldn’t force them to undergo a treatment which would harm them because of a choice they made before they had all the information they needed,’ he said.

‘That would be immoral and wrong. And yet when it comes to Brexit, that’s precisely what we are doing. The public are being told that they don’t have the right to be given another choice, regardless of what we know now and the consequences this could have.’

And those who make interventions without informed consent may, quite reasonably, be accused of wrongdoing. It is the needless attacks on the health service which the BMA is trying to stop.

Read more online GMC plans to survey SAS doctors Shared parental leave boost for juniors Loss of cervical screening contract ‘only right’ Figures fail to reveal extent of vacancies Brexit: put patients first Read all the latest stories online at bma.org.uk/news

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A neglected An expert review gathers dust, coroners issue strongly worded warnings, but in a fragmented health service, patients are still dying needlessly of asthma.

Peter Blackburn investigates

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killer M

ichelle Aydin stood helplessly outside her home waiting for an ambulance as neighbours performed CPR on her daughter.

‘I couldn’t watch it – she was just so little, lying there on the floor,’ Ms Aydin recalls, sitting just feet from where seven-year-old Isabel had lain.

‘I’m sorry, mummy,’ had been among Isabel’s last words before she fell unconscious in her mother’s arms. Her breathing difficulties had become too much for her frail body.

‘It all just seemed to happen so quickly,’ says Ms Aydin, from east London.

‘Her breathing wasn’t great during that day but she seemed OK, I thought she was fine.

But suddenly it changed. I have never heard a sound like it. She was really struggling.’

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SARAH TURTON

TAKEN AWAY: ‘You never think you are going to lose your child – and not to asthma,’ says Ms Aydin

Just hours later in hospital Isabel was pronounced dead. A little girl with so much potential – a keen footballer and karate medallist with an adoring family. In a rich country with a universal healthcare system, few would even consider that asthma could snatch a loved one away.

Isabel’s death highlights a whole host of questions in the NHS and wider society – shining a light on an underfunded, fragmented health service and a society complacent to the risks of asthma. And, sadly, the Aydin family’s tragedy is not an isolated case.

Coughing fit

‘Suddenly it changed.

I have never heard a sound like it. She was really struggling’

Just weeks before Isabel’s inquest, earlier this year, The Doctor was present at another hearing, addressing the circumstances around Sophie Holman’s death.

Ten-year-old Sophie, who also lived in east London, had 48 asthma attacks in her short life. At her death she had been admitted to hospital 13 times, attended emergency care on six occasions, and been treated 29 times at her GP surgery.

In December 2017 after suffering breathing difficulties her family took her to hospital. On the way to the hospital, Sophie had a coughing fit and got out of the car to try to catch her breath.

She lost consciousness by the side of the road, lips blue, unable to take in any air. She later died.

The inquest heard that Sophie and her family were let down in many ways: she had no proper asthma plan and she was discharged from secondary care because appointments had been missed and hospital staff assumed that she was OK. Despite so much contact with the health service in her short life, no one clinician took charge of Sophie’s care, and no obvious strategy for prevention or treatment was put in place.

Coroner Shirley Radcliffe felt the circumstances were so serious she issued a regulation 28 statement – a warning of potential future deaths if the system does not change – to health secretary Matt Hancock and NHS England chief executive Simon Stevens.

The statement was unequivocal. It said: ‘There were many missed opportunities to optimise and coordinate Sophie’s medical management during her 48 attendances and admissions in the practice and hospitals (at least 10 of which included life-threatening features)…

‘There were a number of missed opportunities to refer this child to a specialist respiratory team for investigation to characterise the nature and triggers of her chronic asthma condition and to optimise her

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‘There was no long-term cohesive plan’

RECOMMENDED: The NRAD report

medical management. it examined were avoidable.

‘The medical records in the The majority of patients who practice and hospitals lacked died had not been under clear information highlighting specialist supervision or had the severe ongoing risk of a personal asthma plan. poor outcome including It came up with 19 future asthma death in recommendations, such the case of this child; there as patients having followwas no cohesive long-term up appointments after emergency admissions or plan for managing Sophie’s ISABEL AYDIN: using the out-of-hours service, asthma with the result that no one Her death was not an isolated case annual structured reviews and recognised the cumulative risk named clinical asthma leads in factors that should have led to a hospitals and general practice. Five specialist respiratory referral which years on, only one of the recommendations has may have resulted in a very different outcome.’

Closing the inquest at Walthamstow been implemented – a national asthma audit – although it has yet to report its findings.

Coroner’s Court Dr Radcliffe said Sophie’s Mark Levy was expert witness at the four long-term management by primary and inquests and co-wrote the NRAD. The failure of secondary care was ‘inadequate’, adding Government and NHS England to act upon the that a ‘fuller assessment, earlier steroid report’s findings is a source of great distress to administration and better safety netting’ the north London GP. would have prevented her death.

‘I’m very depressed really – I have sat behind At the conclusion of the long and painful four families crying at an inquest when they inquest Sophie’s grandmother, struggling realised that the care of their loved child could through tears, said she was ‘devastated’. have been a hell of a lot better. I’ve found it Warnings ignored extremely sad and I’m incredibly angry.

Another family torn apart. And another warning ‘There’s no kind way of putting it. I keep that the problems experienced in these cases banging on about it, but the Department of could be gaps in the system for others to fall Health commissioned the review and the through: the case for change could hardly be recommendations have not been implemented more obvious. nationally. And that’s despite three different Yet this is far from the first such warning regulation 28 statements on childhood asthma to be issued. In April 2014 Terence Carney, in which each recommends implementation of senior coroner for Gateshead and South the review on a national basis.’

Tyneside, was strongly critical of the management of 13-year-old Tamara Mills’ Investment and education asthma in a regulation 28 statement. She had There were 1,446 asthma deaths recorded had 47 acute asthmatic episodes in the last in England, Wales and Scotland in 2017, a four years of her life but it was never considered 19 per cent increase in five years. that each was a ‘deteriorating step in her overall The Global Asthma Report 2018 found respiratory wellbeing’. the UK’s mortality rate for 2011-15 was in And Dr Radcliffe had also ruled in the case of the top-10 of high-income countries where nine-year-old Michael Uriely. In March 2017 she asthma is separately coded as a cause of issued a regulation 28 report to NHS England, death. It was higher than any other European Health Education England and NICE in which country in the table, except Estonia. she said Michael’s asthma was uncontrolled Dr Levy says proper resourcing is essential, and with no evidence of an ongoing, coherent and that the right investment could save plan. Nor had he been referred to or seen by money by reducing hospital admissions. a specialist respiratory paediatrician. These He cites the lack of a national plan, a failure are not isolated cases. NRAD (the National to educate patients and their families and the Review of Asthma Deaths), commissioned by inadequacy of the quality and outcomes the Department of Health and published in framework in general practice in addressing 2014, found that almost half of the fatalities the complexity of the condition. thedoctor | April 2019 09

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‘Instead of taking her to school every day we’re at the cemetery’

Dr Levy also blames the same issue that seems to underlie so many problems in the health service, that of fragmentation.

Isabel Aydin had 13 consultations in general practice, at least nine of which suggested her symptoms were uncontrolled, over a seven-year period. And yet she was not under the care of a specialist asthma service and there was no clear plan for the prevention of further attacks or continuity in future treatment.

This appears to be a health service which still has a wall between primary and secondary care, one which is more than capable of treating acute incidents, but with nothing like the same sophistication in tracking patient care and sharing records.

Dr Levy says: ‘Because of the fragmented care it’s hard to know what’s happening with the patient – I said, for example, give them a frequent-attender card like a maternity folder – then every time it would be obvious. It’s a no-brainer to do something. If something like that was produced nationally for everyone with asthma it would definitely help.’

Best practice In terms of treatment, it can be expensive – a study for the British Thoracic Society estimated treatment costs for severe asthma as more than £4,000 per patient, per year. For Dr Levy that only underlines the importance of following best practice.

A pilot project he led for Harrow clinical commissioning group found that if NRAD recommendations had been followed in the case of almost 300 children who had suffered asthma attacks, there would have been a 16 per cent reduction in hospital admissions.

Dr Levy says: ‘It has been clearly demonstrated that people with severe asthma cost as much as conditions such as type 2 diabetes – so the cost of putting services in place might seem a lot but may be good value in the longer term. The way the funding is often dictated by political cycles means this does not always happen.’

Fundamentally, Dr Levy says, the health service is ‘complacent’ about asthma. Even if financial support were available and political will plentiful, he says some clinicians are unaware of the seriousness of the condition, and as a result, patients and families are too.

There is no sense of a national strategy, which could help individual planning for patients.

LEVY: Investment could save money by reducing hospital admissions

There would appear to be quite fundamental gaps in knowledge. In the case of Sophie Holman, a lack of awareness of national guidelines, NRAD recommendations or British National Formulary prescribing advice, said the coroner.

Costly fragmentation BMA council chair Chaand Nagpaul says the ‘tragic stories highlight stark failures in the formation and the funding of the NHS which many patients, families and frontline staff have been adversely affected by over recent years’.

He adds: ‘These tragic stories highlight the stark consequences of the inadequate funding of the NHS and of a service providing piecemeal, reactive care in which many patients, families and frontline staff have been adversely affected by over recent years.

‘The BMA has long argued for an end to the short-sighted, and costly, fragmentation of the service in which patients slip through the net, with a failure of organisations and providers to work together to provide coordinated and proactive care to patients.

‘It is crucial that additional funding promised by the Government finds its way to the front line quickly.’

Ms Aydin says she always had the impression from contact with the NHS that her daughter’s asthma was mild.

She says: ‘I had asthma as a child, but I didn’t realise how common it could be that people die from it. Only since we lost Isabel have I found out that a lot of children die from it. It’s quite shocking. You obviously never think you are going to lose your child – and not to asthma.’

The case for improvement seems indisputable, so how can it be made to happen?

Well, first things first, says Dr Levy, the NRAD recommendations are readily available to NHS leaders. There is already a blueprint for change in place – the next step is finding the will, and the finance, to enact it.

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‘Because of the fragmented care it’s hard to know what’s happening with the patient’

LIVING MEMORY: Isabel’s parents

Dr Levy says if the Government wanted to enhance the evidence base first, it could always try applying NRAD standards in one area first.

‘Take an area like London and put a programme in place where there is a formal recognition that patients who have difficultto-treat or severe asthma are referred to a specialist clinic and start there. Implement the recommendations in the report… and you could make a big difference.’

NHS England national clinical director for children, young people and transition to adulthood Jacqueline Cornish said the NHS Long-Term Plan would ‘improve asthma diagnosis and has… set up a database to understand the causes of harm to young people’. She also said that a new dedicated programme for young people’s health in the plan would tackle major conditions including breathing problems.

The Department of Health and Social Care did not provide a comment.

There may be cause for optimism when it comes to the establishment of PCNs (primary care networks) where groups of GP practices, serving populations of up to 50,000, will come together to encourage integration and the creation of local solutions to local problems.

Dr Levy hopes that each PCN would have its

own asthma lead overseeing care and access to a specialist service.

Dr Nagpaul says: ‘Doctors like Dr Levy and patients must be put at the forefront of efforts to redesign care locally if integrated services are to be achieved – and as we move toward PCNs and other local partnerships these tragic lessons must be learned and acted upon.’

When it comes to recommendations, standards and reports, perhaps the men and women sitting in the offices of state or standing at the helm of the NHS can only hear so many demands for change. But this isn’t just about recommendations, standards and reports – it’s about the lives of the families the health service is designed to care for.

Sitting on the sofa where Isabel Aydin used to snuggle with her mum, a bag of sweets on her lap and a film on the TV, it’s much more difficult to turn a blind eye to the tragedy caused when calls for action are ignored.

‘We’ve been robbed,’ Ms Aydin says, trying to express what Isabel’s death has done to her family. ‘Instead of taking her to school every day we’re at the cemetery every day. There’s no one around, the house is empty and there’s nothing now – no laughing.

‘We have been let down. There’s no second chance for us.’

SARAH TURTON

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ISTOCK

EYE SPY: Is cataract surgery really of ‘limited clinical value’?

Glaring oversight M Cataract surgery, one of the safest procedures and with some of the best outcomes, has been deemed of ‘limited clinical value’ by commissioners in what’s seen as nothing more than a money-saving ruse.

Tim Tonkin reports

any things have been said about cataract surgery.

Life-changing, for sure. ‘Miraculous’ is not to everyone’s taste, but restoring sight has biblical connotations and it’s hard to underestimate going from near blindness to seeing the world through new prescription lenses.

It’s one of the safest procedures, with the best outcomes. What you don’t tend to hear is that it’s of ‘limited clinical value’.

‘Limited clinical value’ – are we talking about the same procedure? But that’s the reason given by large swathes of the NHS for restricting access to it.

The BMA has always said

that if the NHS is going to ration (or ‘prioritise’ – the word ‘ration’ is itself rationed) then it should be an open and honest debate, involving the public.

However, research by the MTG (Medical Technology Group) last month found that more than half of English CCGs (clinical commissioning groups) are restricting access to cataract surgery by listing it as a ‘procedure of limited clinical value’ or ‘procedure of prior approval’.

Under this designation, the surgery is classed alongside cosmetic treatments such as dermabrasion and tattoo removal.

The MTG, which is made up of patient groups, research charities and medical device

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manufacturers and lobbies for greater access to medical technologies and treatments, found that ‘just over half of English CCGs listed cataract removal in that way’.

Lack of vision NHS Clinical Commissioners, the national body representing CCGs, has responded to the findings by describing the limitations on accessing treatment as a regrettable but often unavoidable consequence of the systemic financial pressures on the health service.

‘Wherever possible they [CCGs] want to give them what they need,’ a spokesperson says.

‘Unfortunately, the NHS does not have unlimited resources and ensuring patients get the best possible care against a backdrop of spiralling demands, competing priorities and increasing financial pressures is one of the biggest issues CCGs face.’

Many CCGs are also choosing to make access to surgery contingent on patients scoring sufficiently low enough on a visual acuity assessment before they will be prioritised for treatment; in direct contradiction to NICE (National Institute for Health and Care Excellence) guidelines in 2017.

East Midlands consultant ophthalmologist Amar Alwitry says that while he

‘Patients are having to endure long delays before they can undergo cataract removal’

understands the financial pressures faced by all parts of the NHS, it is unfair to place access restrictions on such an important and costeffective treatment.

Mr Alwitry says that in his own professional experience he has encountered patients with cataracts whose visual acuity was above the threshold in one eye but below it in the other.

He says that by labelling cataract surgery as of limited clinical value, was effectively creating a situation whereby patients might be told that they could only receive treatment for one of their eyes.

‘Cataract surgery is one of the safest and most common procedures we undertake.

We continually strive to improve and preserve our patients’ sight, and it is hard to turn patients away when you know they deserve and would benefit from second eye surgeries.

‘I appreciate the need to balance the books and as a nation we need to understand the necessity of using our finite resources wisely but refusing second eye cataract surgery does not save money. It simply delays the procedure and leaves our patients with poor vision for longer.’

While there is no national policy on how to define medical procedures as being of limited clinical value, guidance published last November by NHS England identified 17 procedures that it felt should not be routinely commissioned owing to their limited clinical value. Cataract removal is not among them.

‘It is unfair to place restrictions on such an important treatment’

Royal College of Ophthalmologists president Mike Burdon insists that financial pressures provide insufficient reason to limit a patient’s access to treatment.

‘Cataract surgery is one of the most efficient procedures in the health service and

BURDON: ‘Cataract surgery is one of the most efficient procedures’

the new guidelines will significantly improve the safety and quality of patient care, removing variation in treatment across the UK,’ he says.

‘There is no justification for CCGs restricting access to cataract surgery. CCGs must take notice of the NICE recommendations which reinforce the message that cataract surgery should be delivered at point of clinical need.’

BMA council chair Chaand Nagpaul says: ‘The rationing and postcode lottery of such a simple and effective treatment as cataract surgery, is an indictment on the inadequate funding policies of successive governments towards the NHS. ‘The Government has a responsibility to ensure that the NHS provides consistent treatment to patients regardless of their postcode, and to provide the level of resourcing it requires so that patients do not have to endure the health inequalities that underfunding results in.’ thedoctor | April 2019 13

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‘The referrals we get are people screaming through the night.

Not able to wash or dress. Not eating’

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ANNA PANTELIA / MSF

A place of refuge?

A deal to keep migrants fleeing war-torn countries from entering Europe has left thousands in squalid, over-crowded camps where their health often worsens further.

Keith Cooper visits one of the largest camps, on the Greek island of Lesvos

T

hey call them ‘soft signs’ in the paediatric clinic outside Moria, a refugee camp. Bed-wetting is one. ‘We see it a lot,’ says the Italian consultant paediatrician Carola Buscemi who helps run the clinic on Lesvos, Greece, for medical charity MSF (Médecins Sans Frontières).

Then there are the children who have panic attacks in the clinic, as young as six or seven, at least once a week. The babies who stop growing, under the conditions of the camp.

‘This is not normal,’ says Dr Buscemi. ‘These people are completely collapsing. The conditions in the camp are terrible.’

Yet these and other horrors are the new normality in Moria and other camps, on a chain of Greek islands between Turkey and Europe. Together, they make up a ‘sea border’ on the eastern edge of the continent.

Concerns about the ‘abhorrent conditions’ in camps on two of the islands, Lesvos and Samos, have been raised by MSF and others for years and each year the conditions worsen. The deterioration is linked to a deal between the EU and Turkey in 2016.

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SOCRATES BALTAGIANNIS

DOWN AT HEEL: Junior doctor Leonidas Alexakis examines Omid Mahdi Sultani from Afghanistan, aged 11

49%

12%

12%

9%

Afghanistan

Palestine

awful conditions of the camps? And what is the effect of the EU-Turkey deal?

Under the deal, Turkey received €6bn to take back asylum seekers who arrive in Greece by boat without official permission. To aid these returns, the Greek authorities prevent them from leaving the island, trapping thousands in camps of limited capacity. The number returned has been far lower than expected, as Greek courts find in favour of refugees’ claims that Turkey doesn’t offer adequate protection.

EU member states including the UK, however, consider the deal a ‘success’ for significantly stemming arrivals and reducing fatalities from perilous sea crossings. Migrants who do still arrive from war-torn

‘You have enormous overcrowding, people living here for one to two years in circumstances that are not acceptable’ countries such as Afghanistan, the Democratic Republic of the Congo and Syria have responded by switching to other routes.

Others, unable to reach European shores, remain scattered. There are millions of displaced people held in limbo in Jordan and the Lebanon. Among the unluckiest are those being held in appalling conditions in Libyan detention centres, vulnerable to extortion, torture, sexual violence, and forced labour (see ‘Humanity let down by its leaders’, on page 19).

The dead and missing at sea are still in the thousands, and although numbers of people on the sea are reducing, the UN said last September that one in 18 trying to cross the Mediterranean died en route.

MSF Lesvos field coordinator Caroline Willemen says the EU-Turkey agreement has worsened conditions in the camp, despite the drop-off in arrivals.

‘When people arrived in thousands, they would stay in Lesvos for one or two days before taking the boat to Athens to continue their journeys,’ she says.

Source: UNHCR, figures for February 2019

Iraq

Syria

6%

Democratic Republic of the Congo

Gr

Country of origin of refugees arriving in Greece by sea

‘Now there are fewer people arriving but the impact is much, much worse. You have enormous overcrowding, people living here for one to two years in circumstances that are not acceptable.’

Prefabs and high fences MSF closed its clinic inside the camp when the deal was signed and no longer takes funding from the EU or its member states.

‘We want to provide care to those who need it most; not be influenced by political actors,’ Ms Willemen says. The vast majority of its income comes from private donors.

The paediatric clinic is now in a medical compound, across the street from the high walls and barbed wire fences of Moria. Through a gate in the compound’s chain-link fence, you arrive at shipping containers, prefab buildings and tents, families standing around, children clambering over wooden benches, whiling away time. It’s 10am and Leonidas Alexakis, a junior doctor who grew up in Belgium and trained in Thessaloniki, sits at a plastic picnic table in a prefab hut, questioning parents, scribbling notes.

First in today is a two-year-old asthmatic, recovering from a chest infection. Next, a young man arrives in flip-flops with a sore toe. It’s examined, cleaned, dressed and antibiotics are dispensed from the on-site pharmacy. Dr Alexakis consults a colleague, Dr Buscemi, about an opening in the neck of a young girl, which weeps – an infection risk. She agrees it’s a thyroglossal cyst. In the UK there would be a straightforward surgical solution, but in the camp, there is the perennial problem of limited access to washing facilities for patients to keep wounds clean after surgery. Women and girls fear walking to the washroom at night.

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SOCRATES BALTAGIANNIS

Capacity and occupancy on the islands

Chios

3,100

Capacity

4,871

648

Capacity

Occupancy

Kos 816

Capacity

Samos

Greece

1,391

Occupancy

Samos Leros Kos

1,014

Capacity

Lesvos Lesvos

Chios

3,675

773

Occupancy

Leros

Occupancy

Source: 31 January occupancy figures, the Greek Government

860

Capacity

966

Occupancy

‘A newborn and a mother who just gave birth shouldn’t be living in a tent’ You can’t enter the official camp, a former military base, without a permit but you can peer in from a hillside. There are staircases of terraced pre-fab accommodation, toilet blocks, families walking together, children dashing down a steep concrete slick, a main street of sorts.

Conditions inside are tough, parents at the paediatric clinic tell us. ‘We live in an Isobox [a prefab block], sharing it with other people. It makes it really difficult to support her,’ one mother attending the clinic with her two-year-old daughter tells us. ‘Almost all the time, she is sick. It doesn’t feel safe.’

It can take hours to queue for meals, piling further stress on families with sick children. Many come to the clinic with scabies and lice.

Self-harm If conditions are bad in the old military base, they’re much worse in the Olive Grove, an unofficial overspill, where refugees live and sleep in tents, amid the mud and gnarly trees. The official camp’s capacity is 3,100 but almost 5,000 were living here and in the Olive Grove in March.

Conditions worsen with rising numbers, of course.

It’s low season now, after months of reduced crossings through winter. However, last summer, the population rose to 8,000, and doctors in the paediatric clinic spent time stitching together the self-inflicted cuts of young men and women. MSF provides individual and

CARE IN CRISIS: Italian consultant paediatrician Carola Buscemi with a mother and child in Moria

group therapy to help children to cope with the stress, and classes for parents to help spot the signs.

Heavy rain turned the Olive Grove into a muddy bog last winter. Newborns were found by the charity Oxfam to be sleeping in tents. Today, the mud’s turned to dust, spraying as the ground is flattened to prepare for more arrivals. It’s littered with rocks, bottle caps, the rusting hulks of wood burners. We find a family, recently arrived from Afghanistan, with a small baby. ‘No electricity.

Not good for the children,’ one of their party says.

MSF employs three social workers who can seek alternative accommodation for families which come to their attention, when women bring babies to clinics or see midwives for antenatal appointments. ‘You could question why it is necessary for us to intervene,’ says Ms Willemen. ‘Why is it not obvious to every single person that a newborn and a mother who just gave birth shouldn’t be living in a tent?’

They struggle more to find alternative accommodation for less obvious cases, Ms Willemen adds, such as men who are physically strong but victims of torture, from war zones, who are suicidal.

‘It’s important not to forget that group,’ she says.

MSF struggles to convince accommodation providers to take such people in.

‘We argue that putting them in a better place will vastly reduce the risk of suicide,’ she says. ‘They will argue – and to an extent I understand – that they don’t have the staff to support them.’

To help this group, the charity set up in late 2017 a mental health clinic in a suburb of Mytilene, the capital of Lesvos. It’s run by medical activity manager Elizabeth Clark – a Luton GP. Referrals come in via email from other medical NGOs (non-governmental thedoctor | April 2019 17

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SOCRATES BALTAGIANNIS

Arrivals across ‘sea border’ between Turkey and the Greek islands in 2017-18

Feb 1,089

April 1,156

June 2,012

Aug 3,584

Oct 4,134

Dec 2,364

Feb 1,256

Source: UNHCR

LEFT IN LIMBO: Tents in the unofficial overspill of the Olive Grove

Worst-case scenario The most complex cases are seen by Alessandro Barberio, a Rome-trained psychiatrist, born in Bari, Puglia, at the top of Italy’s heel. His patients’ symptoms are not unlike those of schizophrenia, he says, but their conditions are not chronic but ‘reactive’.

‘Here, there’s a concentration of the worst determinants for mental health diseases,’ he says.

‘The environment, the lack of hope, the lack of a possibility to improve, the impossibility of empowerment.

18

SOCRATES BALTAGIANNIS

organisations) on the island, such as the Boat Refugee Foundation, a Dutch one and the UK-based Kitrinos Healthcare.

It only sees victims of torture, violence or sexual violence, but there are not many in Moria who haven’t had such experiences, Dr Clark says.

‘The referrals we get are people screaming through the night. Not able to wash or dress. Not eating. Putting stones in their mouths. Walking into the woods with a rope.’ They often arrive with a carer. ‘They can cower under the sink, they’re so fearful. They’re dissociating.

They think they’re back where they’ve been tortured.’

Their trauma often comes in layers, including the one added by the conditions of the camp. ‘There’s trauma in their country of origin, their journeys, then there’s the environment,’ Dr Clark adds. ‘There’s the fences, the barbed wire, the police going around in Moria, sometimes in riot gear. The noise. The queues for food.’

Then, there’s past history and trauma.’

He uses the word ‘horror’ a lot to describe the experiences he hears. ‘All of our patients are in a different state of mind. Confused, disoriented, terrorised, scared, anguished, hallucinating. During a session, someone might be looking around, asking, you don’t see it? What, are you not afraid? You don’t see my brother, decapitated.

They can smell, also, the blood. It’s always a horror, the violence, the torture. Every time, I feel touched and surprised. Maybe the moment I don’t feel anything, I will leave.’

Dr Barberio recalls the first time he visited Moria, last year. ‘It was overwhelming. There were these contradictions. A lot of people in makeshift tents, this very particular smell. But also a lot of vitality. Children playing in the dust, the dirt. There is still something so vital about these people. They try to survive. Meanwhile, there is this representation of a ghost. Of no freedom, of no basic life conditions.’

The clinic aims to stabilise patients, so they can survive in the camps. For the first weeks, they attend several times a week, are treated by a multidisciplinary team, including doctors and psychologists, and given small amounts of drugs.

They hook patients up with social activities, such as language classes and sports, run by other NGOs or local organisations, such as Shower Power, which providers showers so women can wash in safety. It’s part of its ‘biosocial’ approach and has had surprising success.

‘There can be a very dramatic improvement in their symptoms,’ Dr Clark says. ‘We try to build trust that here is a safe place. That here, nobody can hurt them. It’s fabulous to see them improve but we’re only dealing with the few at the top of this iceberg in Moria.’

Ms Willemen knocks on the table when asked if Moria really is the worst refugee camp on earth, as the BBC once described it.

‘Somehow this feels different,’ she says. ‘I’ve worked in Nepal, after the earthquake. I’ve seen some bad things.

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SOCRATES BALTAGIANNIS

GROWING PAINS: Dr Alexakis sees Afghan refugee Sahar Yaqubi, aged 2

Humanity let down by its leaders

‘There’s trauma in their country of origin, their journeys, then there’s the environment’ But that was force of nature. Here, it’s purely politics. It’s the EU wanting to somehow push migrants towards their border. Somehow you feel personally complicit. It’s my part of the world.’

Dr Clark talks of her defence mechanism. ‘I just repeat to myself: there are lots of people, doing lots of small good things. People are good.’ She’s glad she doesn’t have to visit the Moria camp much. She doesn’t want to.

‘I just feel this thing, coming up inside of me,’ she says, raising her arms to her stomach. ‘We moan at Donald Trump and his Mexican borders. But it’s the same.’

It seems personally affecting to care for people, children and tortured adults, in an overcrowded camp where many live in tents and the mud in a corner of Europe to which they feel connected. With winter at an end, they brace for spring and summer, when arrivals rise, trapped on the island by the EU-Turkey deal – and conditions in this already overcrowded camp inevitably worsen once more. bma.org.uk/humanrights SOCRATES BALTAGIANNIS

GROUNDED: A young boy drags a makeshift kite after him

Asylum seekers have been let down by Europe’s failure to agree on an equitable way to handle forced migration, says BMA senior policy adviser (ethics and human rights) Charlotte Wilson The humanitarian crisis on Lesvos is not a natural disaster – it is the inexorable outcome of a political stalemate.

When refugee and asylum seeker arrivals to Europe peaked in 2015, EU immigration policies saw member states on Europe’s borders – including Greece – become legally responsible for processing and absorbing a disproportionate number of asylum claims. Repeated calls for reform to enable the fair distribution of asylum seekers across the EU have come to nothing. The refusal to contribute by some states has led to a refusal to contribute by other states and as negotiations have dragged on border countries have become overwhelmed.

Unable to reach agreement, Europe has focused on implementing policies which stem migration. One is the EU-Turkey deal, others include the construction of razor wire fences through the Balkans, and an agreement between the Italian and Libyan Governments which has seen tens of thousands of refugees and asylum seekers forcibly returned to Libyan detention facilities where they are vulnerable to human rights abusers.

With the focus on preventing refugees and asylum seekers from reaching Europe, the migration narrative has changed course. It has become easy to paint refugees and asylum seekers as a threat or ‘problem’. The language of human rights and human experience is often lost in this context.

The immigration debate is highly politicised and awash with misinformation – in this case about the effects of immigration (which the evidence shows, are largely positive) and the financial and administrative capacity of EU members states. As a result, public opinion has swung against immigration, undermining the success of evidence-based policies in the future. This is a chilling prospect, as forced migration is set to increase, and will be a defining issue of the 21st century.

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FERTILE GROUND: Patients in east London try their hands at gardening

Prescribing hope The NHS has pledged to create ‘an army’ of 1,000 social prescribers in a bid to help patients lead fitter, healthier lives and combat increasingly common physical and mental health conditions.

Peter Blackburn asks what it might achieve

S

am Everington may work in one of the UK’s poorest areas, but it’s creativity and hope, rather than deprivation, that have made his practice famous.

The Bromley-by-Bow centre in east London has become one of the driving forces for social prescribing, and with it, the idea of treating patients ‘holistically’ – the philosophy that greater emphasis on preventive interventions can dramatically improve the health and wellbeing of the public and save money.

The approach, which Sir Sam and his colleagues have followed for more than 20 years, may at last be about to become more mainstream.

Earlier this year, the BMA

GPs committee and NHS England announced plans to fund social prescribing link workers for PCNs (primary care networks) in England, in a bid to help patients find effective alternatives to traditional medicine.

It came as part of the English GP contract agreement, which included £2.8bn more funding for primary care by 2023/24.

In east London, the need for concerted action could hardly be more acute. The borough of Tower Hamlets has some of the widest health inequalities in the country, with the affluence of Canary Wharf and areas where, anecdotally, 55-year-olds have the kind of health expected of someone 20 years older.

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URBAN SANCTUARY: At Bromley-by-Bow, referrals can be easily made to a social prescribing link worker

In Bromley-by-Bow, there is a scheme that allows GPs to refer patients to a social prescribing link worker who can then get in touch with any of around 1,500 local community organisations, seeking to address the wider determinants of health problems, such as diabetes or anxiety, with supported access to community groups running all sorts of activities and schemes – from

‘The traditional consultation might be a prescription, a leaflet or a referral to a specialist but there’s a fourth dimension – social prescribing’ singing classes, cookery schools or fishing to debt management, benefits advice or housing help.

It builds on the solid body of evidence, amassed by Professor Sir Michael Marmot and others, that so many of the wider determinants of health, such as poverty, housing and early-years education, are outside the traditional scope of the NHS. While no GP practice can solve these problems by itself, what it can do is connect patients with relevant services and healthy activities.

Sir Sam says: ‘We recognise that GPs are under a lot of

pressure in a 10-minute consultation – there’s a referral form in the system which takes 20 or 30 seconds to complete, with tick boxes around weight, unemployment, debt issues or repeat attender, for example. The traditional consultation might be a prescription, a leaflet or a referral to a specialist but there’s a fourth dimension, which is social prescribing.

‘The evidence is very clear that actually it is quite often much more powerful than the drugs and the traditional things we do. It’s providing a much better and more holistic health offering. At your fingertips is a much bigger team – it’s the team that creates quality and safety whether in hospital or in general practice – you can be the most brilliant clinician, but this automatically extends your team and that’s where so often the failures in care are.’

The results of the work in Tower Hamlets have been remarkable.

An evaluation last year said patient wellbeing scores had improved and that every £1 invested in social prescribing locally generated an annual social return on investment of £2.30, which means returns of £864,800 per year for the health and care system in Tower Hamlets.

Local health leaders are confident they will soon have robust evidence of reduced repeat attendance and admission to hospital, too.

Greater access GP leaders are enthusiastic about the potential of social prescribing elsewhere.

BMA GPs committee chair Richard Vautrey says: ‘Social prescribing has the potential to reduce GP workload by supporting patients and, where appropriate, linking them to other services in the community that can offer longer-term help.

‘As a result of our contract negotiations in England we have secured funding for an expansion of social prescribing across primary

EVERINGTON: Social prescribing can be more powerful than traditional treatments

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BIRD: It’s an essential move for the NHS to start using community assets

care networks and this should help provide access to this service for all patients who would benefit VAUTREY: Social prescribing could help reduce GP workload

‘It has the potential to reduce GP workload by supporting patients and, where appropriate, linking them to other services in the community’

in England.’

The work in Tower Hamlets is not the only successful existing example to follow.

In Rotherham a pilot scheme was launched in 2012 and is now fully operational in the area – with every single GP having access to social prescribing in an area with a population of around 260,000.

The project, run by charity Voluntary Action Rotherham, allows GPs or practice staff to refer patients through one of two schemes, one for people with long-term conditions and another for patients with mental health issues but who do not need acute care, to a link worker who spends time with the patient to ascertain what help would be most suitable for them.

The charity holds contracts with a number of local community groups who can help with finances, loneliness or physical activity, among a whole host of other areas.

‘It could be as simple as sending them to a fishing

group or an arts and crafts class,’ chief executive Janet Wheatley says.

‘It’s just common sense really – it’s not replacing clinical intervention, it sits alongside a clinical intervention and provides the missing hole in integrated personalised care about what’s important to you, the patient.

‘It makes people feel they are back in control again rather than their illness being in control of them. In some instances, this is replacing things that are broken down in society, that were provided by charities or family or friends.’

The service has had more than 8,000 referrals and clinicians and local leaders are already seeing the benefits.

Better lives An independent review of Rotherham’s mental health service found that just under half of patients (48 per cent) made progress against at least one of the commonly used wellbeing measures and that the service has already created significant social value and return on investment – estimated at £724,000: a social return on investment of £1.84 for every £1 invested in the service. And that is just measuring the savings over one year, rather than the long-term effect of changing lifestyles and reducing reliance on the NHS. Ms Wheatley says: ‘There’s been a massive

improvement in their quality of life and overall feeling of wellbeing and there has been a reduction in service admission. A reduction in attendances, unplanned admissions and length of hospital stay.’

Rotherham GP Richard Cullen says social prescribing improves the lives of patients and the working lives of doctors.

‘It works really, really well,’ he says. ‘It’s a real success because social prescribers are becoming real parts of primary care – they come into our team meetings.

‘The wider determinants of health are most of the reasons why patients come to see us in primary care – a GP appointment can be their only chance of sitting and talking on a one-to-one basis with someone and these patients traditionally just often don’t get better, their needs never end.

‘The system works because I don’t have to remember much – it’s not added workload – it’s a service where the worker can meet the patient, identify their needs and tailor care for them.’

While the evidence seems to support the case for

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social prescription, making a success of schemes around the country will not be easy.

However, ask those who know and there’s little doubt this is an opportunity to improve patient care, save money and try to fight against the demographic change threatening to engulf the NHS. So what obstacles will need to be overcome?

The most crucial thing, according to Richard Kimberley, senior research fellow in health and social sciences at the University of the West of England in Bristol, is repairing and boosting the fractured community services expected to help deliver social prescribing.

‘It’s crucial to have a third sector that is well supported,’ he says. ‘This is the anxiety I have got about the scheme in the long-term plan – it hasn’t built in any capacity to sustain the third sector.

Having well-supported local services is going to be important and the PCNs need to think about where these link workers and which organisations are best suited to help. The key is those link workers have good knowledge and that PCNs look at their thirdsector organisations and look to see who can help and advise them rather than expecting to turn it all on themselves.’

Support needed Reading GP William Bird, who pioneered early examples of social prescribing, by taking walks with his patients, agrees.

He says: ‘If we get hundreds of thousands of patients being referred

into the third sector it will crumble. Money has been repeatedly taken away and that is a problem.

‘The only way it will work is if it’s supported – in Newham [in east London, where Dr Bird is assisting with social prescribing work] patients have a smart card and as they are seen by a link worker that patient is referred to a third-sector organisation, and when they attend they touch that card on to the phone of the leader and that sends money to the organisation.

‘It might be £4.50 but it is saying the NHS is transferring money into the community.

The NHS has to take the responsibility of the third sector – just as with an NHS physiotherapy clinic. They are providing healthcare, they must be recognised as doing so and they should have a contract and proper support.’

For Dr Bird, who has argued this case for years, the other risk is that the NHS stops here and is satisfied with its efforts

when, actually, there is much more to do.

He says: ‘Social prescribing is a stepping stone – it’s not the answer. The numbers going through it are small in the grand scheme of things and you won’t deal with the whole population but it’s an essential move for the NHS to start using community assets and getting people to recognise the causes of all these problems.

‘The next stage has to be that social movement where the culture changes, people take responsibility.’

There may be much more work to do, but positive intent is a start. Dr Bird’s and Sir Sam’s work may have been decades in the making, but it looks like their arguments are finally being heard.

Sir Sam says: ‘It’s here to stay now and that I’m absolutely certain of. There will be problems and it won’t be perfect, and the NHS will get things wrong, but fundamentally now this is mainstream. I think it’s fantastic.’

COMMUNITY SPIRIT: A walking initiative delivered

by Dr Bird’s organisation

‘If we get hundreds of thousands of patients being referred into the third sector it will crumble’

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IN THE DRIVING SEAT: The contract aims to reduce bureaucracy and create a new kind of primary care

Practice makes perfect O A Scotland-only GP contract came into force a year ago. Jennifer Trueland reports on the progress made so far

n 1 April 2018, GPs in Scotland woke up to the first day of the new Scottish general medical services contract.

Billed as a historic agreement between the BMA and the Scottish Government, the contract aimed to set out a distinctive new direction for general practice north of the border.

Anticipated benefits included improving recruitment and retention of GPs, reducing workload and bureaucracy, and creating a new kind of primary care based on multidisciplinary

teams with the GP at the centre as an expert generalist.

Dr Buist was intimately involved in negotiating the new contract in his then role as deputy chair of SGPC – he took over as chair of the committee in August 2018 – and believes it is already having an effect, although he cautions that it’s very early days.

‘We’re just one year into a three-year implementation period,’ he says. ‘If you compare it to any major project when it’s only a third done, you’ll know that it might not look much yet, but

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that a lot of the hard work has been done. It’s those foundations that we’ll be building on in the next two years and beyond.’

On track So what has changed so far?

Arguably one of the most significant planks of the contract process will start to show results this month with the deployment of a tracking tool to measure contract implementation across the country.

The tool will be used in partnership by Scotland’s 31 health and social care partnerships (also called

‘There is a mixed picture across Scotland at the moment’ integration authorities) which, following health and social integration, have responsibility for most services delivered outside hospital.

‘One of the most important things [about the contract implementation] is delivering on primary care improvement plans,’ says Dr Buist.

‘Every partnership has one, but they will all be at different stages of implementation. The tool means the partnerships can work with the GP subcommittee to track what is being done to reduce GP workload and improve services for patients, close to home.

‘My feeling is that there is a mixed picture across Scotland at the moment, but this will give us the information to see what’s happening, where it’s working, and encouraging people to believe that yes, we can do this – we can make a difference.’

The aim is to run the tool twice a year, in April and October, providing valuable data and useful comparators, and enabling different partnership areas to learn from each other. But it also has another element.

‘I think it’s a great example of collaborative working between the partnerships and GPs, which I think is very positive,’ Dr Buist says.

‘This is a really big opportunity for health and social care partnerships to prove their worth and demonstrate that they are providing more communitybased care. The plan is an important part of that.

It creates capacity in primary care, for example, physiotherapists and link workers, and practice-based pharmacists, which frees up GP time so that they can work as the expert generalists they are.’

Ownership A central tenet of the new contract is what former SGPC chair Alan McDevitt always called reducing the risks of general practice. The idea is to make becoming a GP an attractive career choice for young doctors by lessening some of the burdens, such as responsibility for employing a large practice-based team, and the risks associated with owning practice premises.

To this end, the Scottish Government is funding a practice sustainability loans scheme with £50m over three years. Under the scheme, eligible practices can apply for an interest-free loan of up to 20 per cent of the value of their premises to reduce the risks of premises

ownership and to support the transition to a model where GP contractors are no longer required to provide premises.

‘Following the first round of applications, 172 have been approved,’ says Dr Buist, adding that legal discussions on the terms of the loans are progressing and are expected conclude in the next few weeks.

Although the profession backed the new contract overwhelmingly both at a special conference of local medical committees and in a national survey, there have been concerns expressed about how well it will work for remote and rural practices.

This is something that Dr Buist has been keen to address head on, and he admits that more needs to be done.

‘We are hoping that we can start to look at flexibilities to help very remote practices to deliver the style of general practice that they want to,’ he says.

Dr Buist hopes that the contract will prove so attractive that Scotland’s current recruitment and retention problems will be alleviated.

‘That will be the acid test – the success of the contract,’ he says. ‘We want to see the graph of numbers of GPs start to rise again.

We want the vacancies data to improve. We want young doctors to choose to become GP partners.’

BUIST: It’s still early days

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

Botched rota monitoring, TOIL and trouble and lost PAs Giving notice Junior doctors have grown mightily weary of being sent important information late – be it their rotas, decisions on their annual leave or even, sometimes, the hospital in which they will be working.

However, a group of juniors have won an important case with BMA help, after tardy notifications from their employer meant a monitoring exercise became invalid.

The doctors were emailed on a Friday afternoon to be told that monitoring – a requirement to test the banding of a rota under the previous contract – would begin the following Monday. This is much less than the seven days’ notice recommended by NHS Employers.

Hospital management defended the late email by saying that in addition there were posters advertising the upcoming monitoring exercise. However, the posters did not include the exact date of the monitoring (only the month) and the members the BMA represented could not recall seeing them.

The obvious thing would have been to repeat the monitoring, with proper notice, but this didn’t happen. As the monitoring was invalid, the rota defaulted from band 1A to 3. Subject to written confirmation from the trust, the two doctors – and

approximately 20 others who worked on it three years ago when the botched monitoring took place – will receive a payment of about £17,000 each.

TOILING unaware The health service relies on its organisational memory.

The problem is that, with the natural turnover of staff and so much focus on day-to-day pressures, important things get forgotten.

At one hospital, the local negotiating committee had reached an agreement that consultants could take lieu time for their on-call commitments rather than have them job-planned in full.

The arrangement seemed to work satisfactorily – but only for the consultants who knew about it. Some had never been told. The agreement had been made more than six years ago, and the employer did not seem to mention it in job planning, induction meetings or any form of written guidance.

On becoming aware of the problem, the BMA industrial relations officer canvassed consultant members to find out how many of them were unaware of the policy.

Four were found. It was no longer practical for them to take the lieu time instead, so a payment was worked out based on their length

of service. The members received between £1,000 and £6,000.

There was also an agreement that, in the future, there would be written confirmation of the arrangement at induction and all job-planning meetings.

Unrewarded work In an understaffed health service, consultants willing to take on extra PAs (professional activities) are vitally important.

The BMA helped a consultant who had not been paid her proper salary for more than a year.

Her two extra PAs were a temporary agreement, which had been extended but HR had not dealt with the necessary paperwork, so the payment had not been continued.

When she called the BMA, one of the extra PAs had gone unpaid for a year, one for more than six months. She had rung and sent numerous emails but to no avail.

Fortunately, the BMA employment adviser worked out just the right person in HR to contact and sorted it out in time for her proper salary and full arrears – more than £10,000 – to appear in her next pay packet.

Within weeks of contacting the BMA the doctor’s problem was solved.

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the secret doctor

When you have to let go It feels as though every few months there is another harrowing court case involving cessation of life-prolonging care for a young child.

Reporting of these tragic episodes has settled into a predictable format: the photos of the baby, seemingly perfect but for the endotracheal tube protruding from one nostril; the interviews with the grief-stricken parents; the campaigners with placards and teddy bears; and – sometimes – creepy socialmedia threats made to the intensive care staff.

There’s another common theme, as well. In the news bulletins, in the carefully crafted newspaper think pieces, even in the judge’s summing up, a certain phrase appears again and again: ‘Any parent would…’

It’s a kind phrase, meant to express empathy as well as sympathy. It says: we understand these people’s desperation. We have tried to stand in their shoes. We see how wrenchingly painful any decision in these hideous circumstances must be.

It’s a kind phrase, and kindness, in these

acrimonious disputes, is valuable. But truth is valuable too, and this well-meant cliché is not true.

Not ‘any’ parent would fight tooth and nail to prolong the life of their dying child.

Not ‘any’ parent would reject medical advice in desperate search of a miracle. Not ‘any’ parent would strive to keep their baby breathing at all costs, even through intensive and painful medical intervention.

I can state this as a fact because I’ve had the privilege of meeting some of the other parents. I once sat in clinic with a mother who, after bitter indecision, turned down a lifeprolonging but non-curative treatment for her baby’s degenerative disorder.

She could not face, either for the baby or herself, the vista of progressive symptoms, increasingly frequent hospital admissions, and ever more invasive treatments that the child’s life would be.

The rest of the consultation was spent discussing measures for the baby’s care and comfort. But there was one other piece of advice I had to give that mother before she left.

HAND IN HAND: Parents need support with treatment decisions

I told her to get off Facebook. To leave social media, to turn her back on the previously supportive parents’ forums, and to tell no one except trusted friends and family about her decision.

Otherwise, she risked facing real hostility from people who disagreed with her, at a time when she would be least equipped to deal with conflict.

After all, if the media repeatedly tell us that ‘any’ parent will fight to the bitter end, what kind of unnatural, inadequate parent is it who accepts palliation?

Some parents are indeed unable to accept the inevitable, and they deserve our pity, understanding and support. But many, many others look death in the face and approach it with acceptance as well as grief, and they deserve our admiration.

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

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the consultation

DARAGH MCSWEENEY

The Doctor will see you now

O’MAHONY: Patients are being exposed to futile interventions

Consultant gastroenterologist Seamus O’Mahony tackled Western society’s attitude to death in The Way We Die Now. His new book – Can Medicine Be Cured?

– critiques consumerist attitudes to healthcare. He talks to Tim Tonkin Medicine had a golden age which I caught the very end of. This was roughly from the mid-1930s to the mid-1980s. During this time, medicine and medical science gained huge prestige and a vast medicalindustrial complex emerged as a result.

My central thesis in this book is that this medicalindustrial complex’s main goal is its own survival and continued dominance.

In a way, medicine has become almost a pseudo religion. The huge advances during the golden age helped to create it. The medicalisation of life and death, which was what [the philosopher] Ivan Illich and various other people argued against, has to a great extent happened.

There appears to be almost a conspiracy among their doctors and their families to not have the ‘difficult conversation’ with people at the end of life. This is one of the reasons I wrote The Way We Die Now. I felt that people were exposed to unnecessary and futile technological interventions right up to the very end. Many people were at the end of life in acute hospitals in situations where they didn’t know they were dying.

I’m not blaming doctors directly for this. The whole culture and atmosphere of acute hospitals makes it very difficult for professionals to have these conversations, and very often families put pressure on doctors not to have these difficult conversations with patients.

‘Personalised medicine’ will be incredibly expensive and accessed mainly by the rich. It’s another construct of the medical-industrial complex. If we simply applied fairly and evenly what we already know on a global scale, medicine would be transformed.

The foot soldiers in medicine need to rebel against things such as the excessive emphasis on targets and metrics. I think we need to return to core values. Medicine is not about curing all diseases and increasing longevity indefinitely, it’s about easing the path of people from the cradle to the grave and making the conditions of human life more tolerable.

Search for Seamus O’Mahony at headofzeus.com

28 thedoctor | April 2019

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it happened to me Doctors’ experiences in their working lives

Is there a male, middle-aged doctor on board?

‘Do you have any credentials?’ asked the cabin-crew steward.

This wasn’t quite the response I had anticipated, at a cruising altitude of 35,000 feet midway across the Atlantic Ocean, after I had pressed the call bell to offer my medical assistance.

‘No,’ I replied, ‘I don’t have any proof of credentials.’ I had plenty of credentials; I just couldn’t produce any of them. And so, the request for help was made again booming through the Tannoy system.

This time the doctor fitted the bill – he had quite a lot of grey hair.

A short while later our aircraft was continuing to its intended destination.

I wondered if the other doctor had any credentials.

Nearly 15 years later and I now have a few grey hairs but I still don’t carry any ‘credentials’. Do you?

When you’re kneeling on an ice-covered supermarket car park in the depths of midwinter, performing CPR along with a brave

supermarket employee, no one asks if you have any credentials.

As a dutiful doctor, I had dispatched my husband and two young children to complete the weekly shop.

It was an understatement to say that I was missing the familiarity and sterility of the hospital environment. I was very relieved when the ambulance arrived and I had helped transfer this poor soul to be carried to hospital; surely just a pit stop on the way to another very cold place.

The adrenaline and cold were then causing my whole body to shake. I had no idea how long had passed but at least the shopping would be completed and we could go home and have a nice cup of tea. How wrong could I be?

‘We were waiting for you,’ said my husband and children when I found them. ‘We thought you’d like to choose what food to buy.’ I really should have checked their credentials.

Clare Bostock is a consultant geriatrician in Aberdeen thedoctor | April 2019 29

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and finally...

THANK YOU ANYWAY: Dr Docherty tries out the unlikely reward for his cataract surgery

Tokens of appreciation Whether it is owing to their charming personalities, their bedside manner or that they are just lucky, some doctors are favoured by the number and value of the gifts they receive from their patients.

Lacking all those attributes, I can give you a complete list of the gifts I received during a 50-year medical career in the short space available here.

Let’s start with the smallest.

I remember the package arriving one morning. I cut through the paper and tape, to reach a layer of tissue, and inside a tiny, glittering object, which has brought great joy in the 30 years since.

A patient had visited me at home and the door handle had come off in his hand. He blamed himself, rather than my inept home maintenance, and made good with exactly the right kind of screw to reattach it.

The screw was only slightly larger than the piece of grit I removed from the eye of a friend of a friend, who called me in much distress on a Sunday morning. A bit

of local anaesthetic and eversion of the lid took me less than 30 seconds, and so the six bottles of vintage wine pressed upon me for the service equates to my best ever hourly rate.

The most valuable gift I’ve received is a painting worth several million pounds, depending on fluctuations in the art market and whether the ‘Co…’ I can make out on the signature in the corner is really that of John Constable, as I’ve always fancied.

In reality, the painting, a rustic scene which has hung in the lounge since I was left it in a will, is more likely to have been painted by a police constable.

Patients might occasionally like to relate their gifts to the specialty of the doctor concerned but my experience would suggest no thanks, you’re fine with the wine. I’m thinking of my antique guillotine egg

opener (pictured), which is charming but has never really asserted its place on the breakfast table.

I owe this particular fortune to having somewhat inaccurately compared making a section to reach a cataractous lens with topping a boiled egg. The patient took me literally.

Perhaps my patients were simply keeping me out of trouble. Medical defence organisations urge caution and the GMC, while not banning the practice, says no gift received should affect the care you give.

If I were still on the register – I took voluntary erasure after retirement – this is one area where I really would have nothing to fear.

Peter Docherty is a retired consultant ophthalmologist from Derby

30 thedoctor | April 2019

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what’s on

April

May

June

23 Promoting positive workplace culture, Ayr, 6pm to 7.30pm

01 Armed forces conference, London, 9.30am to 4.30pm

05 Recruitment, selection and contracts of employment, Edinburgh, 9.30am to 4.30pm

24 Promoting positive workplace culture, Glasgow, 6pm to 7.30pm 25 Absence and leave management, Kirkcaldy, 9.30am to 4.30pm 25 Absence and leave management, Kilmarnock, 9.30am to 4.30pm 29 LNC chairs conference, London, 10am to 4.30pm

02 Creating better healthcare, Belfast, 7pm to 9pm 09 Practical skills... for human factors in healthcare, Cardiff, 9am to 5pm 10-11 European Junior Doctors’ Association General Assembly, Edinburgh, 7pm 15 Practical skills... time management and taking control, Bristol, 9am to 5pm 18 Junior doctors conference 2019, London, 9.15am

14 Recruitment, selection and contracts of employment, Bellshill, North Lanarkshire, 9.30am to 4.30pm 19 Practical skills... leadership and management for doctors, London, 9am to 5pm 24-25 GP general update, Birmingham, 9.30am to 4.30pm 23-27 BMA annual representative meeting, ICC Belfast, 2 Lanyan Place, Belfast, 9am

21 Staff and associate specialists conference 2019, London, 9am to 5pm

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

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