R-UK
Issue No. 1 - June 2008
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The independent journal from RemedyUK
Also inside: The dumbing down of surgical training, Back to the future with RemedyUK, Patsy’s gold-tipped Boots, Who’s Who in MMC, NHS Pensions Scheme changes, The inimitable Dr Rant
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EDITORIAL
RUK - N°1
Welcome to the first issue of R-UK
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he medical profession has undergone seismic changes in the past 18 months, and is now unsure of what the future holds. Doctors of all grades appear to be wandering, dazed and confused, unable to make sense of the constant uncertainty. Our aim at R-UK is to give some perspective, review what has happened, and most importantly, provide some light relief. We will have a regular column from the irascible Dr Rant, espousing views that many of us would not repeat in polite society. The column will be updated regularly on the website. Our roving reporter, Dr Luther Cadogan, goes behind the headlines to bring the real news in the medical world, the news that the powers-that-be would prefer remained hidden. Those of a nervous disposition, look away now. Plus, Cadogan answers the question on the lips of every doctor in the country: what is our favourite former Health Secretary doing now she has washed her hands of MMC? In other sections, we have an update on the movers and shakers in MMC, as well as a surprisingly simple explanation of the new NHS pension scheme that every doctor should know about. Finally, we hear from two other medical organisations, BAPIO and the HCSA, their views on Remedy, the current state of the NHS, the medical profession, and what they are going to do about it.
Cover artwork by Hairy Aerosol
We hope R-UK can give you a moment away from recent problems to make you laugh, think, as well as inform and educate. R-UK is your magazine with features generated by doctors, for doctors. We do not have strict guidelines on the type of article. We only ask for pieces that you think will interest your colleagues, be it news, comment, humour, cartoons and so on. We will be publishing author guidelines in due course on the website, so log in there for more details. The R-UK website accessible from remedyuk.org will have all the magazine content, as well as extended interviews, podcasts, videos and much, much more. If you want to get involved, you can pitch an idea, or if you just want to get in touch, contact us at editor@rukmag.org.
Contents Issue N°1 - June 2008
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The dumbing down of surgical training
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Back to the future with RemedyUK
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The damp squib - HSC Report into MMC
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A pivotal time for the profession
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Rob Finch interview
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Junior doctors deserve better
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Mind The Gaps - GMC on rotas
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Who’s Who in MMC
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News in brief
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Auntie Maureen’s careers advice
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NHS Pensions Scheme changes
News & Views from Dr Luther Cadogan Patsy’s gold-tipped Boots
The inimitable Dr Rant
Board Editor : Nidhi Gupta Sales Adverting : Jemma Errigo Advertising inquiries contact Jemma on : 0845 680 5627 Layout Artists :
Chris McCullough Maxime Sauvaget
The personal opinions and views expressed in R-UK are not necessarily those of RemedyUK and are of the authors specifically. For more information please contact : editor@rukmag.org
Nidhi Gupta
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VIEWS
NEWS
Dumbing down surgical training It has been known for over a year now that high-quality surgical training is in danger. But how much danger?
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n recent years basic science and anatomy, the foundations upon which a surgical knowledge base is built, have been left to rot at an undergraduate level with sylabbi cut and dissection abandoned altogether at some universities. The emphasis seems to be on communication skills and various forms of self directed learning these days. Basic anatomical knowledge just isn’t politically correct enough these days. This is bad enough in itself but when one combines this with the blatant watering down of postgraduate surgical examinations, then one has a recipe for disaster. The MRCS is changing as of September 2008 to conform with PMETB regulations for the new ‘pattern of surgical training’ that has been introduced courtesy of MMC (http://www.intercollegiatemrcs.org.uk/new).
The tricky viva examination and clinical examination are set to be merged into one set of Objective Structured Clinical Examinations (OSCEs), and it is rumoured that instead of being marked by respected consultant surgeons they may be ‘box ticked’ by technicians and nurses. The end result of all this reform is that one can become a Surgical Registrar having done no anatomy at medical school and without having to satisfy one’s senior surgical peers that one has the sufficient level of surgical knowledge and skills to proceed to the next level. Remedy wants the views of any surgical trainees out there, are you happy with this erosion of professional standards? Or do you want Remedy to fight to maintain a degree of common sense and reason in higher surgican become a Surgical cal exams before it is too late?”
The end result of all this reform is that one Registrar having done no anatomy at medical school and without having to satisfy one’s senior surgical peers that one has the sufficient level of surgical knowledge and skills to proceed to the next level.
Ben Dean
RemedyUK goes back to the future RemedyUK was born from the grassroots in late 2006 when Mat Shaw and Matt Jameson Evans planted a banner in the ground that said, ‘No to MMC/MTAS.’
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octors from all specialties and all seniorities rallied to it. In March 2007, an unprecedented 12,000 doctors and their families took to the streets in London and Glasgow – and began a revolution in medical politics.
tions which many perceive have failed them so badly, and the selfselected activists - in the interests of medicine and those it serves. We’ve begun to put in place a core representative structure with our first AGM; the adoption of our Constitution; the endorsement of the existing committee for the second year of their term and the election of three new members. But it’s not enough – nor can ‘representative democracy’ ever be enough.
RemedyUK 2008 is an organisation in transition. In committee, we have debated long and hard and passionately about what Remedy was, is now and might be – as well as whether there is a need for it at all given the comAs is so often the case, we’ve been clear about what Our ambition requires a new and plexity of the situation we now face. As is so we don’t want: to become institutionalised, inflexible, radical vision and interpretation of often the case, we’ve ‘democracy’ and the development perceived as closed, elitist and unresponsive. been clear about what of innovative methods of e-particiwe don’t want: to become institutionalised, inflexible, perceived as pation, e-consultation and e-voting. In other words, it requires that closed, elitist and unresponsive. Again and again we’ve come back we can be confident we’re expressing your views and concerns. to the core of our mission statement – our commitment to providing a channel for the stifled voice of grassroots doctors. Soon, you’ll be able to access a new Remedy website. At its centre will be the only gift Remedy can realistically offer – the promise that Our ambition and our passion is to transform medical politics and the your voice will be heard. Please use it. way it is done. We want to build a lean, mean and flexible organisation that exists only to serve its constituency; provides a new model of leadership – leadership ‘with’ not leadership ‘over’; and reclaims the medico-political arena from the ‘great and the good’, the instituThe RemedyUK Team
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NEWS
The damp squib - Health Select Comittee Report into MMC Lindsay Cooke of Mums4Medics gives R-UK her personal response to the Health Select Committee Report on MMC & MTAS
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hen I was a child, my grandfather always organized our Guy Fawkes firework display. We’d all have to stand just outside the French windows while Gramps, at the far end of the lawn, wearing a pair of goggles and his thickest gardening gloves, struggled to light the succession of matches which would, eventually, set the Catherine Wheels spinning, the Roman Candles sparking and the rockets climbing into the north London sky. No bangers – Nanna and Gramps didn’t approve. We were allowed a sparkler each, under my grandmother’s strict supervision.
We seem to be in the 2008 version of the surreal parallel universe many of us felt we were inhabiting last year. So far, a High Court Judge, the Douglas Review, the Tooke Review and the House of Commons Health Select Committee have achieved no more than to tell us what we were telling them a year ago. We now have consensus that MMC/MTAS has been a disaster. Goody.
The problem is that we still have the people in post who presided over that disaster – and what’s more, they are the people the Report is calling on to put things right! Yes, the Gramps always saved the best and biggest rocket to last. I icing on this particular cake is that the Committee didn’t much loved fireworks – still do – and every year I’d pester him like the sound of NHS:MEE – ‘establishing a new organization about how big, how colourful, how absolutely extraordinary would be expensive and time-consuming and would this year’s finale rocket was going to be. potentially disrupt the implementation of future change’ – and suggests instead that Inevitably, the a ‘swiftly strengthened So far, a High Court judge, the Douglas Review, the year came when and reconstituted MMC Tooke Review and The House of Commons Health Gramps lit the Programme Board’ Select Committee have achieved no more than blue touch-paper, should assume this coto tell us what we were telling them a year ago. retired the recomordinating role. Over the mended distance corpses of the careers of … and nothing happened. The great, glorious explosion of the new ‘lost tribe’ they have been responsible for creating, light and colour I’d looked forward to for months fizzled out presumably. on that damp, suburban lawn. I was so sad and angry and felt so denied and cheated that I burst into tears – and could So, once again, we wait – this time for the Darzi Review. The hardly be consoled by an extra sausage and more butter on futures of doctors at the grassroots are in the hands of a Demy supper baked potato than Nanna really approved of. partment of Health whose leadership the report has called ‘totally inadequate’ and ‘inept’; a Programme Board staffed Fifty years later, sitting in a House of Commons committee by many of the people responsible for delivering last year’s room leafing through the long-awaited Health Committee disaster; leaders of the profession the report says were ‘inReport – the report we hoped would establish responsibility effective, divided by factional interests and unable to speak and hold those who presided over the disaster that is MMC with a coherent voice – and Lord Darzi. to account – I was overcome with the same sense of bitter disappointment. Like that long-ago rocket, it held so much My children asked me some time ago to flag up when I’m promise. Just skimming the first page of the Summary, which about to deliver a ‘Mummy lecture’ so they can have a wee, spoke of ‘a divided and inappropriate governance structure, make a cup of coffee or try to leave the room. You have been flawed project and risk management … poor communica- warned. tion with junior doctors … the defective application form … the unsafe computer system’ … and the second page, ‘the It’s time – past time – for you brothers and sisters to do it leadership shown by the Department of Health was totally for yourselves. Sure as hell, nobody else is going to. There inadequate … the Chief Medical Officer chose not to take on seems to me to be no tradition of grassroots democracy in a clear leadership role and thus did not accept responsibil- the medical profession. Medico-politics is something that’s ity’ … ‘ the medical profession was often more concerned by largely been done for you by ‘the great and the good’. You factional interests than by the common good’ … I was ex- are living the result. pecting an explosion of brilliant light to expose the incompetence and arrogance of those who have caused so much ‘See one, do one, teach one’ is part of your working lives. misery to thousands of doctors and so much damage to the You’ve seen. Now do something about it. And teach somefuture of the service. But no. It’s a damp squib. It talks the one else to do something too. talk, but it signally fails to walk the walk. And nobody offered me an extra sausage either. Lindsay Cooke
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News & VIEWS By our roving reporter Dr Luther Cadogan
NEWS
R-UK’s roving reporter, the irrepressible Dr Luther Cadogan, has been roaming the country for the stories you need to know but they don’t want you to know. The powers-that-be may try to silence him, but they never will.
R-UK EXCLUSIVE! Dono fashioning exit strategy to WHO?
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MC architect, Sir Liam ‘Dono’ Donaldson may be paving the way for a new post as a public health supremo at the World Health Organization, R-UK sources can exclusively reveal. The seasoned politico, CMO and author of Unfinished Business has apparently been smoothing the way with regular meetings, a tapered cross-over period and detailed consultation. A team of junior doctors has been recruited as advisers and brief him jointly on DH matters and the WHO.
proach with the MMC phase-in. Seems like he’s trousered some of the fallout lessons, however. How reassuring. Dono has proved tougher to shift than the hardiest strains tackled in his communicable diseases career and has been consistently unrepentant about his accountability for MTAS/MMC. A defiant letter dated January 2007 stating that MMC would be ‘good for patients, staff and the future of the NHS’ is now a priceless collector’s item. Our sources report that he looks set to decamp by the end of 2008. His new job remit will include responding to world food shortages, handling pandemics, and curbing natural disasters. Prayers are, we’re told, already being offered that he’s not at the helm if one pops up in our neck of the woods.
You may feel it’s a pity that Dono didn’t take such a collegiate ap-
‘Bed snatcher’ Keen in raid on sleep quota
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nn Keen, the Health Services Minister, has barred doctors from a good night’s sleep and plunged them further into a spiral of debt. The Labour Minister (MP for Brentford & Isleworth, 30 minutes from Waterloo) who with her husband (MP for Hounslow, 35 minutes from Waterloo) claims £34,000 a year in MPs’ expenses for a luxury apartment in Covent Garden, has dismantled accommodation support for FY1s with immediate effect. Juniors - already tens of thousands of pounds in debt by qualification and working many hours more than rotated - now face sleep deprivation and corridor catnaps when taking up posts far from home. A Department of Health spokesperson said: “Changes to working
patterns and new rotas making it unnecessary for junior doctors to be ‘on call’ have allowed the Government to remove the residency requirement. We consider it appropriate junior doctors are treated exactly the same as other NHS staff.” The raid – apparently sanctioned by Health Secretary Alan ‘keep m’hands clean’ Johnson – has provoked outcry in messes across the UK. Keen, a previous political non-entity, is now a hate figure among medics. A Freedom of Information request by R-UK detailing the number of taxpayer-funded goosedown pillows in Mrs Keen’s possession went unanswered as R-UK went to press. However, R-UK sources in the Liberty of London bedding department informed us on April 1 that she likes her pillows to be ‘premium quality and of the king size variety’.
Ivan Lewis, so-called Minister for Grannies, in identity crisis
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van ‘The Terrible’ Lewis, the Minister for Social Care, has been branded an ‘arsehole’ by a fellow MP during a recent parliamentary debate. Lewis was filibustering his way through a speech on hospice care and refused to allow questions from the floor. Lib Dem MP Greg Mulholland was heard berating the minister for his stone walling tactics. “He should be less interested in trying to score points and actually listen to issues of
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real concern in his area of responsibility,” countered Mr Mulholland. Lewis is a veteran of MTAS and the only surviving Health Minister from the era of Patricia Hewitt. He has been labelled the Minister for Grannies because of his care homes and OAP portfolio. During a recent summit with women
magazine editors, his manner was ‘arrogant and aggressive’ according to one anonymous source. Arguably not the kind of individual you want heading up the needs of the country’s most vulnerable people? At the time of going to press Mr Lewis was unavailable for comment. A DH spokesman refused to comment stating that doctors’ ‘opinion of Mr Lewis was entirely a matter for their own judgment.’
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R-UK EXCLUSIVE! ANOTHER ONE!
MPs and DH set for DOPS-style social control experiment An innovative junior doctor has floated a series of DOPS-like 360 degree appraisal tools for MPs and DH civil servants. The free thinking public health trainee, with a passion for improving professional standards, has tabled proposals to a parliamentary subcommittee. Waxing lyrical about the newly introduced NHS wide competency assessments, Mark Hohenberg said ‘Directly Observed Parliamentary Scenarios’ would produce more rounded professional politicians and civil servants. DOPS, mini-CEX et al have been widely labelled by disgruntled junior doctors as a form of social control, a drain on aspirations for excellence, and a bureaucratic migraine from hell - all rolled into one. Non-enthusiastic trainees are hauled in front of ‘compliance’ committees and given a jolly good telling off if their portfolio is not up to date.
MPs Economy with the truth – Can you keep facial movements to a minimum and not quiver? Filibustering – Can you effectively drown out the voice of reason? Cronyism – Have you scoped your FTSE 100 boardroom seat in readiness? Civil servants Strong arm tactics - Can you bully subordinates and walk away not feeling guilty? Truth suppression – Are you up to date on the principles of neototalitarianism and media manipulation? Empire building – Character assassination, insinuation and the marginalising of enemies – the basics.
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Undeterred by this distinct lack of enthusiasm, the bullish Dr Hohenberg has devised separate syllabuses for MPs and DH civil servants. Rebutting suggestions that they are ‘a law unto themselves’, Dr Hohenberg contends that a gentle prod in the right direction can guide any group aspiring for public trust, stifling mediocrity, and loss of free will.
What do you think of the proposed assessment scenarios?
From a sinking ship to a golden galleon:
Dr Luther Cadogan shares the result of a very personal epiphany to R-UK readers
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atricia Hewitt has been in her new job as an an adviser to the private equity owned Alliance Boots for four months. It must be a nice life. No more aggressive interrogations by bolshy and assiduous journalists. No more being hauled in to Parliament and Health Select Committees to explain the disastrous incompetence of the Department of Health. Recollections of her last days in office, when she was harangued by junior doctors at Question Time, have faded into a distant memory. Now she slides into a few board meetings a month, offloads a a few nuggets of strategic insight from her time as a Minister, and toddles off back to Leicester, her bank balance considerably healthier. And the prospects look even better. In a few years she will be presented with the enviable prospect of cashing in on some juicy share options and even taking a slice of profits from the inevitable sell-on of the business by her private equity employers. Patsy is not going to be just well off, she is going to be uber wealthy. She has left a sinking ship and hopped on to galleon piled high with gold. About once every six weeks, my toiletry supplies start to run a little low. The shaving foam lacks texture, the razor blades begin to lose their sharpness and I have trouble squeezing that last smidgin of toothpaste from the tube. It’s time for a visit to the chemists. Boots is my local pharmacy and this week off I strolled along for a bulk buy stock up. As I was approaching, Patricia
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suddenly popped into my head. It wasn’t the most pleasant vision to greet me on a bright spring morning. I started thinking of MTAS and its fallout. I remembered the apologies she had made, the promises of additional ‘career guidance’, the job guarantees, and the ‘terrible anxiety’ that had been so passively enacted. I remembered the Tooke review that she had commissioned, its aspiration for excellence and the hope that its recommendations would be implemented as she had so vigorously tried to convince us. I thought of the profound and unrelenting anger and dismay that I had witnessed on the faces of my friends and colleagues over the past year.
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I thought about the innumerable individuals who were still I stood outside Boots, another great British institution, and drew struggling, trying to overcome impossible dilemmas about their a line in the sand. There was no way I was going allow my hard own futures, finances, career paths and health. I contemplated the earned toothpaste expenditure to be creamed off by Patricia hidden personal traumas, depression, helplessness and despair, Hewitt to plump up her retirement fund. I considered that the that had slipped from the headlines, but were still as acute and Choice agenda had just come home to roost. unrelenting as in MTAS’s infancy. I considered the wanton and indiscriminate attrition of talent It can only be inferred that Patricia’s extensive government from the NHS, its unquantifiable and irreversible impact, its experience involving a two way dialogue between herself selective bias against those who and her current employers was the overriding factor in her were often the most rounded, appointment. academically able and brimming with leadership capability.
INTERVIEW
I thought about the costs - financial, emotional, human and institutional of this vast, monumental monstrosity of a cock up. I recognised that not one individual can be held responsible, but that responsibility does equate to being held accountable. I then considered, that although unprecedented and seismic in its effects, MTAS was only one minute fragment of the malign ideological disarray that Patricia and her cohorts had facilitated. I thought about the open door policy she had with management consultants, US healthcare management organizations and the IT industry. I considered the grotesque, bloated trashing of public monies which had bolstered this unctious, cosy love-in between the civil service and the City. I considered that Patricia was effectively CEO of the world’s largest not-for-profit health organisation and that she had presided over a systematic dismantling of community spirit, professionalism, patient advocacy and ethical guidance in the provision of healthcare in the NHS. I wondered at the notion that she had endorsed the baffling and at times brainwashing tone of the propaganda emanating from the DH as if it were the indisputable truth and it should somehow be imbibed as if we were credulous muppets.
Appointing directors to a board carries considerable scrutiny of veracity and reputation. It is inconceivable that a disqualified company director or doctor disciplined by the GMC would be allowed to hold a position of such responsibility. It can only be inferred that Patricia’s extensive government experience involving a two way dialogue between herself and her current employers was the overriding factor in her appointment. Would it then be naïve to believe that she has no influence with the DH from her current position in the same way as she seemed to be lobbied into submission by so many corporations of similar repute while a minister herself? I will not be purchasing my toiletries from Boots until Patricia has left the board. Any healthcare professional who feels the same may wish to consider this as a resolute and firm assertion of their views.
Rob FINCH Rob Finch, former editor of the now defunct Hospital Doctor talked to R-UK exclusively about his time at the magazine, the medical profession and the impact of RemedyUK, and reveals that his aim was to speak to and for the forgotten doctor. Nidhi Gupta interview… mous word from real hospital doctors and news stories the rest of the medical establishment shied away from. He talks to us on his mobile phone from a busy office and the occasional hubbub of the office punctuates our interview. When Rob talks to R-UK, it has been a week since he officially left Hospital Doctor. Hospital Doctor (HD) was the magazine found in doctors’ messes up and down the country with its bright and brash colours, the anony-
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Luther CADOGAN
Originally studying Marine Biology, Rob quickly entered into medical journalism which eventually led to the GP magazine Pulse for five years, then HD, where he was first News Editor then quickly rose to Editor. When asked about his time at HD,
he has nothing but fond memories. ‘It was the best job in journalism. Some people might disagree with that but the people were a pleasure to work with…the doctors in my daily life were also a pleasure to work for’. It seems that HD not only reached hospital doctors up and down the country, but also upper echelons, ‘I know it was read carefully in the Department of Health because we used to get the occasional letter from the Chief Medical Officer about it’.
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As someone who was an ‘outsider’ who became a medical ‘insider’, his view of the medical profession has been of learning that ‘doctors are a bit of a broader breed than perhaps the general public and politicians would have you believe; there are heroes and villains and there are lots of people who are just doing their best to get by’. He has also, better than most, been able to see the changes within the NHS with an objective eye and see the reasons for the changes. ‘They are being made for essentially financial reasons be-
cause I guess the government does not want to continue to pay for, or have the taxpayer pay for those things it’s not politically acceptable to raise taxes for’. The issue of money comes up again, when asked about MMC and MTAS. ‘It was in part manufactured out of a need for reform…but it was done… rather on the hoof, rather quickly in order to not spend any money on it. I think we had a story on the cost of the MTAS website and I thought it was ridiculously high, but thinking
back now, if they had spent a little more time and money on it, it might have all been a bit different’. When asked about Remedy, Rob has nothing but praise. ‘I think it has been a bit of a wake up call. I don’t think anybody really expected it to go from such humble beginnings to getting 10 000 people and the Leader of the Opposition out on the streets!’ Nidhi Gupta
A pivotal time for the medical profession.
The profession is at a crossroads.
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he role of the Doctor is clearly discussed in The Tooke Report which concludes ‘there needs to be a common shared understanding of the roles of all doctors in the contemporary healthcare team that takes due account of public expectations.’ The Hospital Consultants and Specialists Association agrees - but would add that, however defined, that must enable doctors to be fully engaged in, and contribute to, the emerging role which hitherto has been left largely to the Royal Colleges and ‘Establishment’ organisations to develop. That has left a vacuum in which many doctors have felt disenfranchised; and often fundamentally opposed to a direction that has been taken on their behalf. One has only to look at the emerging themes behind the Darzi Review, or the catastrophic events around medical training, or indeed the political dogma behind the use of the private sector, to see how the role of the doctor has been so fundamentally changed, yet without effective involvement.
Acting in the best interests of patients, and the profession, may sound simple. In reality it is complex. It needs doctors to ensure decisions made on their behalf are not taken behind closed doors or in the corridors of power. It needs doctors to ensure their representatives and leaders involve them, and it requires doctors to insist on openness and transparency. That might ruffle a few feathers; it might be uncomfortable putting people on the spot. But that is what being in the kitchen is all about – Stephen CAMPION and if the heat is too hot then HCSA perhaps the HCSA could provide a few more chefs. The important thing is that if Consultants really want to end professional erosion and terminal damage to the doctor/patient relationship, and all that goes with it, then the time is right to highlight the need for accountability. Leadership is about steering the profession not only to where it wants to be, but to where it should be. Stephen Campion H.C.S.A
This is our first edition of R-UK. Do you like it, do you hate it, or are you somewhere in between? We want to produce a magazine doctors want to read. We would love to hear your comments at editor@r-uk.org, along with any articles, news, song lyrics and pictures, whatever you think doctors would like. Send your letters to letters@rukmag.org They’ll be put on the web-site and the best ones will be printed in the next issue. Thanks for reading and get in touch! Editor
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Junior Doctors Deserve Better
Medics in the UK, trained and skilled professionals, have worked beyond the call of duty for decades to provide outstanding health care to British people through the NHS.
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e are a heterogeneous group, a rainbow of colours, nationalities and beliefs, coming together to give our best to the healthcare of this beautiful nation. What has united us has been our love for the NHS, the environment it provides to support excellence and the joy of providing equitable care to all, based on need rather than ability to pay. This concept is holy to most of us. Overseas doctors in general and those from the Indian subcontinent in particular have been integral to the NHS since its inception. There has always been a harmonious relationship between these doctors and those trained locally and we are pleased to note that despite the MTAS/MMC fiasco and disastrous workforce management of the DH this hasn’t changed. BAPIO is highly appreciative of the constructive and non divisive role played by RemedyUK in this matter. Over the last 10 years much money has been pumped into the NHS. Waiting times have come down and more jobs have been created. Yet we find that there is despair and
low morale almost everywhere, especially amongst our young, bright junior doctors. We cannot blame them. Many are working very difficult shifts heavily skewed towards service delivery with mere lip service to training needs. Many fear that the shortened training times, in spite of the often repeated mantra of competency based training, will produce a generation of doctors who have completed specialist training on paper but may lack the confidence needed to take consultant level responsibility.This would play nicely into the hands of those pushing for a sub consultant grade. BAPIO has been concerned regarding a number of issues which affect both UK and International graduates - the lack of workforce management that leaves junior doctors at considerable disadvantage, the widespread withdrawal of study leave budgets, the removal of on call rooms for doctors on shift work, the increasing number of non-training dead end jobs, the poor support provided to trainee doctors who find themselves in difficulty and the
unfairness with which the GMC treats many doctors who come up for disciplinary hearings. There is a clear need for organisations to look after vulnerable groups, in particular trainee doctors, and speak out loudly and clearly on their behalf. BAPIO wholeheartedly supports the leaders and members of RemedyUK in their quest to find just solutions for the future. We look forward to working together as we share identical ideals of fairness and justice for all doctors. Together we will be stronger. Dr Ramesh Mehta- President BAPIO Dr. Raman Lakshman- Vice Chair BAPIO
Gaps in Rotas and Unfilled Training Places - GMC Guidance. Many hospitals are having to cope with shortages of doctors this year, and this is placing individuals in an awkward position. Some juniors are being asked to cross-cover other specialties or to cover extra shifts, which may extend their hours beyond WTD-approved guidelines. We have also heard allegations that individuals are being pressurised into working these shifts. It has been suggested that units that cannot attract sufficient doctors to be viable should be closed. Remedy has written to the GMC Ethics Committee to ask for guidance on this. An edited version of their reply is set out below. The full text is available at www.remedyuk.org and all emphases are Remedy’s. We are grateful to the GMC for their advice. Good Medical Practice states that, in providing care, doctors must recognise and work within the limits of their competence. The relevance of this duty is clear to those who are asked to work in specialties other than that in which they usually work. The propriety of agreeing to the request would depend on a professional judgement made by the individual doctor concerned, having taken appropriate advice (from senior colleagues, defence organisations or professional bodies like your own, as appropriate) about the safe limits of their own competence. All doctors, whatever their position, should follow the advice in GMP on raising concerns about patient safety: If you have good reason to think that patient safety is or may be seriously compromised by inadequate premises, equipment, or other resources, policies or systems, you should put the matter right if that is possible. In all other cases you should draw the matter to the attention of your employing or contracting body. If they do not take adequate action, you should take independent advice on how to take the matter further. You must record your concerns and the steps you have taken to try to resolve them. If doctors are concerned that their working hours are putting patients at risk because of fatigue, for example, they should put the matter right. They should also ensure that, when they are off duty, suitable arrangements are made for patients’ care. If they are concerned that such arrangements are not suitable, they should follow the advice in paragraph 6 of GMP. Hospital managers have moral and legal/contractual obligations to fulfil too. There are obligations on senior doctors and other managers requiring doctors to work extra hours or in unfamiliar roles which are separate from doctors’ individual choice as to whether they do what they are asked. When it’s a question of fitness to practise, the risks to which the doctor’s patients
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are exposed by their insisting on working within their contract would clearly be a key factor in the consideration of any complaint, and doctors should consider those risks, alternatives, etc. when thinking of refusing to work extra hours or take on roles outside their experience (if not competence). If doctors are concerned about bullying or harassment by consultants, they should consider the advice and references outlined above. They should also consider using formal complaints or grievance procedures within the Trust or NHS or complaining directly to the GMC. You can find out more about our fitness to practise procedures at www.gmc-uk.org/concerns. Doctors must make the care of their patients their first concern. They have a duty to work with colleagues for the benefit of patients, identifying risks to patients welfare and participating in systems to address these risks and improve care generally. That might involve working outside normal roles or hours. Of course doctors should not be expected to consistently work beyond the limits of their contractual requirements and should never be required or bullied into breaking the law. We cannot give legal advice about the implications of the Working Time Directive, about which you should seek your own specific legal advice. Finally, while it must be right in theoretically extreme circumstances to close a unit/department, doctors considering such a step must balance the risks of so doing against the risks of continuing to work (e.g. beyond competence or while fatigued). In the end, this has to be a judgement about what is in the best interests of patients.
The RemedyUK Team
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RUK - N°1
FEATURE
FEATURE
Who’s Who in MMC After the chaos of last year, MMC has not left us, and remains the over-arching term to describe medical education. But who are the movers and shakers behind this behemoth? R-UK found out In the world of medicine, there can be few jobs more unappealing than those at Modernising Medical Careers (MMC). Last year’s MTAS disaster forced health secretary Patricia Hewitt to make repeated apologies, and resulted in the ignominious departures of Professors Alan Crockard and Shelley Heard. To improve recruitment and training implementation for 2008, the Department of Health (DH) - in partnership with the medical profession - established the MMC (England) Programme Board. With the board under such intense scrutiny, there can surely have been few willing candidates. The first to be seconded to the team as clinical advisor was Dr Mary Armitage, a consultant endocrinologist and former clinical vice president of the Royal College of Physicians of London (RCP). Announcing her appointment at a conference last June, Dr Armitage said: ‘I tell people to imagine the worst job in the world - they don’t know whether to congratulate me or commiserate.’ Nine months on, and Dr Armitage is more diplomatic, pointing out that her ‘many years of experience’ - as clinical director of medicine at the Royal Bournemouth Hospital and her fouryear stint at the RCP - stand her in good stead for the role.
Prof Sowden is adamant the real situation is ‘more complicated’. First, he says, the MMC Programme Board has ‘at least made a start in bringing together the BMA, royal colleges, NHS Employers and SHAs.‘ And he adds: ‘We’re building things that which will almost certainly underpin future work. Some deaneries are going to be running pilot projects to test things so we can evaluate them for the future - such as assessment centres.’
Jeremy Levy
Although the UK’s four CMOs still meet monthly to discuss the recruitment process, this year sees a continuation of Scotland’s policy to ‘go it alone’. And Scottish Dr Harry Burns says he is ‘happy’ with the way selection and recruitment is progressing in Scotland so far.
She has been Following the move to a local recruitment system, there were joined at the board by sefears that deaneries could be overburdened by junior doctors Most significantly and controversially nior responsubmitting large numbers of applications. - Scotland will consible officer tinue to offer runProf David Sowden, who admits: ‘It is a really difficult area to work in, through posts in all specialties in 2008. Dr Burns says: ‘The and the most challenging jobs are often the ones where the other nations have decided to move to a different system risk of criticism is greatest. But that is often outweighed by offering ‘core training’ posts for two or three years in most the fact that those jobs have the potential to make the great- specialties and retaining run-through in others.’ est contribution to getting the future right for thousands of Although the Tooke report was greeted with almost universal people - both doctors and patients.’ enthusiasm, Dr Armitage warns that it may not be the quick Foremost in the minds of most doctors applying for posts fix that many are hoping for. ‘It would be wrong to assume this year is the extremely high level of competition. Last that 2009 will be the year when a ‘final’ or ‘perfect’ structure year in England there were 15,600 training posts available, for training will be created,’ she says pragmatically. but in 2008 there are just 9,000. Dr Armitage says she has ‘huge sympathy’ for those doctors applying for the most Dr Sowden admits that morale - particularly among those popular specialties, such as neurology and cardiology. But who did not get a run-through post last year - is ‘pretty low’. she continues to toe the official MMC line, insisting: ‘Com- But he adds: ‘Morale among many others, such as those competition in some of those specialties has always been high ing out of the Foundation Programme and applying for ST1 and this is not necessarily the result of the MMC programme.’ posts, is better. I think a lot of junior doctors are worried about the problems that we saw in 2007, but they should be Dr Armitage admits that the particular ‘crunch point’ this year assured that we really have learned some big lessons, both is at ST3 level, and some extra posts have been created to for 2008 and the longer term.’ help ease the bottleneck. ‘Of course we are under pressure to create more,’ she says.
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news IN BRIEF
IN BRIEF
RUK - N°1
BAPIO wins ruling BAPIO finally won their two-year battle with the government to allow Indian doctors on the Highly Skilled Migrant Programme (HSMP) to train and work in the UK, alongside their British and European Union counterparts, without prejudice. The House of Lords ruling affects between 8000 to 10000 Indian doctors in the UK, and will give some relief to the thousands of doctors who were facing virtually overnight unemployment after the Department of Health edict in April 2006 stating HSMP doctors could be employed only after no candidate from Britain and the EU could be found. In addition to the ruling, the House of Lords awarded BAPIO costs. Dr Ramesh Mehta, President of BAPIO called it a ‘landmark victory’.
BMA Staff Revolt The BMA faces revolt among its staff as the results of their staff satisfaction survey were leaked at the same time as they are facing the threat of strike action for the first time in their 175-year history. The BMA conducted their internal staff satisfaction survey in December 2007, which found that only a quarter of employees felt the organisation was able to embrace change. In addition, most of the staff felt the senior management were out of touch with their work, and did not feel inspired to excellence. The document itself admits the results are ‘very disappointing.` The leak has come at a difficult time for the BMA, with the over 200-strong staff threatening strike action over proposals to introduce performance-related pay. Britain’s biggest union the GMB is balloting its members over apparent ‘hypocrisy’ on the BMA’s part for introducing a system of pay that it has opposed for its own members. The BMA have responded, saying that their proposals have been misrepresented.
R-UK is written for doctors, by doctors and we would like to hear from you. Send your letters and comments to editor@rukmag.org, maximum 400 words, and we will put a selection of them on the web-site www.rukmag.org with the best appearing in the next issue of R-UK.
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article
FEATURE
RUK - N°1
Auntie Maureen’s careers advice In the first of an occasional series, Auntie Maureen offers the fruit of her unparalleled experience in the profession to the student with ambitions for a career in medicine.
Around the age of 15 elect to do largely Science ‘A’ levels. Five would be good. Give up football and macrame. Get straight A or A* grades or bin the UCAS form now. Take a gap year by all means, but stuff the rucksack. Head for the nearest Nursing Home and show you care. Charm your way into Medical School. Forget integrity, intelligence or initiative. You will need humility, dedicated selfabnegation and a total absence of critical faculties. The Emperor is indeed a naked fruit-bat but don’t ever say so. Spend five or six years running up awesome debts. Expect to be endlessly harassed by numpties with shit-for-brains and envy for attitude. Try to pass your Finals first time. There are many more expensive exams to come and it will help to keep your loans within the National Debt. Communication skills notwithstanding, you are now a Junior Doctor. Get used to it. You will remain a ‘junior’ doctor for at least the next ten years. You will move around a lot. You will be pushed around a lot. You will not earn a lot. As you enter your fourth decade, with luck you might be making enough to start paying off your debts. You will not be making enough to get a mortgage. Marry someone who is and stop whingeing. By the time you are 35, unless your partner is into self-help in a big way you may be divorced, but you could be competing in the salary stakes with the minor middle-manager who is intercepting your investigations or referrals and making mincemeat of your medical expertise. Your hours will be longer than his and perhaps a tad on the anti-social side. Your daily diet will be death, despair and destruction but you will not mind any of this. You’re entirely dedicated to repaying your debt to society; the quarter of a million pounds it cost the penurious people to train you, every penny usurped from the righteous War on Terror.
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At least 50% of you will be women. YOU will be having babies on the side, divorced or not. This is why God made women multi-taskers. When you are 40 your future will have been decided.You might unfortunately be scrapheaped, considered untrainable despite your PhD, MRCP, FRCS, whatever plastic shibboleth. You could be a salaried serf, gratefully bending the knee and your principles to United Wealth in exchange for a small slice of the action and your mortgage repayments. Some few of you will have toughed it out and become Consultants, GP principals or whatever bloody-minded, independent doctors are called in the parlous future. Yes, you few will have made it. You are now officially workshy, greedy tossers intent on screwing the sick and the sorrowful while destroying the NHS to finance your wildly affluent, idle lifestyles. Strangely, 90% of the patients you are so screwing will still affect to trust you above all others. This trust will not translate into your litigation and complaint-strewn working life. It will NEVER be acknowledged by managers or politicians and their Press puppets. The underlying assumption, despite any evidence to the contrary, will be that Mammon has you by the mammaries. This is the dichotomy that might finally do your head in. You are now in real danger and so are your patients. Despair, drudgery, drink, drugs or medical politics? The choice is yours. Wise up or crack up. Whatever you decide, make mine a large one. And send the bill to the BMA. They owe me.
Dr Maureen Mull
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FEATURE
NHS Pension Scheme changes The new NHS pension has been introduced throughout the NHS. Marc Woodward of Legal & Medical goes through what you need to know to maximise your pension.
As you will no doubt be aware the NHS pension scheme is changing and April 2008 brings amendments to the existing scheme as well as a new scheme for new entrants. The background to this lies in the fact that the NHS scheme is an ‘unfunded’ scheme where the pensions in payment are paid for by the contributions being received from working members. The cost of providing these benefits has increased due to greater longevity and increasing numbers of retirees. Increased member contributions The employee contribution is now increasing for both members in the existing scheme and for entrants to the new NHS pension scheme. As of this year contributions are tiered depending on your level of full time equivalent earnings. For doctors this means that the starting contribution is 6½% up to £65,000, 7½% if your earnings are above £65,000 but less than £102,500, and 8½% if your pensionable pay is £102,500 or more. Withdrawal of Added Years Under the old scheme there was previously an option to buy guaranteed added years but this option has now expired (unless you registered an interest before 31/03/2008). From 1st April 2008 it is now possible to buy additional pension subject to a maximum of £5,000 extra pension. The alternative to this scheme is to fund either an additional voluntary contribution or a personal pension which can both be best described as ‘money purchase’ schemes. In other words your payments are invested and build up a fund which gives you the ability to take some tax free cash and additional income. More cash, Sir? Under the existing scheme you achieve a pension of 1/80th of your full time equivalent salary (plus any pensionable awards) for each year worked. Therefore if you work 40 years you achieve a pension of 40/80ths i.e. 50% of your pensionable pay. In addition a lump sum is also payable of three times the pension.
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Under the new scheme there is a faster accrual rate. This means that for each year that you work you will achieve a 60th of your salary. Therefore, 40 years service achieves 40/60ths i.e. 66% of pensionable pay. The catch is that there is no automatic lump sum and you have to commute part of this pension to obtain a lump sum. To look at an example of this, if you were earning £100,000 and achieved 40 years service you would receive a pension of £50,000 and a lump sum of £150,000 under the old scheme. Under the new scheme with 40 years service you would achieve a pension of £66,666. If you want to have a tax free lump sum you can commute part of your pension at a rate of 12-1 to obtain it. If, for example, you wanted to draw a lump sum and were happy to receive a pension of around £50,000 (in line with that which would have been given under the old scheme), you would commute £16,666 of your pension, which, at a ratio of 12-1, would give you a lump sum of £199,992 and a pension of £50,000. On the face of it this appears to be an improvement on the existing scheme, but it will now also be possible to take a larger lump sum from the existing scheme under a similar commutation calculation – although the terms are less attractive. However before you rush to switch into the new scheme (which will be possible for a limited time from next year), it is worth remembering that the retirement age under the new scheme is set at 65 not 60 and retirement before 65 results in an ‘early retirement’ reduction. This is a reduction in your pension based not only on the fact that you will have less service, but also because you are drawing the pension earlier than 65 and the calculations are amended to reflect the fact that they are likely to pay you for more years than would have been the case if you drew it at 65. Nevertheless there is a case for an existing member to consider changing to the new scheme if they are committed to working to age 65 anyway (for example, a consultant with younger children going through private education or university who feels that the chance of retiring at 60 is minimal). Of course new entrants to the scheme will have no choice but to accept the new rules and the retirement age of 65 that now applies. If you are committed to retiring earlier than 65 and are a new entrant, then the best option is probably to build up a significant personal pension fund that can either make up for any reduction in NHS pension that comes about due to drawing the benefit early, or better still, allows you to fund your lifestyle for the five years between 60 and 65, so that the main scheme benefits can be deferred to 65 if you cease working before that age. These are areas that need careful consideration and discussion with a financial adviser. Ill health retirement changes A further change that applies to both the existing NHS scheme and the new scheme is in the form of significant alterations to the ill health retirement benefit. Up until now, should you become unable to continue working in your role within the NHS, you could apply for an ill health pension which is calculated on the basis of the number of years service you have (as 80ths) plus an enhancement. Under the new rules these enhancements are changing and a new two tier ill health scheme applies. Basically if you have more than two years service and your illness makes you permanently incapable of any regular work, the pension is increased by the addition of 2/3rds of the actual membership that you could have got had you continued working until your normal benefit age. This is added to your actual membership at the time of sickness. To give an example, if you could have worked 40 years (assuming you qualified at 25 and were likely to work to 65), but you fell ill after only ten years, you will receive an additional 20 years added to the ten that you already have, giving you 30/60ths i.e. a pension of ½ pay. This is an improvement on the existing scheme where you would have received an ill health pension of 20/80ths i.e. ¼ pay.
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RUK - N°1
FEATURE However, under the previous scheme you could apply for an ill health pension if you were unable to carry out your job in the NHS, under the new scheme this enhancement is only payable if you are unable to do any form of regular work on a permanent basis. If you are permanently incapable of doing your present NHS job because of ill health, the ill health pension is simply calculated on the basis of your entitlement to pension without any additional enhancement. These changes are on one hand less generous to those who are incapable of working in their normal employment but on the other hand more generous to those who are so ill thatthey are unable to do any form of work. It seems likely that the majority of claims for ill health pension would now fail to be treated under the first category and therefore lose the enhancement that would otherwise have applied. This has repercussions in the way in which you calculate your income protection requirements as insurance companies have always insisted that the ill health pension be calculated and taken into account in arriving at the maximum benefit to which you are entitled and for which you can insure yourself. As the ill health pen-
sion is likely to be less generous for the majority of claimants there is probably a requirement to review and possibly increase your income protection cover. Again this is an area you should discuss with your financial adviser. These are some of the main points (and for the sake of easy examples we have used the accrual rates that apply for hospital doctors although the calculation method is different for GPs, the results are broadly very similar), however there are a number of other changes which will affect doctors and which could influence your future financial planning. It pays to understand your pension and Legal and Medical will be pleased to help with individual enquiries – please contact us through our website: http://www.legalandmedical.co.uk or contact our head office on 01822 855707
Marc WOODWARD Managing Director, Legal and Medical Independent Financial Advisors
Dr RANT R-UK welcomes the famous, if not infamous, Dr Rant in a regular column to cut through the rhetoric and get to the crux of medicine. Those who are easily offended, or anyone in the DoH, turn away now.
W
ell, it’s about time. I wondered when RemedyUK would finally get their act together and put something in print. I like nothing more than a good fight, and it seems that Remedy are putting in a jolly good effort. Back in my day, all we had to organise a protest was a phone, a few letters and a megaphone. And maybe a naked protest or two. It seems that with the advent of RemedyUK’s style of ‘e-democracy’, there are more ways to get your voice heard. Last year’s email campaign led to the March in March. I came along, ready to walk shoulder to shoulder. Remedy welcomed my presence, but suggested I put my clothes back on. Indeed, e-democracy might just be the ideal concept to fight the Department of Health’s version – e-Stalinism. Whereas electronic democracy uses a variety of means to communicate with members to find out their viewpoint, e-Stalinism uses IT to give the illusion of choice, whereas in reality it offers very little in return. Look at some of the gems it has come up with.
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First of all, MTAS. It was announced as a way of allowing doctors a choice in their future careers. In reality, the choice was more along the lines of ‘Computer says would you like a year-long trust grade job in elderly genitourinary medicine, or would you like to bugger off to Australia?’ Then look at Connecting for Health, or NSHIT (that’s NHS-IT – Ed). The NHS national program seems all about choice for the masses, using the NHS logo as a central pillar. In reality, for the cost of the Olympics, it is a half-completed load of cack. ‘Choose and Book’ purports to give patients a selection of hospitals when GPs refer them to secondary care. What actually happens is that the hospitals the computer picks, many of them miles away, need be accessed through a series of confusing passwords. On the few occasions I’ve used C&B, patients look at the choices and invariably ask me ‘well, which one should I choose’? ‘The Spine’ collects personal information in a way that even Stalin’s secret police would be envious of. What happens when a private healthcare provider is running an NHS polyclinic? Will it make information from the Spine available to its insurance branch? Its mortgage branch?
And what about NHS ‘N3’ broadband or ‘NHSmail’ email? When personal web-based email accounts are blocked by the majority of trusts, it is clear that the only choice is whether to use them, or to go without. E-Stalinism has continued with ‘Son-ofMTAS’. With many surgical trainees applying for both their dream careers and the backup of GP training schemes, many have been offered the ‘choice’ of either a job offer for GP training, or an interview for their higher training in surgery, but not both. ‘Would you like a punch in the face, or a firm kick in the testicles?’ ‘Erm, not the face please…OUCH!’ ‘Don’t complain. After all, that’s what you chose.’ E-democracy offers proper choice, and proper interaction. It can be the perfect antidote to e-Stalinism, provided one thing happens. People need to get involved. If you truly care about the fate of medical training, about the fate of junior doctors, about the fate of the NHS, and about the fate of Remedy UK, then I would urge you to take part.
www.drrant.net
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