The Doctor – issue 2, October by The BMA

The magazine for BMA members

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Issue 2

| October 2018

Papering over the cracks?

Can a health service battered by austerity make the bold investments it needs?

Tell me what’s wrong The ‘whistleblowing tsar’ on why doctors should speak up

Leaving Saddam The NHS through the eyes of an Iraqi doctor

Nice place for a holiday... ... but how can doctors be persuaded to work in remote and rural areas?

A wall of our making reaking the artificial barriers between physical and mental health

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

Email thedoctor@bma.org.uk

Call a BMA adviser 0300 123 1233 @TheDrMagazine 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 ÂŁ160 (UK) or ÂŁ225 (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: 362 no: 8167

Editor Neil Hallows (020) 7383 6321 Chief sub-editor Chris Patterson en o s a e s Peter Blackburn (020) 7874 7398 Keith Cooper (020) 7383 6390 a e Tim Tonkin (020) 7383 6753 o e n e and ne s ema 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

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Welcome to The Doctor Chaand Nagpaul, BMA council chair

contents

Welcome to the second issue of The Doctor – the BMA’s new magazine. It was wonderful to hear so many positive reactions to the September issue, the first in our striking new monthly format built around insightful features and detailed analysis, which included pieces about Brexit, immigration, bullying and harassment, and fatigue. The October issue continues that trend of looking at the topics that most concern doctors working on the front line in the NHS. These issues appear in our landmark survey report, Caring, supportive, collaborative, which was launched last month, and features the response of nearly 8,000 doctors across the UK. The results are stark. Many doctors feel that they are working in a dangerous and toxic environment, with a culture of blame and fear, jeopardising patient safety and discouraging learning and reflection. They also show the damaging effects of asking doctors to provide

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care without enough funding, doctors, other NHS staff, beds and equipment to meet the needs of patients. Added to this, the results suggest that poor lines of communication and lack of IT support is holding back efforts to encourage greater innovation and collaboration in our health services. It is clear from these findings that a new and bold approach is needed: one that prioritises patient safety over top-down targets, removes barriers to collaboration and innovation, and replaces a culture of blame with a culture of learning. Achieving this will require a major shift in how the NHS operates, with a renewed focus on ensuring that staff are valued and supported. Among many other topics inside you will also find excellent pieces looking at recruiting doctors in the Scottish Highlands and an interview with the BMA president Dinesh Bhugra, who focuses on two vital issues – mental health and race equality. Thank you for reading.

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12-15

16-19

Best-laid plans?

Tell me what’s on

en a s epp n stone becomes a home

Will an NHS short of doctors lose even more and will relations with the DDRB survive?

Will new NHS money be invested boldly or swallowed up by day-today needs?

20-23

24-25

26-29

30-31

You take the oad

To be fair

Life experience

From parity of healthcare to fairness at work – the BMA president plans to even the score

Toxic ‘colleagues’, how pregnancy can alter relationships and combining medicine and performing arts

Explainer/ What’s on

Tourists love them – but can Scotland’s remote and rural areas also attract doctors?

Speak up and help tackle oppressive cultures, says NHS ‘whistleblowing tsar’

One man’s drive to practise medicine in a safe country

New guidance on reflective practice following the Bawa-Garba case

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ues on o e o n on There was a calculated bellicosity in the prime minister’s vow in a recent media interview to end free movement ‘once and for all’. But it was quickly followed with a commitment that, for the right people, the door would remain open. Theresa May’s points-based system, aimed at the most skilled migrants, could still cause problems for health and social care, given the reliance of care homes, for example, on workers from other EU countries. But, given the universal acknowledgement that the UK is short of doctors, you might hope that such a system, if it worked, would not hinder the much needed flow of doctors from overseas. But whatever is planned on immigration, the objectives are at risk of being undermined by the myriad details of Brexit to which ministers have been warned, but to which they have failed to attend.

A no-deal exit could threaten the MRPQ (mutual recognition of professional ualifications , an agreement which enables uropean conomic Area ualified doctors to work throughout the continent. The implications could hardly be more serious – there are around , in ngland alone who ualified in other U countries. The A has identified as one of its five priorities on re it and has consistently lobbied the UK Government for its retention. And now the Standing Committee of European Doctors, of which it is part, has also called on the EU’s lead Brexit negotiator Michel Barnier to work towards a solution. Its letter says: ‘Professional mobility has led to our workforces becoming increasingly integrated and interdependent, and the mutual recognition of professional ualifications plays a vital role in our members’ professional development as well as in meeting varying workforce requirements across Europe.’ MRPQ is vitally important to sustain an under-doctored healthcare system. And yet, ust five months from re it, its future is still uncertain.

Current issues facing doctors

e n no dou Last month saw the launch of Caring, supportive, collaborative: doctors’ views on working in the NHS, a landmark BMA report informed by the views of almost 8,000 doctors working across the health service. The stark survey reveals the damaging effect of asking doctors to provide care without enough funding, staff, beds or e uipment to meet the needs of patients. The results also suggest that poor lines of communication and organisational divisions between general practice and hospitals is undermining patient care. Doctors say that a lack of IT support is holding back efforts to encourage collaboration and greater innovation in our health services. Five years on from the Berwick report – published in response to the tragedies that occurred at id Staffs it seems that not much has changed. In fact, 9 in 10 doctors say that they are working in an environment in which they are fearful of making an error fuelled by systemic pressures in the NHS, underfunding and lack of capacity. Even worse, 55 per cent of doctors feel that they would be unfairly blamed for these errors and as a result, nearly half of doctors say they practise defensively. Berwick said: ‘Fear is toxic to both safety and improvement.’ Clearly his lessons have not been heeded. Health secretary Matt Hancock’s recent warm words towards the NHS workforce, although admirable, will remain empty if he doesn’t prioritise the sta ng crisis. per cent of survey respondents said they feel sta ng levels in the NHS are inadequate to deliver quality patient care and some 74 per cent indicated that this situation has worsened over the last year. On top of that 54 per cent of doctors said

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Caring, supportive, collaborative

a future

vision

for the NHS

that they work significantly beyond their contracted hours. With many junior doctors heading for sunnier climates such as Australia, and a significant number of senior doctors planning early retirement, it’s not hard to see that immediate investment in the workforce is needed, particularly once the effect of re it is fully realised next year. Sixty per cent of doctors surveyed said quality and safety of patient care is compromised as a result of problems at the interface between primary and secondary care. But appetite for genuine progress is there – with per cent of doctors in ngland wanting GPs and hospital doctors to work more collaboratively and in a coordinated manner. If the Government wants to invest in innovative technology, doctors suggest that a good place to start might be the ageing and siloed IT systems across the NHS. PA

STEVENS: The future of the NHS rests on how the long-term plan is implemented

All of this comes as NHS England is preparing to launch the long-term plan, announced by the prime minister earlier this year along with £20bn extra funding a year by 2023. The survey findings clearly set out what needs to change. This is the NHS of 2018 and Mr Stevens’s long-term plan, and initiatives in all nations, must be used as an opportunity to make real, lasting improvements – as well as demand more funding and more support from the Government. For governments across the UK, the evidence from doctors on the front line is in. Now it’s time for solutions.

An independent pay review body – now there’s an idea The doctors’ independent pay review body has resigned en masse in protest at the Government’s refusal to implement its recommendations in full. And in other news, prime minister Harold Wilson clashed with opposition leader Ted Heath as the country heads towards a knife-edge general election, while Pelé’s Brazil looks set to win a third orld up. It was back in 1970, eight years before the current health secretary Matt Hancock was born, that the Review Body on Doctors’ and Dentists’ Remuneration took its principled stand against the Government meddling in its recommendations. It only agreed to reform after an undertaking from ministers that its advice would henceforth be followed unless there were ‘obviously compelling reasons’. After all, what s the point of having an independent, expert body, which weighs the needs of, and demands upon, the profession against the overnment s finances, if it s just going to be ignored? The DDRB of 1970 would not be impressed with the DDRB of 2018. And nor are doctors. Their confidence in its independence and effectiveness has been ‘destroyed’ by the interference of successive governments, said A council chair haand Nagpaul in a letter to Mr Hancock. Dr Nagpaul said the DDRB should be given back its independence and its original

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focus on pay rather than wider contractual matters, and the Government should recommit to respecting and implementing its recommendations. The BMA has given the Government a 12-week deadline, or it will reconsider its involvement with the DDRB. This is the product of years of mounting frustration within the body, during which it accepted per cent limits on pay increases in successive years and made recommendations on the English junior doctor contract which were retrograde and counter-productive. The irony is that there has probably never been a better time to have a that performs to its original remit. Surveys of morale, recruitment and retention repeatedly report grim findings for the future sustainability of the NHS workforce. And we have in existence an organisation which makes pay recommendations to the UK Governments based on, among other things, ‘the need to recruit, retain and motivate doctors’. A really useful organisation. If only it did its job.

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BRAZIL: Like the DDRB, better in 1970

Read more online ‘A celebration of overseas doctors’ ‘BMA NI council chair cites “serious challenges’’’ ‘Flu jab shortage threat to vulnerable patients’ ‘MUP policy nears introduction’ Read all the latest stories online at bma.org.uk/ news

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Can the chronically underfunded NHS in England make bold investments in areas such as integration or public health, or will it be left papering over the cracks? Peter Blackburn reports

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Best-laid plans? I

magine if your team had a player like Lionel Messi. Then imagine he missed half of every game because his bus ran late and he didn’t have proper boots. Now imagine a health service which can do impossible things before breakfast – 3D-printed limbs, personalised drugs – but where desperately ill, lonely, frightened patients have to wait hours on trolleys for the most basic treatment. The NHS is recognised as one of the fairest, most e cient healthcare systems in the world, with some quite extraordinary talent, innovation and compassion. But it is placed in ill fitting boots circumstances which are largely beyond its control – rising demand, a continuing lack of capital investment, shameful failures in provision of mental health and public health. Add to that a perception among staff that it is more a political football than a genuine priority. But don’t worry, the NHS has a plan. Yes, that was meant as a cheap jab, and the emergence of another plan to end all plans from NHS England is likely to cause a collective eye-roll like an ocular Mexican wave around the health service. But while it’s folly to declare a turning point until one’s vessel actually begins to turn (assuming it’s even possible to turn it),

there are reasons to examine, and engage with, what NHS England is trying to do. The background to the plan is this: in June, prime minister Theresa May promised the NHS in England an extra £20bn a year funding by 2023. In return, NHS chief executive Simon Stevens was charged with drawing up a longterm plan to ensure how the extra investment was best spent. To be clear, the BMA strongly believes that the funding, while welcome, is insu cient to meet the demands on the health service, and that it is needed now, not in several years’ time. But this is at least an opportunity to address what Chris Ham, the outgoing chief executive of the King’s Fund, describes as a system which is fundamentally broken, whether financially or in how patients access care . Professor Ham, one of the UK’s most respected health economists, told a King’s Fund conference earlier this month that it would be a ‘huge missed opportunity’ if the new money was funnelled away from change and transformation into covering e isting deficits. It’s fair to say that the words ‘plan’, ‘change’ and ‘transformation’ haven’t always had the best press in the health service. But what might be different, what needs to be different, in this thedoctor | October 2018

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DOYLE: ‘We need to get investment into areas where it will make a difference

HAM: The system is ‘fundamentally broken’

MAY: Promise of an extra £20bn a year of funding by 2023

case is that there is a near-consensus about the path the NHS needs to take. It is for closer collaborative working between the different parts of the NHS, and for integration of services. This was an overwhelming finding in the survey that informs the BMA’s major new project, which aims to set out a positive vision for a more caring, supportive and collaborative healthcare system. Of the 8,000 respondents, 93 per cent wanted GPs and hospital doctors to work together more directly in a collaborative and coordinated manner. There is no disagreement in this from Mr Stevens, who told the NHS Expo in Manchester last month that he wanted to ‘put an end to entrenched, siloed working .

Progress at risk Addressing the fragmentation of the health service is one of the project’s main aims. The project will set out an environment in which people across the NHS are empowered to work together more effectively while 08

maintaining professional autonomy. It will be centred on patients, asking what clinical pathways would look like in a more collaborative system. The concept of integration has been around for a long time, and yet progress has been limited to local initiatives, which have shown encouraging results in bringing care closer to home, managing demand and reducing emergency department admissions. The issue is that, for decades, Government policies have worked against integration rather than for it. In England, increasing marketisation has led to artificial barriers, perverse incentives and wasteful competition. And so, what the Government has done in Parliament to undermine integration, it must undo. As the BMA says in its response to NHS England’s consultation on the long-term plan, there is growing concern that without legislative backing, a real template for progress, or statutory authority for the new organisations and partnerships springing up, then progress will continue to be patchy and perhaps even subject to legal challenge. This lack of a national steer – the contradictory position from the Government of keeping a market system entrenched in law but promoting the opposite in local initiatives – is slowing progress and eroding good intentions. Another priority and one so often neglected in previous NHS plans – is the engagement of NHS staff. As BMA GPs committee chair Richard Vautrey puts it: ‘Ultimately, if you are involving clinicians and enabling them to make decisions about how funding is used you will get a better outcome.’ BMA consultants committee chair Rob

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60%

6 in 10 doctors say that the quality and safety of patient care is being compromised due to barriers between primary and secondary care

Harwood agrees and urged the involvement of secondary clinicians who hold the expertise in services that may be moved to the community, and will often remain involved in delivering the care. ‘There have not been many people out of secondary care that have been involved in it [the plan] up to now and that feels like a real lost opportunity.’ He adds: ‘There will be a focus on doing more stuff out of hospital. That s part of what we are expecting, and that’s not a problem except that there’s an assumption that you stop doing things in hospital that s ust fine but it s got to be better and cheaper, which it might be, but you need to make sure it actually is.’ As well as ensuring quality, it’s essentially that if services move into the community, the funding follows it too. Otherwise it remains Integration little more than a slogan. ‘We have heard this [integration] for s o en talked about many years,’ Dr Vautrey says. ‘It’s something often talked about but we haven t seen that but we haven’t seen delivered in any material way we often see it delivered the work coming to general practice but we don t see the funding coming to match it in any this is an opportunity to do that and to put the material money behind the rhetoric.’ way’ Source for statistics above and overleaf: survey to inform the BMA Caring, supportive, collaborative: A future vision for the NHS project

If integration is destined to play a major role in the long-term plan, which is expected to be published in November, what else can we e pect Keep your ear to the ground in NHS meeting rooms and conferences and the answers to this question seem to be: upgraded mental health services, a focus on improving cancer treatment and outcomes, efforts to improve services in overlooked areas such as autism, a major focus on technological progress and, yes, you guessed it, a ‘radical’ investment in, and focus on, public health.

Room for manoeuvre Heard it all before erhaps so but there is reason for a little more optimism this time around. When Mr Stevens was tasked with drawing up the Five Year Forward View, this was a health service cash-strapped beyond reason, one required to make brutal and unsustainable cuts. No organisation can innovate in those circumstances, even with the NHS’s remarkable record when backs are against the wall, as they so often are. This time around a pocket of money has been promised. Granted it’s nowhere near what most health experts know to be required, but it’s certainly more than anyone could have thedoctor | October 2018

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Caring, supportive, collaborative

a future

vision

23% ‘We have an opportunity to invest where we need it most’

ENGLISH: ‘Encourage people to exercise’

for the NHS

Almost a quarter of doctors say that their hospital/practice cannot usually provide cover for absences or unfilled vacancies

expected six months ago, and that is a very different scenario to the one r Stevens last found himself in. Here there is an opportunity to make things better – and a little more headroom to make those changes stick. When it comes to public health – and the wider determinants of health – the problems the NHS, and society, faces are clear and have been for many years. But they seem to get lost in the here and now. As Duncan Selbie, the founding chief executive of Public Health England, told the NHS Expo conference: ‘We keep talking about the same things, cancer rates and [emergency care] performance. But what about the future? We should be concerned about whether children are ready to learn when they start school, can they read… these are the things that determine their future. ‘The biggest determinant of outcome is not what we do in a renal clinic but the money in our pocket. The decisions we make – do we smoke, what do you eat, how is our blood pressure. o we have e ercise, how much do we drink. And the biggest determinant of all is do I have a job?’ While this requires the shamefully neglected public health services to be rescued from years of cuts to services in areas such as smoking cessation, it is also clear there is a job for the overnment well beyond the confines of the NHS. BMA public health medicine committee chair Peter English says: ‘Much of it comes down to big Government measures – how you do taxation, how you ensure a greater level of equality in society, whether you make the healthy choices the easy choices like taxing unhealthy foods, putting fiscal arrangements in

place that encourage people to take exercise.’ But it seems the Government has been better at talking about public health measures than actually bringing them into being. ‘Prevention has to be a good way to spend some of your healthcare money the di culty is we talk the talk around it but we don’t seem to believe it,’ says Dr Harwood.

Preventive measures One person who does believe in the importance of prevention is Amanda Doyle, a practising GP and leader of the Lancashire and South Cumbria integrated care system, and one of the people who will draw up NHS England’s plans. She told the King’s Fund conference: ‘What we have got is an opportunity to invest where we need it most – the only time practically speaking we are going to be able to invest up front in prevention and mental health is when there is new money available – it’s vital that we recognise while we are compiling this plan that we need to get investment into those areas where it can make a difference. Of course, a health service that has been neglected for so long needs attention in many areas. The BMA also expects the plan to address long-term workforce planning, capacity in secondary care – England has 6,000 fewer beds than it had in 2014-15, and this has exacerbated winter pressures – for primary care to be given a fair share of the NHS budget, and for mental health to achieve the ‘parity of esteem’ which ministers have promised. And the NHS needs more than merely a shopping list. The BMA believes the aim should be a new kind of health service, rather than the old one with a little bit more

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VAUTREY: f you involve clinicians you will get a better outcome’

NAGPAUL: ‘The culture has improved little since the Francis and erwick reports’

TERRIBLE TRIO: Poor diet, smoking and alcohol misuse all undermine public health

‘Prevention has to be a good way to spend money’

49%

49 per cent of doctors practise medicine defensively because they are working in a blame culture

money to paper over the cracks. The A s Caring, supportive, collaborative: A future vision for the NHS project takes on fundamental issues such the culture of the NHS, moving away from one of blame towards one of learning, and the importance of a properly e uipped and rewarded workforce. A council chair haand Nagpaul says t is vital that the overnment and policy makers heed the views of all doctors who provide care at the coalface they are in the best place to know the problems the NHS faces on a daily, hourly basis. They know the scale of impoverishment in the NHS is staggering and they are working in a culture which has improved little since the publication of the rancis and erwick reports following the tragedies in id Staffordshire five years ago.

So the Government must realise that the funding announced in the summer is the beginning, not the end, of a fair and sustainable investment in the NHS. A step in the right direction, but nothing more, and it should be part of a wider cultural change. t is reasonable with any money the overnment spends for it to e pect to know how it will be spent. ut it should not e pect miracles from a health service that has suffered for so long under the effects of its austerity policies. ually, and despite the huge effort it takes to cope with day to day demands, the health service needs to invest, and invest boldly. This might mean missing some targets, but sometimes it’s better to miss a target than it is to miss an opportunity. thedoctor | October 2018

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Tell me what’s wrong There are some seriously oppressive cultures in the health service, says Henrietta Hughes, a doctor and NHS national guardian. She tells Keith Cooper why staff should raise concerns

t must have been awkward when Henrietta Hughes walked in on her first day. The more senior trainees, the registrar and the senior registrar were very concerned, she recalls. was to work for this consultant, and they said, this person is not supposed to have female trainees . t was a bullying and harassment situation. thought, ho hum, ust get on with it. didn t know could do anything about it. Hearing this now, it s a little di cult to believe, coming from this calm and confident head of the N National uardian s ce , a relatively new arm of the NHS. r Hughes pictured , a , is coming up to two years as the national guardian, a whistleblowing tsar in the vernacular. The N seems a modest operation, occupying a share of o ce space on the road to ictoria oach Station. t s so many goldfish bowls, gawping over a courtyard of glass and girders, where people teem beneath. The N is charged with helping staff to speak up and r Hughes is putting her early career e perience out there as a reason why it s needed. hen ve asked other unior doctors if anyone else has heard of anything like this before, hands go up. ike many in medicine, such early e periences stick, and steer careers. Her own, she describes as common or garden . rom a family of doctors, she wanted to be one early on. hen was two, my grandfather made me a surgeon suit from surgical drapes and that was it, she says. After medical school at ford and arts NHS Trust, came house o cer and research roles, then her first choice of specialty training, obstetrics and gynaecology. She later switched paths to become a . thedoctor | October 2018

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e o ed n ea y o o an sa ons u e a so o ed n ea y pos e ones no ee d e o o e e While she casts this move in a positive light (‘it’s the best career decision, ever made , it aided a welcome escape from hospital life. ‘When I go back into hospitals, I do sometimes come across cultures which are really oppressive, really seriously oppressive for the staff, she says. Not ust for the doctors, but for all staff. ife as a is nice and old fashioned in contrast. massively enjoy seeing patients. It’s just an amazing insight into people’s lives. You have that continuity with an individual, the whole family.’

Guide through the maze She compares her role as the national guardian to medical practice. ‘As a GP, I help to navigate individuals through the system,’ she says. ‘As an appraiser for medical directors and GPs, it’s that same thing listening, finding out what people s challenges are, what their goals are and helping them to move along the path to that place. With this role, I’m doing that but for the NHS as an organisation… even if the scale is uite different, she adds with a laugh. The NGO was set up on the say of Sir Robert Francis QC, whose probes found ‘appalling patient care’ at Stafford Hospital and truly shocking treatment of staff who raised concerns, there and elsewhere. Staff who spoke up lost their obs and suffer serious psychological damage’ his report, Freedom to Speak Up, from 2015 says. There are no similar roles to the NGO in Wales, Scotland and Northern Ireland, although the Scottish Government has plans to establish a National histleblowing cer soon. So what does the national guardian do? And how does it e pect to help staff to feel able speak up r Hughes sees her role in three parts. The first is to train and support the network of ‘freedom-tospeak-up guardians’, a chief recommendation of the 2015 report. There are now hundreds, from multiple professional backgrounds, including medicine, nursing and administration. They’re an alternative conduit for raising concerns to o cial channels which have treated whistleblowers so poorly in the past. Freedom-to-speak-up guardians aim to solve problems that get ‘stuck’ in the system, she says, interlacing her fingers into an upward arch. e don t want that pattern: when someone gets ignored, gets a lot of work related stress, goes off sick, or leaves, or it damages their career.’ She speaks of one trust where a single trainee 14

covered the whole site overnight. ‘There were more people in Costa than junior doctors. It had been raised through systems, such as Datix, through the educational supervisor,’ she adds, her hands chopping the table, marking each failed attempt. ‘Nothing had happened. Then the freedom-to-speak-up guardian was approached and immediately contacted the chief executive. Actions were put into place that night.’ The hands rise for a swirl: ‘Those are the things that give me the energy.’

Beyond the doctor Now that all trusts have freedom-to-speak-up guardians, she is turning her attention to primary care: general practice surgeries, opticians, dentists and other providers in this 50,000-strong sector. Funding for recruitment has just come through and she’s working with early adopters . t s not going to be a one si e fits all model,’ Dr Hughes says. The NGO’s second role is to carry out ‘case reviews’, a relatively new system of checks in the NHS to examine how well trusts handle concerns and treat those who raise them. She lacks power to enforce recommendations, relying instead on other regulators in the NHS, such as the Care Quality Commission and NHS Improvement, for ‘teeth’ and ‘bite’. o en pu myse n These reviews launched in June o e peop e s s oes 2017, some eight months after she started. ut the time they took to get off the ground attracted some criticism. When Norman Lamb was Liberal Democrat health spokesperson, he described the NGO as a ‘damp squib’ following its ‘astounding failure to investigate a single case, months after the role was first announced’, in an article in The Mirror, ust weeks after Dr Hughes started. Bringing this up fails to faze Dr Hughes. She was ‘starting from scratch’ she says. (Her predecessor, ame ileen Sills, had resigned after two months in post. ‘Our review system was a pilot,’ Dr Hughes adds. So one of the things that thought would be a really good thing to do would be to recruit some staff, she says before a comedy pause. ‘For a start,’ she adds, with a laugh. The third part of her role is the one she admits to be the most ‘nebulous’. ‘It is to challenge the system,’ she says. ‘To get our regulators and sponsors, the Care Quality Commission, NHS England and NHS Improvement to think about the cultures in their organisations.’ She wants the GMC and unions too –

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‘My ideal situation is that we wouldn’t need a na ona ua d an including the BMA – to appoint freedom-to-speak-up guardians, as hospital trusts have. ‘It’s the culture of the surrounding organisations that derive the culture inside the providers,’ she says. Dr Hughes’s initial prescription for a healthy NHS culture is now infamous for the reception it received. Staff need more trust and oy and love she told The Times in an interview to mark her appointment, appearing to urge them to be like actors in the romcom, Love Actually. ‘Simply ordering people to be happy will not wash,’ replied retired consultant rheumatologist Andrew am i, in one letter of response. latitudes and wishful thinking will not work,’ said another.

‘Quite soppy really’ She admits her Love Actually prescription was received with ‘deep cynicism’. ‘I think I’m quite soppy really, she says, but who wouldn t like the film f she has any regret, it’s in the headline that went with it: “‘Happiness is the best medicine,” grumpy doctors and nurses told”.’ ‘I don’t think grumpy is the right word,’ she says. Harassed, harassed. t s going to happen. will often put myself in other people’s shoes,’ she adds. ‘I’ve had my good days and bad days myself.’ But despite the cynical reception, there’s a serious point behind her love for this syrupy flick, which relates to her work here and her earlier career. ‘I’ve worked in really toxic and dysfunctional organisations but I’ve also worked in really positive ones. I know where I’d like to work better.’ With a more positive, Love Actually vibe in the NHS, she’ll no longer be needed, a laudable goal for sure. ‘My ideal scenario would be that every organisation has supportive line managers, so that we don’t need freedom-to-speak-up guardians, we don’t need a national guardian, and that we have a positive and a supportive culture in the NHS and in all organisations,’ she says with a final dramatic swirl of her hands. Then can go and do something different. And start seeing patients.’ Given the extent of bullying and harassment in the NHS, they may be kept waiting some time. A BMA raising-concerns advice service provides support to members who have concerns about patient safety but are not sure how to raise them. Call 0300 123 1233. thedoctor | October 2018

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A stepping stone becomes a home With the goal of joining his family in the USA and anada, a young ra i medical graduate left his turbulent home country behind and headed west â&#x20AC;&#x201C; except he discovered an island en route that he found he favoured more than anywhere. In the second part of our series celebrating the contribution of doctors who have come to the NHS from overseas, Tim Tonkin talks to Glasgow consultant Mohammed Al Haddad 16

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LONDON GENTLEMAN: r Al Haddad e plores the UK’s capital soon after his arrival

‘T

RETURN TICKET: Dr Al Haddad spent some of his childhood in the UK, returning after the ulf ar came to an end

‘I came to realise I liked the balance that the UK had between socialised and private healthcare’

here were a lot of reasons to come to the UK – the main one was that felt didn t fit into my homeland’s society [Iraq] and I suppose I was always going to leave to go to a more open, tolerant place.’ For the UK, 1996 was a year that was, in many ways, marked by an undeniable, underlying sense of optimism and promise. The country had found its way out of the unemployment and recession that had blighted the start of the decade, while technological and scientific advances such as the Channel Tunnel and the cloning of Dolly the sheep had, or were about to, make their mark. Along with the heady excitement generated by the UEFA Euro 96 football tournament, the cultural phenomenon of Britpop providing the nation’s soundtrack, and a growing anticipation of the new millennium, expectations of a bright future abounded. This was the UK that a 27-year-old Iraqi medical graduate, Mohammed (Mo) Al Haddad, found himself in, following his arrival in February that year. Despite having already spent four years of his childhood in the UK during the 1970s, Dr Al Haddad had spent much of his life growing up in southern Iraq. Part of a medical family – his father and siblings are also doctors – he completed his medical training in 1980s

and early-1990s Iraq, against a backdrop of successive military conflicts and economic challenges. ‘The health system in Iraq, up until the late 1970s, was a leading national health service in the Middle East,’ Dr Al Haddad explains. ‘The universities in Iraq were well established, and people would actually come to Iraq for their medical training. It really started to go downhill after the war with ran which, for me, was the first war saw [prior to the Gulf War]. ‘During the 1980s things started to deteriorate, and when the sanctions kicked in, in the early 1990s, the health service and the whole country was on its knees.’

Flatlining healthcare UN sanctions were imposed on Iraq following its invasion of Kuwait in 1990. In addition to the effects of the eight year ra ran war, this had left the country’s health system barely able to function. ‘In the health service itself there was very little in the way of basic medical supplies such as cannulas, gloves and syringes,’ Dr Al Haddad recalls. ‘We used to have to reuse disposable needles from patient to patient because we didn’t have enough to go around. There was no paper to write on and no up-todate books often someone would bring a [medical] book from abroad and it would be photocopied and distributed to the medical profession. was looking after patients

with renal failure at a time where there were effectively no reliable lab results. With things such as kidney failure, you are relying on lab results to check on things such as potassium levels. Things can go horribly wrong without these – and they did, with patients dying for reasons that would have been very easily avoided [with the right resources].’ eing unable to offer many patients the care and treatment they required owing to technological and material limitations was compounded by the nature of the country’s political regime, which meant doctors, on occasion, did not practise medicine in accordance with medical ethics. While Dr Al Haddad and his colleagues struggled to care for the vast majority of the people they saw, the nature of Iraq’s ruling elite meant that doctors were often put in a position where they would be expected to compromise the most basic and sacred tenets of their profession. ‘You were obliged to treat certain kinds of patients in a different way because they were connected to the regime,’ he says. ‘One of the things that the regime did as a punishment to those who had deserted from the army, was to cut a bit of that person s ear off, to mark them as traitors as it were, and they were asking surgeons to do that.’ By the time the Gulf War had come to an end in 1991, thedoctor | October 2018

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Dr Al Haddad’s desire to move abroad had reached a tipping point. At that point in my career, became very, very disillusioned with medicine because of the way was being forced to work and the lack of resources. also saw the value of my salary, for e ample, go from a few hundred a month, to the e uivalent of a month by the time had graduated.

IRAQ: onflict and instability, which persist to this day, led to a severe deterioration in healthcare services

Team working ollowing his arrival in the UK, r Al Haddad worked for eight months as a phlebotomist at the oyal rompton Hospital, while studying for his A rofessional and inguistic Assessments oard e am. The contrast between UK hospitals and those that r Al Haddad worked in back in ra was notable, not simply in terms of e uipment and resources, but in the ethos and workplace practice. The main difference noticed when walking into an NHS hospital was the role of 18

‘I saw the value of my salary go from a few hundred a month, to the equivalent of £1 a month by the time I had graduated’

teamwork, and the role of nurses. Nursing in the UK held a much more prominent position and role within the team compared to ra . Training, ob prospects and career progression and being able to realise your dreams and professional ambitions were much more likely to happen in a place such as the UK compared with ra . Ad usting to the NHS and clinical practice in the UK was ust one of the changes that r Al Haddad had to contend with. As he soon discovered, the chasm between everyday life in ra and the UK often entailed a steep learning curve. grew up in a place in ra that was completely isolated and cut off from the rest of the world. hen returned to the UK as an adult, there were so many aspects of day to day life that had no knowledge of. There were a lot of things couldn t get my head around,

the ta and legal systems, rent, AT, it was all very, very different. d never had a bank account while in ra , as these weren t in common use, it was all cash and keeping your money hidden in the free er and things like that. ust getting to grips with things like opening an account and debit and credit cards, ust went into banks and picked up leaflets and read through them. The difference in social attitudes in the UK compared with ra also came as a surprise. d come from a society that was uite pre udiced, bigoted and udgemental. There s obviously a little bit of that everywhere in the world, but the difference between ra and the UK was stark. After completing his A , r Al Haddad took a ob in emergency care in oncaster,

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where he worked for a short while before moving to Scotland in 1997. ‘I knew I didn’t want to do surgery,’ he says. ‘My dad was a physician and I was probably influenced by him in veering towards those specialties. At the time, there was a need for anaesthetists, and decided that that was what wanted to do.

‘Proud Scot’ After successfully applying for a training post in Dundee, he spent nearly a decade in the city before moving to Glasgow in 2005 to take up a consultant post, a position in which he continues to work. Having lived continuously in the UK for more than years, r Al Haddad has now become established in his career and raised a family. One of his daughters, Nadia, is at school and enjoys singing and acting, while the other one, Susan, who Dr Al Haddad describes as a ‘proud Scot’, has represented her nation in hockey at an international level. Other than the cuisine, Dr Al Haddad says that he personally misses very little about life in Iraq, adding that he is happy and proud to work in the NHS. Yet at one point in time, a life and career in the UK was not a foregone conclusion. hen left ra , thought I would come to the UK, get some training and then maybe move on to the USA,’ he explains. ‘My brother had emigrated there, and my sister and the rest of my family all went to Canada. ‘I came to realise, however, that I liked the balance

that the UK had between socialised and private healthcare, and living in a place where everybody can access healthcare. ‘I liked that better than what I was hearing [about healthcare] from my brother and friends who had moved over to the states. ‘The way we deal with things in the UK is to see what is needed for the patient. You make your [professional] decisions based on that rather than your personal financial interest. Dr Al Haddad’s life and career are now a world away from his days as a medical student in 1980s Iraq; training under a repressive political system and within a health service that was increasingly living hand to mouth. ‘I don’t think the NHS would have existed or managed to function over the past few decades, without international medical graduates. ‘That’s partly just in terms of filling in the posts but obviously international medical graduates bring in a

SAFE AND SETTLED: Dr Al Haddad outside the Queen Elizabeth University Hospital where he works today

‘I don’t think the NHS would have managed to function over the past few decades, without international medical graduates’

lot of other things to it, such as diversity in the working environment and diversity of professional e perience. ‘I think all [IMGs] international medical graduates, just like UK graduates, have all contributed in their own way to training, education and research. ‘However, I do think it’s a bit more di cult for s to make those contributions and get recognition for it, in terms of career progression and things like that.’ He says that although this had improved in more recent years, certain biases remained. ‘I think the NHS is a fantastic institution, it is probably the envy of the world. ‘I think we do need to look after it, and do think that valuing staff is really key to the success of the NHS. ‘I think this has been somewhat eroded in recent years to the detriment of the NHS.’ bma.org.uk/immigration thedoctor | October 2018

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You take

THE SCENIC CAREER ROUTE: Highland foundation year 1 Eilidh Urquhart at the Knoydart peninsula, Lochaber

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ke the high road A great place for a holiday... but a career too espite their beauty, the most rural areas of Scotland have struggled to attract enough doctors. Jennifer Trueland finds out how this might be changing

f you go to Fort William, perhaps to take in the majesty of Ben Nevis, or the beauty of Loch Linnhe, you might spot a banner displayed on a building with a vantage point on the Scottish town. This building is the much-loved Belford Hospital – and the banner urges doctors to come and work there. t s an unusual recruitment strategy for the public sector but it s one that the local health board hopes will pay off. ‘Audi or any other car dealership makes use of the opportunities for a visual display so why shouldn t we says Katharine ones, associate medical director for the NHS Highland s north and west division, which covers some of the most remote and rural areas of the UK. ‘Thousands of people visit Fort William every year for all the great things it has to offer it s the outdoors capital of the UK. ut unless they know there are obs available, they might not think of applying to work here.

Innovate to attract The banner is part of a wider effort to ensure Belford Hospital remains sustainable for the future, as medical recruitment issues continue to bite. And it s also ust one e ample of how rural areas are innovating to try to reverse a trend of rising medical vacancies. thers include developing new roles, such as the rural practitioner essentially a with enhanced front door and emergency care skills a drive to provide student placements in rural health settings and efforts to attract people while they are young and making career choices see The great outdoors on page .

t s certainly an issue and the situation at the elford is far from uni ue. The latest figures from S nformation Services ivision Scotland show that the consultant vacancy rate in Scotland as a whole is running at . per cent, while in NHS Highland it is . per cent. This rises to . per cent in Shetland, per cent in the estern sles and . per cent in umfries and alloway. S points out that the highest vacancy rates are in boards with rural profiles and that prospective medical students move to Scotland s ma or cities to undertake training. ‘There is an ongoing challenge for boards with a more rural profile to attract them back home once they are ualified, S says. Vacancies – particularly jobs that remain unfilled for si months or more not only put health services at risk and pile pressure on those who are in post, they also have an effect on rural towns and villages, says r ones. The NHS is a significant contributor to the local community. onsultants are relatively highly paid individuals and they contribute to the local economy, she says. Short term locums, on the other hand, usually live and spend the bulk of their money elsewhere.

Lifestyle changes ther health boards covering rural Scotland are also stressing the attractions of the local environment on their recruitment sites. or e ample, anyone thinking of applying for a ob in NHS rkney will be told that it is truly a wonderful place to live and voted one of the happiest places to live in the UK . ‘With spectacular natural surroundings, thedoctor | October 2018

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Doing what you love and what the world needs is key, says Dr Jones

an and u a This map shows vacancy rates across four Scottish regions figures are not available in this form, unfortunately). NHS Lothian, which includes dinburgh, has a much lower vacancy rate than more rural areas.

10.3% unique wildlife and a rich culture it is not hard to understand why,’ it adds. Similarly NHS Shetland sells itself on its ‘low pollution, low crime, excellent schools, great leisure facilities, unique wildlife and amazing scenery’, while NHS Dumfries and Galloway talks of ‘an exceptional quality of life’, citing mountain biking, hill walking and great stargazing opportunities. At just a couple of weeks into the campaign, there is no indication yet of whether it will pay off in terms of applications from suitable candidates. But Dr Jones points to one case where spreading the word led one family to up sticks from urban practices in Doncaster and move to beautiful Jura. Dr Martin Beastall took on the role of Jura’s GP in 2013 following a social media campaign run by the local community, telling BMA News at the time that ‘the idea of being a more oldfashioned GP’ appealed to him. Five years on and he and his wife Abby (pictured below), who is working as a salaried on neighbouring island slay, have settled into the local community – but are taking action to improve the sustainability of the practice. ‘We are currently in the process of renegotiating our out of hours service,’ he says. This was partly prompted by the formal separation of core and out-of-hours work in the new GP contract, but we would have had to change something even if the contract hadn’t changed, as 22

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more than five years of responsibility has been quite tough on our family and personal lives. ‘Our new system will come into place in January, and we’ve been working hard to engage with our community during the redesign process.’ Dr Jones is herself a case in point. Formerly a GP partner in Liverpool, she and her family moved to Scotland months ago after she spent some time working as a locum on Scottish islands. loved it, she says simply. really loved the medicine, but also the culture and the way of life.’ Although she now holds a managerial job with the health board, she still does ‘some GP work on the side’, as she puts it. ‘Working here has really reignited my interest in clinical medicine,’ she says. She cites a Japanese concept called ikigai, which essentially means finding a life where you are in the right place, doing what you love and what the world needs and, ideally, being paid for doing it because it is your job. There are people out there for whom this will be the job they want to do because they love it. We look forward to welcoming them to Highland.

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The great outdoors: r ra i e ca enhance doctors’ careers In her years at medical school in Edinburgh, Eilidh Urquhart worked in numerous clinics, wards and operating theatres. But it was the work experience as a schoolgirl in her local hospital, Raigmore in Inverness, that has really stuck in her mind. She was in the r tc rt a organised Doctors at Work programme, a ve a p ace e t r ec ar c pupils in Highland who are considering a medical career. The idea is to encourage local teenagers to apply to study medicine, give them some practical experience, which will help with the application process and, ideally, will be minded to come back and work in the area when they graduate.

‘I remember going to theatre and watching a hip replacement. Now orthopaedics aren’t really my thing, but it was amazing to see it happening. ‘The work e perie ce c r e r e t at a te to be a doctor – that I a te t it r t e long term.’ That week back i a e t e eci i act r e ii ra this year, Dr Urquhart, a app i r er ati trai i ‘I had studied in Edinburgh and the hospitals were much bigger. That suits some pe p e t that Raigmore, being a er a rie and supportive and etter r e e Doctors at Work programme helped me understand what it means to be a doctor,

and it also helped me with my application as I was able to discuss what I had seen and learnt when I was writing my personal statement and taking part in interviews.’ For Dr Urquhart, who hopes to pursue a career in paediatrics, the rural setting has another advantage. ‘It’s great being so close to the outdoors. I grew up in the mountains and on boats, and it’s good to be back.’ She also thoroughly enjoyed a placement at rt i ia e r ‘Give people pita t ar re clinical experience a a ou there than anywhere of working else and saw much na u a environment more than I did in early in their Edinburgh,’ she adds. BMA Scottish careers’ consultants committee deputy chair Quentin Cox, a consultant orthopaedic surgeon

HIGHER PLANE: The countryside link keeps Dr Urquhart in touch with how she grew up. She is pictured on Beinn Eighe, Torridon

at Raigmore, is strongly supportive t e r experience scheme and other initiatives t e c ra e pe p e to work in Highland. ca ive pe p e a flav r working in a rural environment early in their careers, then they are more likely to consider it as a place to work,’ he says. He points out that around a arter t e c i ica trai i er ee University medical students takes place in Inverness, and that a peci c r ra tra i oversubscribed. The Doctors at Work programme has been a success, says Mr Cox. ta t e t to demonstrate that they have had contact with the NHS, and it really does give t e a vie at happens in hospitals.’

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‘The dichotomy between physical and mental health has been detrimental to the treatment of both’

To be fair Dinesh Bhugra’s year as BMA president will see a strong focus on fairness and e uality both in health outcomes and how NHS staff are treated. m on n reports

iven that our anatomy is so similar, why do people turn out so differently from one another It was this intriguing thought that occurred to Dinesh Bhugra while a secondyear medical student that set him on the road to becoming one of the most eminent and influential psychiatrists of his generation. It was a journey which took him from his university

in une, in the ndian state of aharashtra, to, first, working in a Leicester asylum, and ultimately the nstitute of Psychiatry at King’s College, London, where he was professor of mental health and cultural diversity until his retirement. He was the first ever ritish president of the orld Psychiatric Association, has been president of the oyal ollege of sychiatrists the

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legal discrimination, which resulted in a ill of ights for those affected.

Parity of status

PARITY: rofessor hugra wants to break down barriers between physical and mental health

first Asian ever to do so , and started as A president in the summer. His working roles and research interests have been broad they include migrant mental health, psychose ual medicine and cross cultural psychiatry and two years ago he led an ambitious international study of nearly countries looking at the e tent to which those with mental illness face

n his year as A president rofessor hugra hopes to advance work on long standing mental health issues. A priority is to overcome the artificial distinctions between physical and mental health, and ensuring they are accorded e ual status for clinical and research funding. There is now much more openness about talking about mental illness, he says. ut the dichotomy between physical and mental health has been detrimental to the treatment of both, and we have to bring them together in our approach. e know that people with mental illness die to years younger. e also know that if someone with diabetes and hypertension becomes clinically depressed, it can become very di cult to control their diabetes and hypertension, so we need to bring treatment of the two together. Another priority is tackling racism, to which he himself has been sub ected. This includes an incident where he was aggressively confronted by a patient, but also others which were more subtle but ust as damaging. was once taken off a multi million pound grant application with the e planation that as the research sub ects did not include south Asians they didn t need me. will bet that the very eminent professor who made this remark to me, did not think of it as a

racist comment. Two years ago, he chaired an in uiry into race e uality at ardiff medical school. e the in uiry were still hearing stories that patients would not want to see black students. The medical profession needs to stand up and say that things like this are not acceptable, and not try to e cuse such behaviour as patient choice , when it is not. rofessor hugra s championing of mental health e tends to the medical profession itself. He was due to launch a A survey of doctors and medical students earlier this month, on orld ental Health ay. The survey aims to develop a greater understanding of the e tent to which the profession s health is being affected, what support they are getting and the changes needed to make things better.

Resolute stance rofessor hugra accepts that there are many long standing issues, which will persist well beyond his presidency, but he remains optimistic. n part, this is the result of his tremendous faith and commitment in the NHS. The service urgently needs more integration, he argues. f we were designing the NHS today would we do it in the same way would like to see much greater integration between primary and secondary care, between healthcare and social care and between education, training and delivery of care. ut he adds As long as people are willing to defend and fight for the NHS, it will survive. thedoctor | October 2018

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on the ground Highlighting practical help given to BMA members in di culty

This month, our regular look at the support given to do o s e pe en n d u es a o e ns a s and a oun o e n se ous y unde m ned y a o ea ue

o ead o a o us omp a n

I was the medical coordinator for the hospitalbased child-development centre. We had a clinical psychologist who from the first made it clear that she resented my team leadership role. She uietly did her best to undermine this and upset the nursery nurses and therapists and destroy what had been a happy set up. inally, she wrote a rather ambiguous complaint to my consultant colleagues, which she persuaded a few of our team members to co sign. That left me pretty upset and even threatened, as there was already a bit of friction among my fellow paediatricians and l was not sure of their unanimous support. The BMA representative who l contacted for advice commented that the ealousy and resentment in the letter spoke for itself, and that to proceed in this way was completely unprofessional. There was no real substance to it nor any specific complaint to answer. certainly felt much better. l then tackled the medical chair of the paediatric division, mentioning that l knew what had been going on uno cially behind my back, and that l had not been kept informed from the beginning. l was therefore obliged to ask for professional advice from the A. y colleague was uite taken aback at this outside involvement, particularly when it was pointed out that if it went to an in uiry everything would have to come out. The matter was then uickly dealt with and taken no further. Those who had signed the letter were more or less told never to do it again. inally, the instigator left to relief all round and we had a new chair of the paediatric division. This illustrates how useful it can be to take early, impartial professional advice, and how even the mention of BMA involvement can be effective. This could so easily have escalated with all the added stress involved.

a e n y ea e e u es p o e

aternity leave is legally protected time e cept, it seems, in the eyes of the trust which told a consultant he would still need to cover his on call duties. The consultant returned to work early but took the matter up with the help of the BMA. The trust agreed to change its policy, which should protect staff in the same situation in the future. The consultant was unhappy that the action of his employer had led him to deal with the dispute during what should have been a special time for him and his family, but he paid tribute to the professionalism and e ciency of those who helped him in resolving the case.

e e o n on o

do o s

The vital contribution made by staff, associate specialist and specialty doctors has been recognised by the lack ountry artnership NHS oundation Trust, which has become the first in the est Midlands to give them an extra two days of leave a year after seven years of service in the grade. This re uired a considerable amount of work, in particular by the local negotiating committee, and it is hoped that other trusts in the region will follow suit. o ens around the country have already recognised their SAS doctors in this way, following campaigning on a national level by the A SAS doctors committee, and at local level by A staff and elected doctor representatives on N s.

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the secret doctor

She’s not a ‘lump’ Dr Smith, the intensive care consultant, has a running not-quite-joke that my specialty admits the ‘worst’ patients di cult, comple ones who often fail to make satisfying recoveries. My team has several patients in the intensive care unit today, and Dr Smith goes rapidly through the plans for each one, checking what investigations and treatments are needed. ‘And what about that hopeless dribbling lump in bed seven he asks. ne of yours She isn’t, as it happens: aria is in with a chest infection this time but know her well. She s a regular attender with cerebral palsy and severe learning disabilities. ‘Hopeless,’ in the sense that her underlying condition is incurable, and ‘dribbling’ is factually accurate but even so bristle at the description. It must show, too, because r Smith uickly backs off and changes the sub ect. r Smith is an e cellent clinician. He has helped me out of a number of tight corners with unwell patients, and I happen to know he s helped aria out of some even tighter ones. haven t the slightest doubt that he would always give her the best medical care, and he d never refer to her disparagingly in earshot of her family. So, does it really matter what he calls her in private? sn t this kind of black humour

something we medics rely on to survive the routine grimness of our ob es and no. ou need a certain kind of thick skin to work in critical care. ou need quick wits, strong instincts and a head for detail, but you also need to be able to pour all your skill and care into a patient, and watch them die anyway, and then come back to work a few hours later and do it all again. It’s natural that certain sensibilities end up a little blunted: natural, but not necessarily harmless. By allowing ourselves to dehumanise patients – always easiest with those who are visibly very different from us, and especially those who cannot speak – we gradually

lose our ability to see them as people at all, and the decisions we make for them will be subtly altered as a result. The last thing we need is more people policing our language. octors will always speak among themselves with a freedom that, now and then, crosses the line into poor taste. That s K. ut we should all fear the day when we come into work and look at vulnerable patients and really do see nothing but hopeless, dribbling lumps. The day we can no longer see our patients’ humanity clearly is the day we know that our profession has begun to erode our own. By the Secret Doctor bma.org.uk/thesecretdoctor @TheSecretDr thedoctor | October 2018

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it happened to me Doctors’ experiences in their working lives

When life came between us I look down the clinic list and spot her name. Perhaps we are not supposed to have our favourites but with some patients you just click. Maybe there is a shared experience or understanding, or perhaps they remind you of somebody from your non-medical life – a friend, a loved one. ither way, there s a positive doctor-patient chemistry. She’s 36 years of age and has been struggling with her disease for several years. It’s been a battle to get her symptoms under control. During the past year we have worked hard together to get things right. It’s not always been easy. We have celebrated together; an improving test result, a reduction in medication, commiserated together; her struggles with fertility perpetuated by chronic illness, and cried together; her third miscarriage in as many years. But I am always pleased to see her and, out of all my colleagues, she chooses to see me. ut today, something is different. As stand to welcome her in, her gaze drops and her usually bright expression clouds. The moment is brief and she recovers quickly. But I see it. That flicker of pain. As we sit down there is a barrier. One that has not been there before. My swollen belly and the life growing inside, protrudes into the space between us.

She looks away and starts to talk of the side effects with her medication, but her voice is tight and words stilted. I can see she s fighting back tears. For in that moment, I have everything she longs for. I remind her of all her losses, her great longing and her overwhelming sadness. I want to acknowledge the hurt she is feeling. I want to tell her I’m sorry. That I understand how hard it feels to be on the opposite side of that swollen belly and to worry that it may never be possible. A baby. A family. But she blocks every entry and closes every window of opportunity. It’s a place we cannot go together. As she hurriedly escapes the room, her eyes avoid mine and the consultation is over. am left alone, contemplating the unspoken anguish that has just passed between us. I could never wish away

my own happy situation, but do wish away her pain. Today, I don’t feel like a very kind doctor. Two months later her name appears on the list again but by the end of the clinic she has not entered my room and I know that she has chosen to see one of my colleagues – and not me. Perhaps it’s just her means of self-preservation, and even a small part of me is relieved. However, I can’t deny the rejection doesn’t sting a little. As tidy the case notes into a pile and manoeuvre my expanding self out of the clinic room, I can but only hope that one day soon she will choose to see me again, this time with her own happy news. Emily Claire Vincent is a gastroenterology registrar. She writes under a pseudonym

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the consultation

interview

The Doctor will see you now

GETTING HEARD: Dr Haywood has set up a writers group to support women and the diversity of voices in theatre

Writer, artistic director and consultant paediatrician Serena Haywood on why n s ma I wanted to be one of those ladies with a big white coat and chunky spectacles from those cool T science programmes in the s. That s how approached medicine. also loved nglish but was determined to be a doctor. Medical school was a culture shock. wasn t the cleverest person there, as was at school. went for auditions but didn t get any parts. satisfied myself with writing the reviews for the medical school maga ine. got free tickets. I’ve been told repeatedly I wasn’t good a a n ut found a writers group, when my children were a little bigger. The people met were speaking from the same script. Now I can’t stop writing. It’s like an itch an s a become immensely di cult to live with when have a story coming. stomp around the house. Then write it, and it s like, ah, that is what it was. Writing is magic. ou draw on something in your world, something you ve fallen in love with or hate. ou put it into writing, hear it come out of someone else s mouth. Then listen to the laughs and cries of the audience. would encourage anybody to try. ou ust never know.

I’ve now set up my own writers’ group. t supports women and the diversity of voices in theatre. As a woman in the arts and in medicine, as a woman anywhere, getting heard is not the easiest thing in the world. The Edinburgh Festival was just an amazing experience. e aimed to not end up completely broke, financially and emotionally. e achieved that and played to some really good audiences. There’s a false dichotomy between arts and s en es There s an incredible amount of creativity within science. plan to put together a show where work. t could be chaotic, gloriously muddled. ut also touching, heart warming, and perhaps help staff work out their stresses in an artistic way. Dr Haywood’s latest play, Fallout, was shown a e dn u n e es a and oes on tour next year with plans to take it to n e es a s n de a de and any Dr Haywood’s journey to Edinburgh will be available soon on youtube.com/bmatv thedoctor | October 2018

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explainer NHS jargon, political changes, and contractual intricacies – explained in plain English

Reflective practice Following concerns expressed with the Bawa-Garba case, the GMC and other medical organisations have drawn up u dan e on e e ons Why is it needed?

a s

It was drawn up because of concerns raised by doctors following the Hadiza awa arba case. Some of her reflective statements were used in her fitness to-practise tribunal (though not in the criminal trial that led to her conviction of gross negligence manslaughter, as some thought .

Who drew it up? The GMC, the AoMRC (Academy of Medical oyal olleges , e onference of ostgraduate edical eans and the edical Schools Council following workshops across the UK. The BMA helped to shape them, too.

What does it say? t offers pointers and principles on how to be a reflective practitioner . t says reflections are personal there s no one way of doing it they can cover positive and negative experiences but should focus on learning. Factual details of experiences should be recorded elsewhere and reflections should be anonymised as much as possible.

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There are not hard or fast rules. But the Ao and e have come up with some principles for effective, reflective practice , including a number of e amples of how to do it.

Can you give me an example? ne approach is called hat So hat Now hat Under this, you would focus on your thinking at the time of an experience, think on the significance of what happened, then consider what you can learn from it. Ask yourself the question: what would I do differently ne t time

So what’s this got do with the Dr Bawa-Garba case? The guidance makes clear the will never ask doctors to provide their reflective notes when probing a concern raised about them. ecorded reflections are not, however, sub ect to legal privilege so could be re uested by a court if considered relevant.

A wide range of things. They could be something that happened at work, an interaction or conversation with a colleague or patient, a compliment or complaint, a research article or the exploration of an emotional reaction. 30

BAWA-GARBA: Her reflective notes were used in her tribunal, something the GMC will not request in future

Read the guidance at bma.org.uk/ e e ep a e e o and e s e e practice toolkit can be read at bma.org.uk/rptoolkit

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what’s on

October

November

16 CESR seminar for SAS grade doctors, 9am, Manchester

02 Medico-legal expert report writing course, 9.30am, London

16 Practical skills for effective communication, 8.30am, London 16 Pensions taxation and retirement planning, 7pm, Holiday Inn, Newport 17 ivilian doctors conference, 9.30am, London 19 Planning for retirement, 9.15am, London 19-20 BMJ careers fair 2018, 9.30am, London 23 Introduction to hypnosis, 6.30pm, ld ank usiness Centre, Wednesbury, West Midlands

02 BMJ Masterclasses: neurology for physicians, 9.30am, London 06 Pensions taxation and retirement planning, 7pm, Oxford 08 Trainee doctor LNC reps conference, 10am, London 14-16 Leaders in healthcare conference, 9am, Birmingham

December

January 2019

05 Practical skills for self-management course, 9am, London

18 Planning for retirement seminar – delivered by the A, 9.15am, York

07 Planning for retirement seminar – delivered by the A, 9.15am, Oxford

22 Practical skills... leadership and management course for doctors, 9am, London 23 The England LMCs conference, time TBC, London

Visit bma.org.uk/events o u de a s thedoctor thedoctor || October October2018 2018 31 29

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Keep learning at every s a e o you a ee However you want to learn, we have solutions to help. Online modules Access hundreds of CPD-accredited online learning modules for free, from wherever you are, as part of your membership. Webinars We’re a leading provider of non-clinical learning support. Access live online courses for career development or catch-up on-demand, all for free. Non-clinical masterclasses Learn practical skills that you can use straight away with our one-day face-to-face masterclasses, at discounted rates for BMA members.

Visit bma.org,uk/learning

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