The Doctor – issue 3, November, 2018

The magazine for BMA members

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Issue 3 | November 2018

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

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

A cause for complaint The GP practice left on the brink of collapse by an NHS England investigation

‘Why am I here?’

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

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thedoctor

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 £160 (UK) or £225 (non-UK) a year from the subscriptions department. All rights reserved. Except as permitted under current legislation, no part of this work may be photocopied, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical or otherwise without the written permission of the editor. Printed by YM Chantry. A copy may be obtained from the publishers on written request.

The Doctor is a supplement of BMJ vol: 363 no: 8175

Editor Neil Hallows (020) 7383 6321 Chief sub-editor Chris Patterson Senior staff writers Peter Blackburn (020) 7874 7398 Keith Cooper (020) 7383 6390 Staff writer Tim Tonkin (020) 7383 6753 Northern Ireland news email news@bma.org.uk Scotland correspondent Jennifer Trueland 07775 803 795 Wales correspondent Richard Gurner 07786 035 874 Senior production editor Lisa Bott-Hansson Designers Victoria Rossique, Alex Gay, Andy Bainbridge

ISSN 2631-6412

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Welcome to The Doctor Chaand Nagpaul, BMA council chair

contents

Welcome to the third issue of The Doctor, guest edited by Franz Kafka. Or so it seems from some of the tortuous and frankly harrowing experiences of members in the following pages.

Some of you will be familiar with the story of Shashi Awai and the Home Office’s attempt to deport her, despite her years of dedicated service to the NHS. It’s yet another example of how badly our valued colleagues from abroad are treated by an inflexible immigration system. You’ll find out how Dr Awai navigated her way out of her bureaucratic nightmare and how the BMA did our bit to help.

Few will know about the horrendous experience suffered by Andrew Jones,* a GP whose practice was brought to the brink by an excessive NHS England investigation. But more of you will be familiar with the situation he found himself in. Of how unnecessarily burdensome the heavy hand of officialdom can be in

the health service. You’ll have colleagues left fearful and punished by managers with actions far flung from the caring and supportive ones we need in our NHS. You’ll also read about Carrie Adams,* a junior doctor whose baby was removed from her for months because of her mental ill health. We’ve been to court to help tell her story, obtaining papers that reveal some questionable treatment.

These will not be easy stories to read, especially for those of you who have suffered from the inscrutable hand of officialdom, the harrowing effects of inspection, or had to deal with patchy and inadequate care in mental healthcare, yourself or for your patients. But, however uneasy these stories might be to read, they’re no less important for the lessons we can learn from them. About how to respect and care for our colleagues and forge a more collaborative and caring NHS for the future. * Names have been changed

4-5

6-11

12-17

18-21

Briefing

Born of injustice

A significant event

The everlasting winter of NHS pressures, the cost of bullying, and new hopes to battle harmful competition rules

Could a junior doctor’s day in court improve the way perinatal mental healthcare is delivered?

The GP practice brought to its knees by an ‘aggressive’ and relentless NHS England investigation

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26-29

30-31

‘Why am I here?’

Life experience

Surgeon Philippa Whitford on finding a new role in politics – and her initial doubts about giving up a ‘useful’ job for Westminster

A GP evokes the Great War to promote community relations, and the long, difficult process of ruling out abuse concerns

Explainer/ What’s on

Hostile treatment Trying to deport a committed doctor during a recruitment crisis – that’s the Home Office at work

The BMA has launched an app to help doctors stay on top of their workload – try out Dr Diary

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What’s getting in the way of integration?

briefing

‘APPALLING STATE OF AFFAIRS’: Thousands are left in cramped corridors untreated

Current issues facing doctors

When winter never ends Remember winter? The World Cup, the barbecues, those endless days of sunshine?

Yes, winter – at least in hospitals, where pressures on emergency care services between July and September were at a level previously only seen in the depths of winter.

A new analysis by the BMA shows that what was once a winter crisis now extends the whole year round.

Recently published NHS England data shows that for the summer months (July to September), a smaller proportion of patients – 89.3 per cent – were seen within four hours in emergency departments than in any of the winters (January to March) between 2011 and 2015.

There were more emergency admissions between July and September than any of the previous winter or summer periods going back seven years.

And with trolley waits the figures are even more alarming. There were more than 125,000 patients waiting for more than four hours between the decision to admit, and admission. That’s four times more than the winter of 2011, and considerably more than in any of the four winters which followed.

‘Behind these figures lie real stories of misery,’ says BMA

council chair Chaand Nagpaul.

‘Tens of thousands of patients are being left in crowded, cramped corridors, waiting for treatment while others are having to endure longer waits to even see a doctor or nurse.

We cannot and should not allow this appalling state of affairs to continue.’

The Government can hardly claim the new figures are a surprise. They have been heading in the wrong direction for years. In June, the BMA predicted that emergency department waiting times, trolley waits and emergency admissions would be, at best, similar to the winter of 2015 and, at worst, similar to that of 2016, and they did indeed fall between that range.

Dr Nagpaul adds: ‘The recent budget showed signs that the Government is beginning to understand that extra investment is needed. But this analysis shows the NHS needs this funding urgently.

‘The BMA remains unconvinced that what has been pledged will meet the sheer scale of the problems underlined by our analysis.

It is vital that the Government ensures that frontline healthcare staff are given the resources they need to deliver the standard of care that patients deserve.’

‘Don’t ask for permission’ sounds an unlikely management mantra, but we reported earlier this year on a growing culture where senior NHS figures seemed to be urging greater integration of services without waiting for the say-so from Whitehall.

More integration? Less bureaucracy?

It sounded too good to be true.

It was, to an extent. For while it was welcome that the NHS in England, as its chief executive Simon Stevens said last year, was aiming for ‘the biggest national move to integrating care of any major western country’, there was a problem.

And that problem was no less than the legislative foundations on which it was built.

The Health and Social Care Act 2012 cemented an internal market already two decades old, and which has promoted and reinforced fragmentation of services.

You can’t really have an internal market without setting one part of the system against another. A wholly unnecessary and divisive system of competition is the result.

Even the Government recognises this. Last year, the Conservative Party manifesto said the internal market ‘can fail to act in the interests of patients and creates costly bureaucracy’.

The great danger has been that doctors will press ahead locally with bold, clinically led plans for integration only for a litigious multinational to roll up and sue on the grounds it was being cut out of

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PA

bidding for future services.

We were in, as one health policy expert told us, a ‘shadowy era of extralegislative reform’.

Let’s come into the light. The competition law, the purchaser/ provider split, it’s simply got to go.

BMA council chair Chaand Nagpaul, says it is ‘totally incompatible’ with the Government claims to want integrated care.

The fact that Dr Nagpaul first got involved in representing doctors almost 30 years ago because of his opposition to the internal market, created by Kenneth Clarke, shows this continues to be a long fight.

But – and this is a big change – Mr Stevens appears to have joined the fray.

At the NHS Providers conference in Manchester last month he said he wanted to remove ‘impediments’ to

local areas working as systems rather than institutions, and, surprisingly enough, it was the Government which asked him to design an alternative.

‘We are now at the point where we are able to declare our hand – we will be accelerated on the journey if we can get pragmatic changes [to legislation and structures delivering care].’

Mr Stevens seems to have the stomach for an internal battle, given his success in securing limited extra NHS funding.

If he’s up for another, then the ‘impediment’ he needs to overcome is that flagship piece of legislation which Andrew Lansley gave the health service in England six years ago.

The flagship belongs at the bottom of the sea.

CLARKE: Architect of the internal market

Read more online ‘Integrated care providers usher in commercialisation concerns’ ‘Government ‘‘devaluing’’ HEE’s role’ ‘Low female CEA applications under review’ ‘Call to bolster recovery from alcoholism’ Read all the latest stories online at bma.org.uk/news

Bullying and the bottom line

MOWAT: End culture of bullying once and for all

What price bad behaviour in the NHS? An awful atmosphere on the ward?

A daily dread of working with THAT colleague again. Poor patient care, perhaps. But how about £2.3bn?

Given that health service management is often accused of knowing the price of everything and the value of nothing, perhaps the recent paper co-authored by the workforce expert Roger Kline will

encourage them to take notice.

The estimate – ‘conservative’ and for England alone – includes the costs of workplace sickness, lost productivity and legal costs.

Another implication of a culture where staff are afraid to speak out was highlighted at the BMA’s women in academic medicine conference last month.

Former Royal College of Physicians president Dame Jane Dacre said the disparity in the receipt of CEAs (clinical excellence awards) between male and female consultants was a major contributor to the gender pay gap in medicine. The CEA system relies to an extent on doctors putting themselves forward, and she said that the culture of bullying in the NHS ‘makes people feel less confident in asking for things that they should

Keep in touch with the BMA online at

instagram.com/thebma

have as rights’.

It seems we have a situation where one systemic inequity in the NHS is fuelling another.

Bullying and harassment is a major focus of the BMA’s work.

BMA representative body chair Anthea Mowat launched a report earlier this month, calling for action on a personal and institutional level.

It sets out steps as to how doctors can end the silence by, for example, raising awareness of the problem and with whom people can raise concerns. It also calls for better dispute resolution and the means to create a more supportive and inclusive culture.

As Dr Mowat puts it: ‘We need to end the culture of bullying and harassment where it has taken hold once and for all.’

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Born o

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n of injustice Junior doctor Carrie Adams had her baby taken away when she was a day old.

Now, with the BMA’s help, she has won the right to reveal what happened to her. Psychiatrists say mothers with unmet mental health needs are being unnecessarily parted from their children.

Keith Cooper reports

C

arrie Adams,* a junior doctor and mother of two, is back in family court. The same one which ordered her first child, Evie,* to be removed, a day after she was born. She’s to face the same judge, who agreed after nine months for her daughter to go home. But Dr Adams is here today, years later, under very different circumstances.

She’s helping The Doctor and BMA lawyers to obtain private papers which might reveal shortcomings in her care to help others with mental ill health by letting them in on intimate details of her experience.

But right now we’re waiting, sharing her biscuits and family snaps (there’s Evie on a bridge in the park, beaming, mum behind her). We’re sitting on metal chairs, encircled by locked courtrooms, keeping company with anxious parents, their weak smiles seemingly seeking solidarity.

We’re bringing this action amid growing concern about childcare cases. Doctors are struggling to convince courts that mothers with mental ill health can and should be treated instead of separating them from their babies.

One recent study, Born into Care by the Nuffield Family Justice Observatory, found a doubling in the number of newborns caught up in family courts between 2007-08 and 2016-17.

‘In my view, there are

gross miscarriages of human rights going on,’ says South London and Maudsley NHS Foundation Trust consultant perinatal psychiatrist Trudi Seneviratne, who chairs the RCPsych’s (Royal College of Psychiatrists) perinatal faculty.

‘We’ve got this expansion of [MBUs] mother and baby units in England, which is great. But our local authorities and legal processes don’t understand that these mothers’ conditions are treatable.’

A wall of doubt So what’s going on? What can the case of Dr Adams tell us?

Our time with the judge is over in minutes. Reports are released and in our hands.

They reveal much, tragically, about the way Dr Adams and other mothers with mental ill health are treated by councils, the courts, and the NHS. The struggle to get help.

Desperation as the due date approaches. The accusations.

The wall of doubt that your illness is treatable, that you’ll be well enough before the case concludes. There’s also the stigma, which Dr Adams faced, unbeknownst, as a patient and doctor.

Her first contact with professionals in the case was at a booking appointment 10 weeks into pregnancy by IVF. There and then she disclosed her mental health problems: depression, thedoctor | November 2018

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anxiety and OCD (obsessive compulsive disorder), according to reports by her senior specialist midwife.

She’d stopped medication ‘due to her pregnancy’ (other court papers point to her worries about how medication ‘would impact on the baby’). She claims support from family and friends at that meeting. She is referred to a vulnerable babies’ service and perinatal psychiatrist.

But her appointment with the specialist doesn’t come ‘I was told through for four months.

I had a There’s more contact daughter. with midwives at weeks 14 I got to see and 21, when she speaks of this cute button nose, worsening OCD symptoms.

Her care transfers to a a perfect female obstetrician as she little ear’ ‘refused to be seen by a male doctor’, the midwife reports. She ‘would not allow’ an intimate examination, making ‘safe management of labour difficult’ (a fear of contamination and men, at the time, is linked to the OCD in other court papers). She elects to have a caesarean section on safety grounds.

At 24 weeks it’s noted, ‘she had no support at home’ but then toured a ward with her mum and ‘formed a plan with the supervisor of midwives’.

Dr Adams is described by the senior specialist midwife as ‘extremely articulate’, a doctor with the ability ‘to gloss over her difficulties’ with professionals. There’s concern about her ‘lack of attachment’ as she’d referred to her unborn baby as ‘the child’. ‘My main concern is for the emotional well-being of the baby,’ the report says.

Questions about the midwives’ relationship with Dr Adams are raised by a court-appointed consultant psychiatrist, three months after Evie was removed.

Calling an unborn baby ‘the child’ was ‘quite normal’. She had called hers ‘Wrigglesworth when active’ too, it says. ‘She had started to have a relationship with affection and some humour before delivery.’

Her behaviour was ‘fitted to an assumption that she will be incapable of normal

bonding’, it adds. ‘There was considerable scepticism and tension in the relationship with Dr Adams and the midwives.’

Four months before her due date, Dr Adams becomes desperate for treatment, calling her specialist midwife in a ‘stressed state’. She is ‘despondent about getting her mental ill health sorted in time’. She expressed suicidal thoughts, the court papers add. Weeks later she’s assessed by an experienced clinical psychologist, who then sees her regularly.

Concerns mount Dr Adams admits she ‘laid it on with a trowel’. ‘My fear wasn’t that they would take the baby away, but that the help wouldn’t be there,’ she says. Court papers show there were episodes of depression, an overdose in her teens, and some self-harm. The court-appointed psychiatrist ‘tried to makes sense’ of her struggle to get treatment.

‘NHS protocols’ were likely to blame, they say.

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She was eventually seen by a perinatal psychiatrist some six months in. But after a ‘detailed assessment’ at that appointment it is ‘clearly envisaged’ her baby would go home, the papers say.

A few notable incidents are recorded in the following weeks.

She misses a single appointment with an anaesthetist (a sign of ‘poor engagement’, they say; she attended ‘the majority of her antenatal appointments’ the senior specialist midwife notes). A blood test finds ‘In my anaemia. ‘I took iron tablets,’ view, there Dr Adams says. A social are gross miscarriages worker notes a ‘bad day’, after ‘brushing her bag against a of human rights going man on a bus’. A week later, children’s services decide not on’ to get involved, following a ‘vulnerable babies’ meeting.

With her due date approaching, she is seen by a community psychiatrist who finds she is ‘looking forward to the birth’ but admits there’s rubbish ‘everywhere in the house’. She’s struggling to clear it up. There’s mice.

Her mum helps but there’s no ‘concrete plans’ to sort things out, the community psychiatrist says. She is ‘engaging’ with treatment and staff, still not willing to consider medication, but ‘is hopeful the psychotherapy will help’, their record adds.

Two weeks later a ‘meeting of professionals’ is called amid ‘increasing concerns’ about her mental state.

She’s not invited. There’s a ‘unanimous decision’ to refer to children’s services. Days later, a date for a caesarean section is set.

A letter from her psychotherapist to that

professionals meeting – which they could not attend – describes her as ‘committed’ and ‘motivated’, that she’d made an ‘important step forward’ in her therapy.

They advise extra support in the ‘early days following birth’ and that her mother is moving in. It points to the support of two friends (a GP and paediatrician, The Doctor has confirmed).

Dr Adams sought legal advice after social workers told her of their concerns but thought the plan she had agreed with midwives was in place: some days with support on the ward that she had toured with her mum.

But the day before admission, a woman she considered a close friend called the senior specialist midwife anonymously ‘expressing serious safeguarding concerns’. The same woman later submitted a 57-page letter to the court. The ‘majority of points’ it raises had already been disclosed

by Dr Adams, court papers confirm.

On the day of the operation, the professionals meet again. They decide to seek an emergency protection order to remove Evie several days after her birth. The perinatal psychiatrist refuses a bed on an MBU, saying the ‘chronicity’ and severity of her illness makes it ‘highly unlikely’ she would improve in a ‘few weeks’. ‘Dr Adams was not aware of the decision at the time,’ a note of that meeting says.

Meanwhile, she walks into theatre to deliver.

‘Evie came out howling her head off, arms and legs

going,’ she says of the birth.

‘I was told I had a daughter.

I got to see this cute button nose, a perfect little ear.

Mostly, I’m in a state of shock. She’s here. The world has changed. My world has changed. It was overwhelming.’

3am the next morning, she’s up, attempting to breastfeed, helped by midwives and her mum.

9.10am, her obstetrician notes, ‘she appears comfortable and confident with baby’.

11.05am, she shows signs of distress. Her mum says the crying ‘is too loud for her’.

12 noon, she vomits. At 2.45pm, she’s found in a corridor, distressed, asking for help. Minutes later, she reports feeling unwell, asks for blood tests (she’s not eaten since the operation).

Half an hour later, a hook on the wall is ‘turning into a spider’, she says. The psychiatric registrar is called.

They urge sectioning under the Mental Health Act if she tries to leave.

Hours later, social workers accelerate the removal, asking the police to attend.

Then the notes fall silent.

Until after Evie’s removed.

Dr Adams recalls being confronted by a police officer in a tactical vest, a social worker, midwife and psychiatrist, as she sat on her hospital bed. ‘I just started to cry because I knew why they were there. There was no other reason.’

They tried to detain her under a Mental Health Act section but didn’t. She stays overnight. The next morning her community psychiatric nurse arrives, speaks of a thedoctor | November 2018 09

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‘I hold no concern about the ability of Dr Adams or her mother to meet the basic needs of Evie’

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‘knee-jerk reaction’. Then she’s discharged. Her discharge note, according to court papers, records a ‘low blood haemoglobin’ of 82 grams per litre, ‘significantly below normal (130-150)’.

Days later, Dr Adams faces the judge for the first time and an interim care order is granted. The council claims her condition makes it ‘impossible for her to be able to care adequately for a young baby’. It cites evidence, of hour-long showers and that Dr Adams disputes this; of her distress ‘if something drops on to the floor’. Her baby crib was ‘covered with cellophane’ to prevent ‘contamination’.

Contradictory findings The court-appointed psychiatrist, however, finds the ‘decision-making’ leading to Evie’s removal to be ‘not entirely clear’ in their report, three months on. ‘She had responded positively to the baby, shown signs of early bonding and engaged in breast feeding,’ it says.

‘The difficulties she had were primarily related to physical problems, not her OCD.’ Police records show she was seen as ‘difficult’ and ‘compared unfavourably with other mothers by NHS staff ’.

‘The factual basis for this is not clear,’ the psychiatrist adds.

‘Most of the observations were within 12 to 18 hours of a caesarean section. She describes clear evidence of mild confusion and has been vomiting and bleeding.’

A week later, social workers find Dr Adams is ‘clearing the

house’. Days later, her perinatal psychiatrist describes her as ‘considerably improved in her functioning’ but refuses her appeal for a bed on their MBU. She’s discharged from perinatal care to the community team and her community psychiatrist also asks for an MBU bed.

‘She was not accepted,’ their record says.

The court-appointed psychiatrist, who is not a perinatal specialist, equivocates about reuniting Evie with her mum in an MBU in their report. It ‘would not be optimal’, ‘probably not the best approach’ but ‘one that could potentially be considered’. It flags concerns about ‘increased symptoms in a shared environment’.

The RCPsych’s Dr Seneviratne is, however, clear that Dr Adams should ‘absolutely’ have been given the chance to stay with Evie in a psychiatric MBU. ‘She had a history of chronic anxiety, depression and severe OCD. These aren’t reasons to remove a wanted baby even if there was something else underlying those conditions,’ she says.

‘We know that medication can work in anxiety disorders but we also absolutely know that some people respond really well to psychological therapy.’

Over the nine months of their separation, Dr Adams sees Evie a few hours a week, supervised by contact workers.

She continued therapy.

Three months after Evie’s removal, ‘important inroads’ have been made into changing her ‘long-standing pattern of severe difficulties’. Her therapist notes ‘important

behavioural change’. By month four, she is no longer troubled by the concept of ‘dirtiness’.

Month five, she’s picking up dropped objects without washing her hands.

Despite improvements early on, the court-appointed psychiatrist questions whether sufficient progress can be made to meet Evie’s emotional and development needs. But no such concerns are raised by the ISW (independent social worker) in a later assessment, six months after removal.

The contact centre workers, who supervised her time with Evie, describe it as ‘superb text book’, the ISW report says. ‘I hold no concern about the ability of Dr Adams or her mother to meet the basic needs of Evie and to provide high levels of emotional warmth,’ it adds.

Her mum, who moved in shortly after Evie’s removal, is called a ‘stabilising factor’ and ‘eminently suitable’ to act as a safeguard if her mental ill health relapses.

A month on, another report from the court-appointed psychiatrist finds Dr Adams ‘symptom free’ and a ‘good chance that she will be able to parent reasonably well’.

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The next month, her psychologist describes her prognosis as ‘good’. The next, Evie is back home.

So what lessons can be learned from this case?

That mothers should never be separated from children, especially their firstborns, unless absolutely necessary?

That NHS units for mothers and babies are there to be used? That the stigma around mental ill health is alive and well in the health service?

Perhaps it’s that the traumas of separation will always be carried, will always remain with the mothers who bear them. When leaving the court, Dr Adams insists on a visit to its mother and baby room. ‘I didn’t know it was there,’ she says. ‘The whole time I was here.’

Perhaps the lesson is just that mental ill health is treatable without such trauma. It’s something of which many still need convincing, be they councils, the courts or the NHS. * Names have been changed

We must learn from Carrie’s case Our investigation into the removal of Carrie Adams’s daughter raises serious questions about her treatment.

We’ve found tensions in her relationship with her midwives.

That she struggled to receive consistent help for her mental ill health before giving birth. On the ward, the confusion of this knownanaemic new mother, post-op, was assumed to be owing to her mental health. It’s appalling that a physical cause doesn’t appear to have been considered.

And why deny her and her baby a bed in an MBU (mother and baby unit)? While hindsight’s a great thing, it looks as though Dr Adams’s symptoms were eminently treatable.

We don’t know all the details. But there’s enough evidence to suggest something went wrong, leaving Dr Adams with a trauma she’ll forever bear.

As in any area of medicine, we must soberly reflect on the evidence to learn lessons.

Mothers need to feel safe to disclose mental ill health and get help. How do we get there?

They need access to treatment, such as talking therapies, well before birth. Many are not, as the

Nuffield Family Justice Observatory for England and Wales has found.

Family court cases costs thousands.

Why not spend that on treatment instead, avoiding proceedings in the first place? It’s a point Bristol family court judge Stephen Wildblood QC repeatedly makes.

When risks to a baby seem high – or difficult to predict – families can often be kept together in MBUs until informed decisions are made.

Not separated. More resources will help, as the Maternal Mental Health Alliance points out.

We need to reduce big swings from the extremes of a ‘hands-off ’ to the reactive ‘full-on’ approach in how cases are managed. Professionals must work together in a clear and sustained way.

Then there’s the stigma about mental ill health in the NHS to be erased.

There’s much to be done and perinatal care will be a focus of BMA work this year. Sometimes it takes just one story to move us to further action. Let’s not forget this one.

Gary Wannan is deputy chair of the BMA consultants committee and a consultant child and adolescent psychiatrist

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A significant event A complaint brought a thriving GP practice to the brink of collapse – not because of what it uncovered, but the way NHS England handled it. One of the GPs tells Neil Hallows how he endured 14 months of aggression and suspicion, and asks how many others may be facing the same treatment

A

ndrew Jones’s* practice is a good one: a training practice, well-respected by patients and colleagues, with experienced staff. Yet a complaint almost destroyed it.

Difficulties began when a GP partner resigned following a dispute about management. Shortly afterwards the doctor referred the practice to NHS England, alleging concerns with quality of care. This resulted in a 14-month investigation that left it on the point of collapse.

The case raises fundamental issues about the support given to GPs when there are concerns about performance. It also highlights the duty of care owed by the NHS to those who work in the NHS, and an investigatory system that lacks transparency and safeguards. There may be many other such cases but despite a request by The Doctor, the NHS can’t or won’t provide any figures.

The referral in this case cited ‘a lack of understanding of the significant event process’. It included four cases where there had been very brief delays in sending twoweek-wait cancer referrals, and another four

cases where there had been short delays in copying entries from written home-visit records on to the clinical system.

Three further clinical cases were cited: –– the medication of a patient with diabetes was stopped (because of risk of hypoglycaemia), which then had to be reintroduced at a lower dose –– a patient had fallen on an outstretched arm and attended with symptoms of shoulder pain. Two months later the patient attended with unrelated symptoms (of cough syncope) and mentioned persisting neck pain. Given the history of a fall, Dr Jones requested an X-ray, which showed a healing fracture dislocation of C7 facet joint, subsequently treated with a collar –– a pre-op clinic letter had been received three years previously noting a new diagnosis of atrial fibrillation. The diagnosis was coded, but anticoagulation wasn’t started following surgery at that time.

‘We don’t dispute that some of these cases could have been managed better,’ says Dr Jones.

‘But it was notable that, of all of these

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issues, only one case had been flagged up by our former partner before they sent the referral, and this had not yet been discussed with the other GPs.’ The four remaining partners responded immediately to NHS England. ‘We stated that we wished to facilitate an early review and that we would make all relevant information available. We wrote that we would carefully discuss and consider any concerns, that we were very willing to learn from the review and that we were prepared to make any necessary changes.’

Complaints are handled at a local level by NHS PAGs (performance advisory groups). According to NHS guidance, these should consist of two NHS managers, a lay member, and a clinician from the specialty.

Highly critical One month later, the PAG informed the practice that a clinical investigation would be undertaken. It gave a timescale of two months to complete the process.

A case investigator visited the practice the following month to view patient records, and visited again after a further six weeks to

‘They were putting words in my mouth – they had come with an agenda’

interview GPs individually.

‘We found the investigator to be hostile and confrontational, to the extent that one of our GPs was left crying at interview. In my case, they were putting words in my mouth and it seemed clear that they had come with an agenda. At that time, this appeared inexplicable,’ says Dr Jones.

It then took a further three months – now more than six months after the original complaint – for the practice to receive the investigator’s 30-page report (with a further 13 appendices). The practice was initially given three days to respond.

The report was highly critical. ‘As an example, I was formally criticised in the conclusion for not recording DVLA driving guidance for my patient with cough syncope.

This was despite telling the investigator that this patient didn’t drive and had never held a driving licence.’

The practice called the Medical Protection Society. ‘We went through the report line by line with them. We drafted a response which accepted fault where it was valid, and which corrected factual errors. We set out the steps that we’d taken to address any issues raised, thedoctor | November 2018 13

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which included carrying out audits and relevant courses. We made it very clear that we were keen to learn from any mistakes and to identify areas of improvement.’

However, on the basis of this critical report, the PAG commissioned a further investigation.

This was to be a random case review, with two investigators each assessing 30 cases.

The terms of reference for the investigation said: ‘The expectation is that records will be compliant with good medical practice, including NICE-compliant.’

The investigators first visited one month later and, after a meeting with the GPs, provided a final report after a further three months. The findings of the two investigators were very different.

‘One investigator was highly supportive of our care, but the other had questions regarding 20 of the 30 cases they looked at.’

This investigator stated that Dr Jones had ‘consciously gone against NICE [National Institute for Health and Care Excellence] guidance’ in one case when he had treated a frail 84-year-old patient with a cough and chest discomfort with antibiotics. However, the guidance cited (CG69) specifies that antibiotics are appropriate if a patient had been hospitalised in the previous year or had a history of heart failure, both of which applied in this case.

NICE guidance misinterpreted Dr Jones was also criticised for not following NICE guidance in the case of an older patient with fatigue (who had a history of cancer and hypothyroidism) as he had ordered blood tests immediately. The investigator stated that the NICE guidance Tiredness and Fatigue in Adults recommends delaying blood tests for a month. However, this guidance relates specifically to the management of patients with chronic fatigue syndrome.

There was even more serious criticism.

Dr Jones had seen and assessed and ordered tests for an older patient with symptoms of reduced appetite. According to the report ‘… the patient died the following day in A&E. It is my opinion that a clinician who is imminently [sic] involved in the management of a patient who dies shortly afterwards unexpectedly has a duty to perform a significant event analysis.

I believe this contravenes the standards set out by the GMC in relation to the duty of

‘One investigator was highly supportive of our care, but the other had questions regarding 20 of the 30 cases they looked at’

clinicians to contribute to and comply with systems to protect patients’.

Dr Jones states this simply wasn’t true.

‘This patient had unexpectedly fallen the next morning and had been admitted to hospital.

Unfortunately, they had died of a myocardial infarction in hospital a week later, but this was unrelated to the symptoms that I had assessed them for.

‘It’s very concerning when there is a medical investigator saying that a doctor’s practice does not meet professional standards. I feared that I was going to be referred to the GMC.’ The investigator’s mistakes were basic and yet the impact was potentially devastating. ‘There were multiple errors in the report. With the help of the MPS we provided a definitive response.’

Two months later, 14 months after the original complaint, the practice received formal notice that the investigation was closed. The concerns noted above had been dropped. The final report stated that the investigators ‘could not find any evidence of poor patient care, and there were numerous examples of good care provided.

Overall the care provided compared very well with that expected of GPs working in similar circumstances’.

By this point, the practice was under severe pressure. During the course of the investigation, both of the practice’s nurses had resigned and more than half of the reception and administrative staff had resigned or had been on long-term sick leave.

‘The seriousness and uncertainty of an investigation contaminates a practice, and we came perilously close to disaster. If a GP or another key member of staff had left the practice we could certainly have folded.

‘Recruiting replacement staff during the process had been impossible, as we had to disclose the ongoing investigation. We employed locums to help cover the workload, but at great expense. At times our workload was overwhelming.’

Enormous stress The stress for the practice during the course of the investigation was enormous. Dr Jones says this contributed to one of the GPs developing pneumonia and requiring hospital admission.

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‘Our only contact with the department was by email. There was absolutely no support from the NHS during the whole process.

When we raised this with the case manager at the end they expressed surprise: “Did you not receive our support leaflet?”

‘Later we received funding from the vulnerable practice programme, which was NHS funding designed to get the most at-risk practices back from the brink of closure.’

Dr Jones had originally been criticised for not conducting a significant event analysis. But perhaps › Continues overleaf

‘We found the investigator to be hostile and confrontational’

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the way he and his colleagues were treated needs to be regarded as a significant event in its own right. It caused harm, certainly to his GP partner with pneumonia, and seriously destabilised a GP practice – potentially affecting the care of thousands of patients.

The practice received an apology from NHS England and was promised that it would learn from the experience and that this would inform other investigations.

But it is difficult to see how much learning will go on when NHS England either does not know or will not reveal the annual number of investigations. It initially told us that it collected ‘centrally aggregate[d] information in relation to both GP practice and GP performer performance concerns’. However, a request for the overall number of local performance investigations received no response.

This is in sharp contrast to the GMC, which publishes annual data on fitness-to-practise investigations. Without such data for NHS investigations it is impossible to establish if there are regional differences, for example, or to determine if there is a disproportionate number of investigations for different groups of doctors.

The role of the medical investigator needs serious consideration, says Dr Jones.

‘Investigators not only collect evidence, but provide their own judgements based upon the evidence. Their opinions will typically be accepted unequivocally by PAGs, whose lay

and managerial majority have absolutely no clinical experience. Ultimately, the judgements in these reports are not based on a professional consensus, but on the opinion of a single investigator.

‘The ‘The preparation for this role is two days of judgements training, without any testing or assessment of participants. With such a powerful and in these responsible role, it would seem vital to assure reports competence. With individual investigators are not there is also an inherent risk of bias or conflict based on a professional of interest.

‘While our investigation was still ongoing consensus, the first investigator posted on social media, but on the mentioning circumstances highly relevant to opinion of our case, that doctors like us should be “struck a single investigator’ off and disbarred”. We believe this indicates that this individual was biased against our practice.’

PAGs operate on a civil standard of proof, which is the balance of probabilities. Therefore, a single critical report can result in referral to the next disciplinary level, the PLDP (Performers List Decision making Panel), which has powers to suspend doctors or refer them to the GMC. While there is a right of appeal against PLDP decisions, there is no right to appeal those made by a PAG. Dr Jones says ‘much of the damage that was caused to our practice was a result of the slowness of the process. PAG panels typically meet monthly, which causes unavoidable delays’.

BMA GPs committee chair Richard Vautrey says: ‘All doctors make mistakes which is

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why it is important for all teams to have mechanisms in place, within a supportive environment, to reflect on what has happened and try to make improvements in future care as a result of the shared learning. External investigations can be needed when serious incidents occur, but these can be extremely stressful for the clinicians involved and therefore need to be done professionally, sensitively and as quickly as possible.

‘Practices should inform their local medical committees if this is happening as they will be able to offer help and support during what is often a difficult time. There also needs to be a much better understanding of the serious consequences on team morale and recruitment and retention an external investigation can have and that if done inappropriately it can cause more harm than good, and makes it less likely in the future that individuals or teams would be prepared to highlight mistakes for fear of the consequences.’

Unrealistic standards Every concern reported to a clinical commissioning group must be forwarded to PAGs for consideration. Dr Jones says panels then have absolutely no discretion to look into or resolve concerns informally. PAGs must either order a formal investigation or take no action. However, even if no investigation occurs, all reported concerns are recorded and stored. GPs will not necessarily ever be informed that these have been received.

‘Much of the damage that was caused to our practice was a result of the slowness of the process’

A critical problem is the standards to which practices are held. Every practice should aspire to high standards of care. However, NICE guidance is not a baseline to judge minimum acceptable standards of practice.

At the conference of England local medical committees later this month, the agenda has a motion calling for effective independent oversight and review of NHS England performance management procedures in primary care.

This includes performance investigations and the functions of PAGs and PLDPs. At the UK LMCs conference in March, GPs agreed unanimously that the assessment of GPs’ and practices’ performance may be based on unreasonably high standards and called for ‘real-world’ benchmarks of practice.

NHS England either does not have or will not reveal any data about investigations, but Dr Jones feels his practice is ‘unusual’ having survived it and in receiving an apology.

Dr Jones warns anyone facing the same situation that they are in for a prolonged and stressful experience. He says his practice had just enough resilience to get through. * Names have been changed If you are a BMA member and have a query or concern about your pay, contract, terms and conditions or any aspect of your working life, you can contact the BMA on 0300 123 1233 thedoctor | November 2018 17

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H

ome secretary Sajid Javid could not have been clearer about the benefits of immigration at last month’s Conservative Party conference.

It had allowed the UK to ‘adopt many of the best bits of other countries’, said Mr Javid, himself the son of immigrants. ‘We want to welcome people to this country.’

So, it was presumably a different Home Office to the one Mr Javid leads that wrote a letter to an ENT doctor, Shashi Awai, which seems in turn callous and patronising.

Dr Awai, a trust-grade doctor from Nepal who has lived in the UK for 15 years, was applying for leave to remain. She loves the NHS and loves this country.

It was a love which the Home Office did not reciprocate. In rejecting her application, a letter from the Home Office told Dr Awai ‘you can maintain contact with your friends in the UK from overseas via the use of modern communications and it is open to them to visit you in Nepal’.

Her education, skills and experience, so 18

valued by her hospital in Surrey, would help her find ‘suitable employment’ in her country of origin – never mind that she has been away from Nepal so long that she can no longer even read or write the language.

It made clear that she should make immediate plans to leave the UK warning she could be detained, forceably removed or imprisoned for up to six months for failing to comply.

‘This decision stopped me from being what I am,’ she says.

For Dr Awai, the practice of medicine is instead indivisible from working in a valuesbased system which offers universal healthcare.

HOME ALONE: Dr Awai could no longer work so spent many anxious days at home

Altruistic values She wanted to be a doctor from an early age, influenced by the death of her sister while they were children. The daughter of farmers-turnedteachers, she grew up valuing the importance of education.

At the age of 18, owing to the limited options at that time for studying medicine in her home

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Hostile treatment Fifteen years in the UK, committed to the NHS and valued by her hospital, Shashi Awai seems just the kind of immigrant the home secretary recently celebrated. Sadly, his own department has treated her very differently. Tim Tonkin reports ‘I am not after money, I just want to use my skills to help people with the greatest need’

country, Dr Awai travelled to Russia where she spent the best part of a decade studying medicine, eventually gaining a master’s degree before completing four years’ training in ENT. Having originally wanted to practise medicine in her home country, she returned briefly to Nepal in 1999, and for six months attempted to provide the care she had sought for years to give.

The reality soon left her disillusioned.

‘The healthcare [in Nepal] is not universal and the resources are not always there. If your patient needs to go to theatre you might find that there’s no ambulance to take them there or no anaesthetic when they arrive. Many patients cannot even afford treatment in the first place.

‘My friends from medical school who went back to Nepal to work are all very well off. If I had remained there I would have gone into private practice, become a consultant and become very rich.

‘For me, however, I am not after money [by being a doctor], I just want to use my skills to

help people with the greatest need.’

In 2003, Dr Awai arrived in the UK and was quickly enchanted by its way of life and its commitment to universal healthcare.

‘I was really taken by the diversity of this country; the language, the food and the different cultures, and the tolerant attitudes within society.’

With limited English, Dr Awai spent the next six years residing on a Tier 4 student visa, completing the various assessments and examinations required for her to be able to practise in the UK. After completing her PLAB (professional and linguistics assessment board) examination in 2012, she secured a locum ENT role at East Surrey Hospital in Redhill in 2013, with the position becoming permanent in June the following year.

Family problems During her time living and working in the UK, Dr Awai met and married a British citizen, and in November 2013, she was granted leave to thedoctor | November 2018 19

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NO QUARTER: A letter from the Home Office demanded Dr Awai leave the country and threatened her with imprisonment if she did not

SIGN OF THE TIMES: Dr Awai developed into a vital member of staff at East Surrey Hospital

remain in the UK until May 2016 on the basis that she was the spouse of a person ‘present and settled in the UK’.

It was in March 2015, following the breakdown of her marriage and after more than a decade in the country, that she applied to the Home Office for indefinite leave to remain.

Two months later, the Home Office contacted Dr Awai to notify her that her application had been rejected, a decision she successfully appealed at the first tier of the immigration tribunal in 2016. In the same year she met now-fiancé Ian, a telecoms analyst, and for a short while, it appeared that her immigration ordeal was over.

Relief proved short-lived, however, with the Home Office moving to appeal the ruling and managing to overturn the decision at the tribunal’s second tier the following year.

Despite lodging another application for indefinite leave, this time on the grounds of 20

human rights, the expiration of her previous leave to remain has meant that Dr Awai has not been able to work since April 2017. Her lack of income coupled with her ongoing legal fees have resulted in her falling into around £20,000 worth of debt.

While the appeals were ongoing her hospital wrote letters of support to both the Home Office and Dr Awai’s MP, telling the latter that she was an ‘extremely valuable member of the ENT team’ and warning of how challenging it was to find ‘doctors with a similar level of experience and ability’.

She says she felt like she was in limbo, with every phone call bringing the possibility of a decision. Her career, her hopes to start a family, were all put on hold.

She says: ‘I was lucky enough that I have a fiancé who, along with friends and family, has supported me financially – how else would I have survived for nearly 20 months not working?

‘I applied for a volunteer job because I know how overburdened the NHS is.

But that’s not allowed if you do not have a visa’

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IN THEATRE: Dr Awai on a postgraduate training module at the Royal Throat, Nose and Ear Hospital in London, shortly after arriving in the UK

‘The most painful thing, however, is the fact that I, as a fully qualified doctor, have had to stop working.

‘I applied for a volunteer job [at the hospital] – because I know how overburdened the NHS is. I thought that even though I cannot work as a doctor maybe I can take blood tests or help a junior doctor with their notes – but discovered that volunteering is also not allowed if you do not have a visa.’

Go to the press Dr Awai finally decided to go public with her situation, giving an interview to BBC Surrey on 19 September.

The BMA took up Dr Awai’s case and wrote to the Home Office, with BMA council chair Chaand Nagpaul describing the treatment she has received as ‘outrageous’.

Dr Nagpaul said in the letter that Dr Awai’s situation demonstrated how the inflexibility of the UK’s immigration system was hindering the

NHS from recruiting the staff that it needed.

After more than a year of uncertainty and unemployment, the pressure from the BMA and the media paid off. Last month, Dr Awai received notification from the Home Office confirming that, after reconsidering her case, it had decided to grant her leave to remain in the UK until 2021.

‘I did not believe it at first,’ says Dr Awai. ‘I was speechless and had to go outside for some fresh air. It took 30 minutes or so for the news to sink in, sometimes it’s still hard to believe that this nightmare has disappeared.’

Once she has her passport returned with a renewed visa, she hopes to resume work this month. Dr Awai also believes she will now have an opportunity to apply for permanent residence. Next year, she plans to marry.

‘I do not want to look backwards now, I just want to thank everyone who supported me during this difficult time.’ bma.org.uk/immigration

‘Sometimes it’s still hard to believe this nightmare has disappeared’

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‘Why am I here?’

Answering that question took a while for Philippa Whitford as she swapped the operating theatre for the theatrics of Westminster.

The surgeon-turned-MP tells Tim Tonkin how – thanks to pressing issues such as privatisation and Brexit – she has found a role

B

eside the window of consultant surgeon and MP Philippa Whitford’s office sits a small placard bearing the words: ‘Well behaved women rarely make history.’

It is a philosophy that appears to have served Dr Whitford well throughout her life.

Prior to becoming the MP for Central Ayrshire for the SNP in 2015, Dr Whitford spent more than three decades working in the NHS. Having embarked on a career in surgery at a time when it was an almost entirely male-dominated specialty, Dr Whitford says she frequently faced everything from incredulous attitudes to open misogyny at job interviews.

‘I was told in the third year of university that I couldn’t actually do surgery because I was a woman… [and] I was

asked very sexist questions in interview panels, just bizarre things like “women don’t have the mental or physical capacity” and “will you promise never to have children?”.’

The hostility she encountered from the more paternalistic sections of the surgical hierarchy evidently did little to deter her ambitions. ‘I decided I was going to give them a run for their money,’ she says.

Thirty-odd years on from when she started, the health service is now a rather different place.

Figures published by NHS Digital show that the proportion of female NHS doctors has been growing every year for nearly a decade, with the number of female consultants rising from 30 per cent in 2009 to 36 per cent this year.

‘I think surgery has

changed dramatically,’ Dr Whitford reflects. ‘When I started, there were no senior women surgeons in Scotland at all and precious few even UK-wide.

‘There was a really competitive, macho “how hard are you?” kind of culture, particularly within surgery, and I think that is changing for both sexes.’

‘When I started, there were no senior women surgeons in Scotland’

Family memories Now a full-time politician, Dr Whitford’s first profession continues to have an everpresent influence, from her political interests and activities right down to her physical environment.

The standard-issue, white-walled interior of her Westminster office is adorned with a series of vivid, abstract artworks painted, Dr Whitford explains, by her late sisterin-law during the art-therapy sessions that accompanied

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THE DOCTOR-POLITICIAN: ‘There was a time when [as a doctor] people trusted you and were polite to you and were respectful to you. Then all of the sudden you are a politician and you are filth’

her cancer treatment.

Her decision to stand for Parliament came following the 2014 Scottish independence referendum, with Dr Whitford admitting that the transition from medicine to politics has not always been an easy one.

‘It’s a real challenge to get around that [mental] curve, that there was a time when [as a doctor] people trusted you and were polite to you and respectful to you,’ Dr Whitford concedes. ‘Then all of a sudden you are a politician and you are filth.’

In an interview given in the weeks following her entrance to politics, she described the sense of disillusionment she had felt during a session of prime minister’s questions, in which the debate seemed to be more about political pointscoring than making progress.

Sat on the benches, she

began asking herself why she had given up a ‘useful job’ in surgery to sit in the Commons.

‘At one point I thought “this is pointless, I might as well leave the chamber”,’ Dr Whitford recalls. ‘In fact, I stood up and gave them my full, The Prime of Miss Jean Brodie ticking off.

‘I pointed out that people who work in hospitals were watching the debate and were frankly depressed at the quality of it. It helped change the tone of the debate.’

Frontline experience The opportunity to bring her clinical and personal experience of the NHS to bear in political debate went some way to reshaping Dr Whitford’s view of her new career.

During her three years as an MP, she has served on the health and social care

select committee, the Health Service Safety Investigations Bill joint committee and is her party’s health spokesperson.

Her personal highlights include having the opportunity to cross-examine the then-health secretary Jeremy Hunt over his misleading using of statistics relating to weekend mortality rates in hospitals.

Dr Whitford was also one of five committee members to put her name to a letter to chancellor Philip Hammond in October 2016, which criticised the Government for erroneously claiming that it intended to invest £10bn into the NHS between 2015/16 and 2020/21, when in real terms the figure was just £4.5bn.

‘In the medical world we are challenged to practise evidence-based medicine,’ she says.

‘Unfortunately, what is

‘I pointed out that people who work in hospitals were watching the debate and were frankly depressed at the quality of it’

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very startling when you come here [Parliament] is the lack of evidence-based politics.’

With her parliamentary commitments oen resulting in close to 100-hour working weeks, she says that her clinical work is now limited to attending one or two breastscreening clinics at University Hospital Crosshouse in Kilmarnock each month.

‘That just keeps me in touch with the real world, which I think is important as a health spokesperson, and hopefully helps me to keep my licence.

‘I miss it [full-time medicine] and I miss a lot of my patients, but I actually meet a lot of my ladies when I am out and about in the constituency.’

Finding a balance between her two careers has never been an easy feat.

It was during her first term in Parliament that Dr Whitford came under fire from a tabloid newspaper, accused of ‘moonlighting’ aer working a series of locum shis at her old hospital.

‘When they attacked me for working in my local

hospital it was a very specific situation. We were four breast surgeons, I had swanned off to here [Parliament], one of my colleagues went on maternity leave, while another had a heart attack.

‘The remaining surgeon had been holding the fort for months was taking two weeks’ leave around Christmas and New Year, so they weren’t going to be operating any clinics. I came in and did five days out of what would have been my [Parliamentary] two-week Christmas holiday.’

She says she could still remember her disbelief when speaking to the journalist ahead of their piece going to press.

‘I found myself asking: “You’re reporting this as a bad story?”’ she recounts with a disbelieving smile.

While quick to point out the ‘English votes for English laws’ protocol enacted under David Cameron’s leadership, which precludes MPs from nonEnglish constituencies voting on matters relating solely to

England, Dr Whitford insists that her concern and advocacy for the NHS is not limited merely to Scotland.

‘From my point of view, one of the motivations to come here [Westminster] was to fight against the privatisation and outsourcing that I think is really fragmenting and undermining the NHS in England. How public services are run in England has quite a big impact on the budget that comes to Scotland.’

During the 2014 referendum, Dr Whitford had publicly warned that: ‘In five years England will not have an NHS as you understand it and in 10 years, if we vote “no”, neither will Scotland.’

‘If you were to ask doctors and nurses who are working in NHS England, I think a lot of them would say they feel the NHS’s core principles are being undermined’

Privatisation warning While tacitly accepting that her timing might have been off, Dr Whitford says she still holds to her conviction that the future of the NHS UKwide is under threat.

‘I’m not sure about the timescales,’ she concedes.

‘But I think if you were to ask doctors and nurses who

EQUALITY CHAMPIONS: An event to promote gender equality in Parliament last year, to which Dr Whitford was invited as guest speaker

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EXPERT EXPORT: Dr Whitford performs surgery at a hospital in Gaza last year

are working in NHS England, I think a lot of them would say that they feel that the NHS’s core principles are being undermined.

‘Patients are already having to pay for quite a lot of things in England, we see huge amounts of rationing for [things like] hip and knee replacements and cataract surgery.’

One thing of which Dr Whitford is in no doubt is her view that the uncertainties posed by Brexit do pose a huge risk to the stability and sustainability of the health service.

‘If the NHS in England is destroyed and we remain in this situation where we pay our taxes down here and we get our pocket money back, we’re not going to get money back

to cover a health service in Scotland if it has disappeared here [in England].

‘I think Brexit is going to create a big financial pressure and make the workforce [crisis] an even bigger issue.

Workforce is actually the biggest challenge that all four UK health systems face.’

Brexit, and what it might mean for EU citizens living and working in the UK, has personal resonance for Dr Whitford, who is married to Hans Pieper, a German-born GP. ‘My husband is very stubborn and very chilled, so he is just ignoring it for the present moment,’ she says.

‘His fear was that there might be a ruling that he couldn’t use the NHS because

they [the Government] were initially talking about how EU citizens would have to take out private insurance.’

While medicine will remain her first calling in life, Dr Whitford predicts that she will probably be ‘too old’ to return to it full time once she calls time on her political career.

She is also emphatic that while she had to adapt herself to politics in a way that she did not for medicine, she no longer has any doubts about her place at Westminster.

‘One of the problems with Parliament at the moment is that it is dominated by career politicians,’ she says.

‘And we need people from the professions and the real world.’

‘Workforce is actually the biggest challenge that all four UK health systems face’

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on the ground

Missing pay, programmed activity confusion, rota woes and unsafe working hours – just a handful of the issues BMA members have faced and overcome with the help of their trade union Off the record

Employer backs down

Many people feel they are not properly rewarded for the time they spend working but, for a group of urology trainees, that turned out to be demonstrably the case.

After completing a rotation at a trust, three junior doctors had not been given any recompense for anticipated work in their work schedules, contrary to their terms and conditions. It was also found that two further trainees, who followed the original three into the rotation, were in the same situation.

The trainees had all worked on-call shifts and had been given availability supplements for their time. But none had then been paid for any actual work. A BMA industrial relations officer found that records of work carried out were quite poor but, after a period of negotiation, came to a settlement with the trust over the work carried out by the trainees who had left.

The five junior doctors received more than £35,000 between them.

Three junior doctors have received a share of £25,000 after repeated delays from their employer to acknowledge their noncompliant rota. Their employer had failed to carry out the required monitoring of hours of duty and, following a request from a doctor for this to be done, the outcome signalled a non-compliant rota.

The BMA repeatedly contacted the employer requesting confirmation it would accept the rota as non-compliant, make arrangements for the payment of a band 3 supplement, and take steps to remedy the issues with the rota. The employer failed to do this, so after discussion with the doctors, it was agreed that the case would be taken through ACAS early conciliation. Through negotiation with the employer’s solicitors the BMA secured backdated pay, which at band 3 comes with a 100 per cent premium.

The wrong rota at the wrong time Highlighting practical help given to BMA members in difficulty

Above and beyond Three months of advice and support, on negotiating with a trust, from a BMA employment adviser paid off for one consultant who was awarded more than £25,000 in backdated pay after working more PAs (programmed activities) than contracted.

Initially, the trust involved offered backdated pay for a limited period but refused to budge any further, but eventually relented agreeing to a longer-term settlement – and further rectified the problem by increasing the number of PAs moving forward and making adjustments to the departmental job planning process. The relieved consultant said they were ‘very grateful’ for all the help received over the course of several months.

A group of junior doctors were handed a disastrous rota, which would have had no educational value, just two working days before it was due to begin.

The rota was cancelled after the intervention of the BMA and the local negotiating committee junior doctor representative, which met with the trust’s guardian of safe working hours and other senior staff.

It was revealed that the trust had ignored the need to consult over the rota properly, had not given the appropriate six weeks’ notice and had not considered the educational needs of the junior doctors who were being asked to work one-in-two weekends in the emergency department despite having already completed a rotation in emergency medicine.

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the secret doctor

Abuse to the fore

Two little boys – early primaryschool age – have been playing an unsuitable game.

Unfortunately, it was a really very unsuitable game and one of them has ended up with a minor injury to his foreskin.

Their parents, understandably, panicked and have brought the boys to the emergency department.

No intervention was needed for the injury, a minuscule abrasion, but of course its location has rung alarm bells. Now it’s my job, as the paediatric registrar, to sort things out.

The first thing is, of course, to see whether anything more sinister is going on. Abuse is always a possibility and, alongside leukaemia, it’s top of the list of things you really mustn’t miss. So, I sit down with the boys, and reassure them that no one is in any trouble, but we need to ask

them lots of questions. Had they seen someone else play this game? Did someone suggest it to them? Had a grown-up ever played it with them? Did they see someone do it on a video?

But no, it appears that this time the regrettable activity really did just occur to one of the kids as the perfect way to enliven a rainy Sunday evening. Children do try out some very odd things – their imaginations are proverbially fertile, and not all the directions their inspiration takes them turn out to be good ones.

Safeguarding protocol, however, makes little allowance for the eclectic fancies of young children.

This incident comes near enough to ‘possible child sexual abuse’ that, after checking with my consultant, I have no choice but to alert

social services and to admit both children overnight, for a senior review in the morning. The boys are thrilled – a sleepover, new toys, and heaps of adult attention.

Their parents are horrified.

They would have been even more horrified if they had been awake at 3am that morning, when two uniformed police officers, alerted by social services, turn up at the children’s observation unit.

Only with considerable persuasion and my best ‘trustme-I’m-a-doctor’ manner can I convince them to go away and come back when the children are awake. The next day, after an unbelievable amount of paperwork on all sides, everything is sorted out and the families are finally allowed home.

So, what did we all learn? I got to practise my awkward-consultation skills.

The parents found out that the machinery of child protection, once activated, is a juggernaut which cannot easily be stopped. There are excellent reasons why safeguarding procedures are so robust, but when you’re on the receiving end they can be pretty scary. And the little boys? Well, they’ve learned that grown-ups are really, really interested in willies.

I suppose they were bound to find out some time.

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it happened to me Doctors’ experiences in their working lives

Both worse for wear SHATTERED LIVES: Collisions take their toll on victims and doctors alike

In emergency medicine we hardly ever see people at their best. Accident victims are often brought to us wearing ragged and torn clothes, covered in blood, vomit, dirt and incontinence; eye makeup washed in tear streams and hair in a mess.

Emotional turmoil prevails where patients are conscious enough to communicate their distress and pain; where relatives are in attendance they too will add to the cacophony and our team will make it even worse. Armed with large pairs of scissors they will cut to ribbons any remaining clothes to expose the bits that need to be examined.

If this sounds like bedlam it’s much worse for paramedics at the roadside.

Recently, for a variety of reasons and in the absence of anyone else, I was called on to attend the scene of a head-on collision between a large truck and a small hatchback. The car had crumpled into the engine compartment of the truck and, despite a large team of fire-service personnel, with every conceivable item of cutting equipment, the hatchback driver could not

be disentangled from the wreckage.

Clambering into the car from the rear was entering a scene of chaos, with broken glass, blood, engine fluids and an unconscious, heavily soiled driver compressed between the remains of the driver’s seat and the undersurface of the dashboard and lorry grill, which were merged into one.

The route backwards out of the vehicle for the victim was blocked by his lower-limb injuries and entanglement in the pedals. Added to the difficulties were darkness and rain, with dismal wetness permeating the scene, despite the tarpaulins and lights erected by first responders.

Finding and securing an airway had been the problem the paramedic had called for assistance with, and, unlike the situation in our resus room where there is ample light, a wide array of equipment designed for this scenario and the support of expert anaesthetists, at the roadside it’s very different.

With insufficient access for intubation, a laryngeal mask seemed the best option and achieved the desired effect permitting ventilation,

although this was only after the airway had been heavily soiled with blood and vomit.

Obtaining intravenous access proved easier and permitted much-needed IV fluids – although it was clear that this resuscitation attempt was compromised from the start and unlikely to succeed.

Eventually, when most of the rear of the hatchback had been cut away along with the roof and doors, it became possible to remove the seatsquab supports to create a backward route for the driver to be extracted along with pieces of impaling metal from the car’s pedal box.

By the time we returned to the emergency department following a traumatic high-speed dash, and after handing over my victim to the in-house team, I visited the decontamination shower suite and found a familiar sight in the mirror – a ragged and soaking-wet individual, with torn clothes covered in blood, vomit and dirt clearly not looking his best.

Charles Lamb is an emergency medicine consultant. He writes under a pseudonym

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the consultation The Doctor will see you now

MALIK: Learn from the past to sustain peace

Nottingham GP Irfan Malik tours the UK and delivers talks on Muslim soldiers’ contribution to the First World War. He talks to The Doctor about how he hopes to use the lessons of the war to promote peace between different communities My ancestral village of Dulmial in Punjab, present-day Pakistan, was the starting point for what has now become quite a journey, looking at the history of the First World War and particularly the roles of people like my great-grandfather who lived in the village and fought in the war. A patient I was speaking to a few years ago said he had researched the role of the Commonwealth in the war and put me in touch with an expert from the University of Nottingham. My interest and involvement just took off from there.

photographs, so I spend my time spreading the message – giving talks across the country.

I have a 1918 Enfield rifle, a 4.5-inch howitzer shell, a trenching tool and a surgical kit, as part of the travelling museum I take around with me.

I’m not interested in glorifying war.

The lesson is about peace and different communities coming together. There is so much for us to learn from the past in order to sustain peace. There are so many negative portrayals of Muslims in the media.

In total around 1.5 million soldiers from undivided India took part in the First World War and 400,000 of them were Muslim soldiers. Dulmial village was awarded a ceremonial cannon in 1925 because it contributed 460 soldiers – a record for any South Asian village. There’s a memorial in the village to this day commemorating the fact.

One of the things I want people to reflect on is how we think about different communities. One hundred years ago it didn’t matter what faith soldiers were, they stood shoulder to shoulder. I’ve got photos showing Christian, Jewish and Muslim soldiers all buried next to one another.

The hidden history of the war remains unknown to many people and they are surprised to hear the figures and see the

Find out more about Dr Malik’s lectures at https://dulmial.co/events thedoctor | November 2018 29

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

Dr Diary Keeping track of workload can be tricky.

Here’s how our new app could help

What does Dr Diary do?

It’s an application we’ve made for mobile phones and desktop computers to help doctors keep tabs on their workload. It will help you work safely and within the correct and contracted number of hours.

Who is it for?

It’s for consultants, staff, associate specialist and specialty doctors and medical academics.

What are job plans?

They’re annual agreements between employers and doctors which set out the What? When? Where? and How much? of their work for their hospital trusts. They can include other stuff too, such as the resources needed to carry it out.

Job plan reviews made easy For SAS and consultant doctors with NHS employers

on

Next

How does it work?

The app lets users log their work activity using a drop-down menu, which you can design yourself. Data from the log can then be used to generate reports online which can be printed for job-planning meetings.

Why is it needed?

Job-planning meetings can turn into a tug of war between doctors and managers.

One in three consultants feel bullied by them, according to a recent poll by the BMA consultants committee. The app can help by making it easy to collect and present detailed info about workload. Info is power, so they say. Or was that knowledge?

Is it secure?

Yes, you get to pick what goes into any report which you generate and what to leave out if it’s confidential.

All data is stored securely and amalgamated.

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Amalga-what?

It means everyone’s data is digitally blended with others’, so cannot be identified as your own in the event of a breach.

Is this the future?

We think so. Thousands of doctors are using it already but the app will be subject to ‘continued improvement’, so say our techs. You can suggest changes through its feedback section. Please do!

Download the app at bma.org.uk/drdiary

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what’s on

November

December

14-16 Leaders in healthcare conference, 9am, Birmingham

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

20 Pensions taxation and retirement planning, 7pm, Bath 22 Practical skills... leadership and management course for doctors, 9am, London

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

January 2019 26-27 BMA junior members forum, 10am, Brighton

23 The conference of England LMCs, 9am, London

February 2019

27 Retired BMA members lunch, 10.30am, Edinburgh

02 Clinical academic trainees conference, 10am, London

29 BMJ Masterclasses: GP general update, 9.30am, London

08 Planning for retirement seminar – delivered by the BMA, 9.15am, Edinburgh

30 Planning for retirement – delivered by the BMA, 9.15am, Manchester

27 Consultants conference, 9am, London

Visit bma.org.uk/events for full details thedoctor | November 2018

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ADVERTISEMENT

Dr Diary The app that supports job planning for consultants and SAS doctors

Track your workload on the go with Dr Diary.

Download the app now

bma.org.uk/drdiary

Download your reports online and ensure your hours are reected in your job plan.

Built by doctors, for doctors.

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