The Doctor – issue 13, September, 2019 by The BMA

The magazine for BMA members

thedoctor

Issue 13 | September 2019

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Excluded from school, pregnant at 16, then a job in the chip shop.

This is Laura. Dr Laura Why a better social mix in medicine benefits us all

Speaking up How David Nicholl braved a politician’s insults to warn about a no-deal Brexit

A plan or a wish list?

Can the Government keep its pledge to improve mental healthcare?

09/09/2019 11:25

thedoctor

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

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Editor Neil Hallows (020) 7383 6321

Call a BMA adviser

Chief sub-editor Chris Patterson

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

Senior staﬀ writers Peter Blackburn (020) 7874 7398 Keith Cooper (020) 7383 6390 Staﬀ writer Tim Tonkin (020) 7383 6753 Scotland correspondent Jennifer Trueland 07775 803 795 Senior production editor Lisa Bott-Hansson Design BMA creative services Cover photographer Paul Hermann

The Doctor is a supplement of BMJ vol: 366 no: 8213 ISSN 2631-6412

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In this issue 4-5

Briefing

Welcome Chaand Nagpaul, BMA council chair ‘People like me don’t become doctors.’ I find it very sad when those with the talent to join the medical profession are deterred because of their backgrounds. They are a loss to medicine, and to the patients they might have served. Some people make it, against the most overwhelming odds. Laura McManus, who said the words above, grew up in very difficult circumstances; she was excluded from school at 15 and pregnant at 16. Through sheer determination she is now a doctor. Our feature on the need to widen access to medicine also highlights a new initiative from the BMA, Aspiring Doctors, where medical students and doctors encourage applications from those who might have thought medicine was beyond their reach. The theme of social exclusion runs deep through this issue of The Doctor. We hear from the medical staff at the Homeless World Cup, an event held in Wales which aims to challenge public perceptions of some of the most vulnerable people in society. And we learn of the Street Doctors, a charity which has recently received BMA financial support. Volunteer medical students and doctors help young people explore the consequences of violent crime and teach basic first aid to those caught up in it. Equality of opportunity and achievement for the medical workforce is central to the BMA Caring, supportive, collaborative project, its vision for a better NHS, and it also underpins the BMA’s new programme Equality Matters. This seeks to improve fairness across the health service as a whole by setting examples of best practice and by continuing to lobby for change in workplace cultures. As part of this, we plan to launch a series of online learning resources and face-to-face training for all members, designed to raise awareness on issues around equality and discrimination and how such considerations must form part of our day-to-day professional conduct. There is a moral duty to treat applicants fairly, and a chronically under-staffed health service should not be turning away good doctors because of bureaucratic intransigence. If the NHS can build, value and bring out the best in its workforce, then many other benefits will follow. But until it does, many of its ambitions – such as those we highlight in the new mental health implementation plan – will be difficult to deliver.

David Nicholl, the doctor insulted by Jacob Rees-Mogg for raising concerns about a no-deal Brexit, and why he was right to speak out

6-9

Testing times Shorter waits planned for overseas doctors taking the PLAB test

10-13

A plan or a wish list? Can the Government keep its pledge to tackle serious deficiencies in mental healthcare?

14-21

Against the odds Doctors overcoming tough backgrounds to enter the profession

22-25 New goals

How football can help change perceptions of the homeless

26-29

The sharp end Valuable lessons on treating knife violence delivered by volunteer doctors and students

On the ground Helping junior doctors take their breaks

What’s on Keep on top of events

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briefing

No-deal Brexit: doctor defends right to speak out

Current issues facing doctors

A consultant who advised the Government on no-deal Brexit planning – and yet was publicly accused of fearmongering by Jacob Rees-Mogg when he raised concerns – has said doctors should speak out on risks to patients’ health. Birmingham consultant neurologist David Nicholl told The Doctor that it was his responsibility to point out the risks of patient harm and increased mortality from a no-deal Brexit. BMA council chair Chaand Nagpaul offered his strong support. ‘Individuals such as Dr Nicholl who, with vast experience and clinical judgement and after careful consideration, decide to speak out, should be supported and listened to, not dismissed and insulted by those in positions of responsibility and power,’ he said.

Drug shortages Earlier this month, Dr Nicholl called Nick Ferrari’s live LBC radio show, in which Mr Rees-Mogg, the leader of the House of Commons and prominent Brexit supporter, was appearing. Having raised the issue of drug shortages and asked Mr Rees-Mogg what excess mortality he would be willing to accept in the event of a no-deal Brexit, the Cabinet member replied: ‘I’m surprised that a doctor in your position

NICHOLL: ‘I am sure that patients will die if there’s a chaotic no-deal Brexit’

would be fearmongering in this way on public radio. ‘I think it is deeply irresponsible, Dr Nicholl, of you to call in and try and spread fear across the country. I think it is typical of remainer campaigners, and you should be quite ashamed I’m afraid.’ However, Dr Nagpaul said the opposite was true – that by speaking up on behalf of his patients, Dr Nicholl had acted profoundly responsibly. And far from ‘fearmongering’, he was

raising concerns which were widely and justifiably held among doctors. He said: ‘The BMA is in no doubt that Brexit and specifically a no-deal exit from the EU, could have catastrophic consequences for patients and the NHS, with the potential for shortages in medicines being one of the key areas of risk identified in the association’s recent policy paper on no deal.’ Dr Nicholl chose to go public with his concerns

REES-MOGG: Told Dr Nicholl he ought to be ashamed

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because he did not believe supplies of medicines were being adequately safeguarded in the event of a no-deal Brexit. He said: ‘I’m glad I rattled him [Rees-Mogg] because I think this is a question that needs asking. Every organisation from the King’s Fund to the BMA and the [medical] royal colleges have been pointing out the risks of harm from Brexit, and particularly a no-deal Brexit. When we say harm, we mean actual patient harm. ‘No one can deﬁne how much harm that will be, in my own mind – I have to be blunt, I am sure that patients will die if there’s a chaotic no-deal Brexit, what no one knows is the scale of that. I think it’s quite wrong for someone to suggest that we can crash out with there not being any harm at all, that’s just untrue.’ Mr Rees-Mogg’s response to Dr Nicholl was a factor cited by the former minister and GP Phillip Lee in his decision to leave the Conservative Party for the Liberal Democrats. He said his former colleague had shown ‘disdain and disregard’. The issue was also raised at prime minister’s questions, where the Government was accused by opposition leader Jeremy Corbyn of ‘hiding the facts’. Mr Rees-Mogg, however, insulted Dr Nicholl again, saying he was as irresponsible as the disgraced researcher Andrew Wakeﬁeld. The comments, described by the BMA as ‘utterly disgraceful’, could not be subject to a defamation action as they were made in Parliament. This led to the chief medical

oﬃcer for England Professor Dame Sally Davies publicly expressing her ‘sincere disappointment’ at the comments. Mr Rees-Mogg later apologised for the comparison with Dr Wakeﬁeld, an apology Dr Nicholl accepted.

Public interest Dr Nicholl was one of a number of specialist doctors approached earlier this year to assist in the drafting of the Government’s contingency plans for a no-deal Brexit. In April, the BBC’s Newsnight reported that the Government had been unable to stockpile certain drugs for six weeks, as health secretary Matt Hancock had said it would. They included drugs for epilepsy and neuropathic pain. Dr Nicholl questioned at the time why the approach to doctors about the potential shortages was made in such a secretive fashion. Dr Nicholl said the leaked publication of the Government’s Operation Yellowhammer report had vindicated the concerns about possible drug shortages which he had publicly expressed. ‘When Yellowhammer came out, it basically backed up 100 per cent what I had been saying but obviously on a much bigger scale.’ He said he found recent press reports that the Government had not approached the medical royal colleges over making updates to the original Yellowhammer planning ‘jaw-dropping’. ‘I ﬁnd that incredible given that we’re nearly six months ahead.’ Dr Nicholl emphasised that

Keep in touch with the BMA online at

patients should not go to their GPs with concerns about medicine shortages, as there was nothing that individual doctors could do about the situation. He said, however, that given the deadline for Brexit it was crucial that doctors spoke out on matters of concern around patients’ health. He said: ‘This goes back to the GMC’s Good Medical Practice which is quite explicit in saying that if a doctor is concerned about patient safety or even patient discomfort, they should be speaking up. ‘It is very diﬃcult to have faith in the Government when they persistently and repeatedly lie. ‘It is particularly troubling with the whole proroguing issue because that means there is no Parliamentary scrutiny and the Commons health select committee cannot drag ministers in to have these kinds of discussions.’ – The BMA issued a report this month warning of ‘irreparable harm’ to the NHS if a no-deal Brexit takes place on 1 November. Find it at bma.org.uk/nodealbrexit

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NAGPAUL: ‘Individuals such as Dr Nicholl should be supported’

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Testing times

IN ROLE: Actor and mannequin play the part of doctor and patient at the GMC’s new clinical skills centre

Overseas doctors wanting to work in the UK have often faced long delays before they can demonstrate they are safe to practise. A new GMC test centre aims to cut waiting times. Tim Tonkin reports

foundation doctor 2 named Emily Hayworth enters the room of a bed-bound older patient in central Manchester. The woman, who was originally admitted for a suspected UTI, audibly struggles for breath, is afraid and groans in obvious discomfort. Introducing herself, Dr Hayworth begins to assess her patient, who she discovers has oxygen saturation of 90 per cent, is tachycardic and has blood pressure of 86 over 60. As the consultation

proceeds, the doctor continues to question and attempt to reassure her patient, while issuing verbal updates on her ‘The exam is based clinical assessment to the consultant on scenarios you observing her work would expect a from the corner doctor to be likely of the room. to experience’ It is a scene that is probably familiar to any doctor and one which could conceivably be played out on any day and in any hospital in the NHS.

Play the part

VOICE COACH: An actor provides the voice of the mannequin

On this occasion, however, Dr Hayworth and her senior colleague are, in fact, being played by actors. The critically ill patient under their care is a hi-tech mannequin, complete with artificial vital signs and voiced by yet another actor observing events from an unseen location. The entire scenario,

simulated for the benefit of the press as part of a special open-day event, is just one of the 300 tests of clinical skills likely to be faced by overseas doctors taking the second part of their PLAB (Professional and Linguistic Assessments Board) exams. Administered by the GMC, the PLAB exam is used to determine whether a non-EEA trained doctor looking to work in the UK will be granted a medical licence. Demand for PLAB exams has been on the rise for a number of years, with the number of applicants doubling between 2016 and 2018. In response, the GMC has opened a £2.5m test centre at its main office in the Spinningfields district of Manchester from which all PLAB 2 examinations take place. It seeks to replicate the

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‘There’s a lot of investment in technology which will improve the way things are being assessed’ ON THE MOVE: Mannequins are transported to GMC test centre

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look and feel of an NHS ward and consists of 20 rooms, 18 of which are used to test doctors across a wide range of medical scenarios covering primary and secondary clinical settings. Doctors taking the exam will move from scenario to scenario, each room having just a single sheet of A4 outlining the basics of the situation they will ﬁnd. Along with hi-tech mannequins, candidates will also have to interact with actors playing a variety of roles such as patient, relative or other health professional. In each case, candidates will have just eight minutes to complete the scenario before moving on to the next room.

Shorter waits ‘The exam is based on scenarios that you would expect a doctor in the second year of the foundation programme to be likely to experience [and] we try and make those scenarios as like a clinical interaction as we can,’ explains GMC head of assessment Richard Hankins. ‘We’re interested in the way doctors interact with colleagues, pharmacists for example, which would be a part of day-to-day life as a medic in the UK.’ The new centre, which the GMC predicts will assess more than 10,000 doctors in 2020, has been welcomed by Alex Vallakalil, a medical graduate from India who completed his PLAB in July 2018 and is now working as a core trainee 1 in psychiatry in Oxford. Dr Vallakalil says the move to increase the number of opportunities for doctors to take a PLAB exam would make 08

a big diﬀerence. ‘There’s a lot of investment in technology which will improve the way things are being assessed. More doctors can do the exams now, at least 72 doctors can do the exam in a day. ‘I personally had to wait for almost four months to book for my PLAB 2 examination. With the new exam centre opening, this wait will probably be reduced to only one month or possibly less. ‘The PLAB 2 visa that international graduates normally gain to take the examinations is just for six HANKINS: ‘Doctors need to demonstrate they have the skills to work in the UK’

START

months, and it is during this period that we have to complete all the assessments. ‘If your visa expires while you’re trying to sit the exam, you would face returning home to renew your visa,’ he says.

Communication skills

MINS

FINISH

Introduced in the 1970s, the PLAB was initially comprised of three written papers and a 20-minute oral exam. In 1998 the style of the assessment underwent signiﬁcant change, shifting to a written and practical exam, with the latter taking an OSCE (objective, structured, clinical examination) format consisting of a dozen clinical scenarios. As well as clinical skills,

the exam aims to test doctors’ communication and interpersonal skills to ensure they will be able to adapt from what in some cases might be a diﬀerent style of practice experienced in their own countries, to the workplace culture of the NHS. ‘We know that communication is a major area of risk and for doctors to be safe to work in the UK they have to have the right set of communication skills,’ says Dr Hankins. ‘We’re assessing to the standard of UK practice, so while we would always try to be fair, doctors need to be able to demonstrate that they have the skills to work in the UK no matter where they’re coming from.’ The PLAB experience can diﬀer for everyone, with everyone encountering their own challenges. Originally from Iran, consultant ophthalmic surgeon Pouya Alaghband came to the UK in 2009, arriving in London. Speaking to The Doctor he says he feels there is not enough easily accessible information for newly arrived international doctors explaining what they could expect from life and work in the UK, and what steps they need to take towards gaining licences. ‘There wasn’t any dedicated website available to get information [on the exam]. I had to rely on my friends and family who had been to the UK before me,’ he says. ‘At that time, I don’t think there was any proper preparatory course [for PLAB] available apart from one which was in East London. I had to commute every day

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for one month from north to east London to attend these courses to prepare myself for the part 2 exam.’

Financial demands In its present form PLAB 1 sees candidates sit a 180-question, three-hour written exam, with the practical assessment of the second part involving the successful completion of 18 clinical scenarios in three hours. The second part of the PLAB assessment, which can only be taken at the GMC’s Manchester centre, costs £860, although this figure is halved for refugee doctors. Applicants are also required to fund their own travel to and accommodation in Manchester. Studying for the exam can further add to costs, particularly if the doctor chooses to attend a training course. Mr Alaghband, now a consultant in York, says he found the financial aspect of preparing and taking the PLAB exams onerous. ‘At that time, I didn’t have a credit card. ‘I had to find a family member who had one and ask them to pay for me and then later repay them in cash.’ Mr Alaghband says that while he had not found the clinical assessment side of the PLAB particularly challenging, adapting certain aspects of his practice style so that it was more in keeping with the NHS had been the real challenge. He says that attending the course, which could last up to 10 hours a day, had been ‘a little difficult’ but what he learned from it later proved to

be a ‘godsend’ in the exam. ‘It took me through the whole process both in the PLAB and in working in the NHS and the culture related to that. By the time I came to the UK, I had already been practising medicine for a number of years. The only thing that was different was the presentation style and how I spoke to patients – fortunately the course helped me quite a lot. ‘Probably if you’re coming from the east side of the world, I think the culture [in medicine] is quite different to western countries.’

Acclimatisation While the GMC offers support to acclimatise to working life in the UK to post-PLAB doctors through half-day practice workshops, a recent study commissioned by the regulator has underlined the challenges these staff face. The GMC-commissioned Fair to Refer report on the disproportionate level of referrals to fitness-to-practise proceedings, found that nonUK doctors were two-and-ahalf times more likely to be referred to an employer than their UK-trained counterparts. It further warns that many overseas doctors find transitioning to practising in the UK ‘challenging and daunting’, and that those doctors who do not receive support from the outset can continue to feel isolated and be disadvantaged in their careers. Mr Alaghband adds that ultimately the GMC’s new, dedicated assessment centre sounds promising, particularly because it allows for exams to be run more regularly, which

ALAGHBAND: Overseas doctors face considerable costs in going through PLAB

‘The transition to practice can be challenging and daunting’

would make a real difference. ‘At the time I was trying to take my exams I was so desperate to get my GMC registration sorted, but the initial availability [for tests] was four or five months down the line,’ he says. ‘If they [the GMC] are going to run the exam on a monthly basis there will be more availability.’ Access the BMA’s free, online information resource to support overseas doctors coming to work in the UK at bma.org.uk/bmjoverseas-module

A history of the PLAB exam – Doctors who have graduated from a medical school outside of the UK, EEA (European Economic Area) or Switzerland, are required to take the PLAB (Professional and Linguistic Assessments Board) test – PLAB assessments were first introduced in 1975 and were then known as the TRAB exam (Temporary Registration Assessments Board), before being renamed PLAB in 1978 – Prior to PLAB there was no single system for assessing overseas doctors coming to work in the UK, applicants were required to have overseas qualifications recognised in the UK – PLAB was a single exam until 1995 when a separate test for English language proficiency IELTS (International English Language Testing System) was introduced alongside it. The PLAB exam itself was split into two parts in 1998 – Once both parts of the PLAB have been successfully completed, candidates can register for a licence to practise. Applications must be approved within two years of passing the second part of the PLAB exam.

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MATTHEW SAYWELL

A plan or a wish list? The Government has pledged to tackle serious deficiencies in mental healthcare. The changes are potentially significant, but the details are sketchy and will there be enough staff to deliver it? Keith Cooper reports

ong-standing flaws in mental healthcare can have tragic consequences for patients – and those who care for them. Chronic NHS bed shortages have forced thousands into socalled OOA (out-of-area) beds for years, an endemic practice which separates very ill people from their families and carers – and is a well-known risk factor for suicide. Almost 200 people in the UK took their own lives after leaving ‘non-local’ hospitals between 2014 and 2016, says the latest study by the University of Manchester. Each lost life is, of course, devastating for families, for example that of David Knight, which the BMA covered

in 2017. Mr Knight was given a bed hours away from friends and family, and according to medical evidence given at his inquest, it was ‘very likely’ to have been a contributory factor to him taking his own life. Hundreds of patients wait more than a year at home for standard talking therapies and hundreds more are ‘warehoused’ on private wards far from home, for want of NHS beds and staff with the skills to get their lives back on track.

Care close to home So, what is the NHS planning to do about the chronic shortages of facilities and skills, which have such an awful effect on patients and frustrate the efforts of doctors in charge of their care?

The latest detail of what’s being done to tackle these seemingly intractable issues are laid out in the NHS Mental Health Implementation Plan, slipped out late July, on the eve of Boris Johnson becoming prime minister. Its ambitions include a promise to spend £2.3bn to help two million more people. It aims to reduce the long waits for treatment for the severely ill, eradicate OOA beds, and set up new services with new structures to bring care closer to home. NHS England national director for mental health services Claire Murdoch said she has ‘never seen such a strong commitment to improve mental health in England’ in her blog on the

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JOHN HARRIS

LET DOWN: David Knight’s parents, with a picture of their son who was given an out-of-area bed, which may have been a factor in him taking his own life. The plan seeks to end the use of such beds

plan last month. ‘There had been an impressive momentum to bring change’ from Government and frontline staff but people now want ‘actions not words’. So, what does it say and how realistic is it? As with many plans of this kind, it offers more of a sketch than a fully formed picture of what NHS England wants by 2024, the year it runs to. The traces it offers, however, point to some potentially significant changes for doctors and others in mental healthcare. It suggests, unsurprisingly, a further shift away from hospital care to more ‘care in the community’. Ward stays, if necessary, should be ‘short and purposeful’, close to home,

and offer treatment – not just a room and a watchful eye, as some have become. Such basics are sadly lacking in much of the NHS and in the private hospitals to which it increasingly outsources care. At least five million people live in areas with no mental health rehabilitation beds for the most seriously ill, where stays last months or years, the July edition of The Doctor revealed. Hundreds are ‘warehoused’ in private wards, many hours’ drive from home, where stays last twice as long as in the NHS.

New services On acute wards, where admissions should last weeks, more than 700 were in OOA beds in May, many

for more than a month. The Government’s goal of ending OOA beds in the acute sector by 2021 looks increasingly unlikely. The plan also promises to open services for people with serious gambling problems, rough sleepers, and for people with severe mental ill health, including those with a diagnosis of personality disorder, a much-neglected area in recent years. It pledges also to extend services already being revamped by an earlier plan, the FYFV (Five Year Forward View). It runs until April next year, when this new one effectively takes over. Perinatal care will, for instance, start to offer limited help to mothers’ partners, such as ‘assessment’

HELPING HAND: Mary Shiers, and her parents, who pressured the NHS for a local rehabilitation service to help treat her psychosis, as reported in the July issue of The Doctor. The plan says ward stays should be short, purposeful and close to home

‘We have to increase the pipeline of people working in this area but this won’t happen very quickly’

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Planned cumulative increase in psychiatrists in England

600 550 500 450 400 350 300 250 200 150 100 50 0 2019/20

BELL: ‘The NHS isn’t a good employer on the whole’

and ‘signposting’. But there’s little or no pledges of extra resources for people with learning disabilities, dementia or for substance abuse services. The plan itself is sketchy on what these services will look like but does lay down hard figures for how many extra staff it expects will be needed. King’s Fund health policy fellow Helen Gilburt says it is difficult to know what these figures mean in ‘There’s quite practice without extra detail. a lot of “we ‘There’s quite a lot will have these of “we will have these services” but services” but not not much about what the services much about what the services will look like,’ will look like’ she adds. ‘It is really difficult to know what this plan actually means.’ What the King’s Fund and other mental health policy analysts can say, however, is that the plans for a massive

2020/21

2021/22

expansion of the workforce are ‘ambitious’, a byword in policy-speak for unrealistic. Ms Murdoch herself calls the plan’s targets ‘very ambitious’. It, however, expects an extra 550 psychiatrists and 4,220 nurses to be recruited at a time when many mental health trusts are struggling to fill posts they already have. These extra posts are on top of the staff increases planned in the FYFV. One in 10 psychiatrist and mental health nursing jobs are unfilled nationally, according to the latest official figures, raising doubts that earlier plans for an increase in workforce have worked. Andy Bell, deputy chief executive of the Centre for Mental Health, agrees the workforce proposals are ambitious but believes the present high profile of mental health – especially among young people – creates a ‘huge opportunity’ to attract new staff. ‘We have to increase the pipeline of people working in this area but this won’t happen very quickly, so we also really need to focus on the people we have got now. We know there are things that need to be done to support the mental health workforce we

2022/23

2023/24

already have. The NHS isn’t a good employer on the whole,’ he says.

Struggling to meet demand Efforts to support mental health and boost the recruitment of psychiatry trainees and consultants has been a focus of medical groups, such as the BMA and the Royal College of Psychiatrists. The RCPsych’s ‘Choose Psychiatry’ campaign has helped push the ‘fill rates’ of trainee posts up to 92 per cent in much of the country. The college has also commissioned University College London to find out why so many trainee psychiatrists drop out of specialist training. ‘Although mental health services are seeing reform throughout the UK, too often we hear about services under immense pressure,’ the RCPsych says. ‘It takes courage and hope to remain working and training in services which are struggling to meet demand.’ BMA consultants committee mental health policy lead Andrew Molodynski says the plan’s workforce figures also point to a potential change in the staff mix of mental

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Psychologists, psychotherapists, and psychological professionals

Nurses

4,220

8,130

Planned expansion of the NHS workforce by 2023/24

Psychiatrists

Peer support workers

550

4,730 Social workers

610 MOLODYNSKI:

Doubts whether the planned staffing increases can be achieved

health teams. Alongside the three-figure increase in psychiatrists’ posts, there are plans for 6,000 extra support staff, 4,700 peer support workers, and large rises in the numbers of nurses, psychologists and others who offer talking therapies (see above and opposite). Dr Gilburt sees the workforce figures as an early indication of a move back to the ‘multidisciplinary’ community mental health team. ‘This is not necessarily a bad thing,’ she adds. ‘Community health teams have been stripped back. They lost social workers and most of the psychologists left to fill gaps in the IAPTs (Increasing Access to Psychological Therapies) service.’ Multidisciplinary teams are the ‘cornerstone’ of goodquality mental healthcare, says Dr Molodynski. ‘We need more of all types of team member but we need also be clear on how

they will be recruited, trained and supported to work in what can be a stressful area. The recruitment of large numbers of people with relatively brief training points to the need for even more high trained and experienced staff. ‘High vacancy and drop out rates for doctors in training and the prospect of many experienced psychiatrists retiring soon raises major doubt about whether the planned increases across all key professions can be achieved. Even the modest targets for extra doctors seem unrealistic.’ he adds.

Talking therapies The plan proposes to boost access to talking therapies for people with more severe mental illness, such as psychosis, bipolar disorder and personality disorder. Many people with these illnesses are excluded from IAPTs, the

mainstay of NHS talking therapy services, leaving them waiting years for appointments. The plan says that ‘new training places’ will be created by Health Education England, a Government agency, to ‘increase competency within the workforce’. The BMA’s Dr Molodynski welcomed the plan’s pledge to address the many shortfalls in mental healthcare. ‘There will, however, be big challenges which we must overcome together. The plan leaves us a long way from having services with the resources to respond quickly and humanely to people with mental health problems, regardlesss of their age, location, background or diagnosis – that’s the real parity we need in the 21st century.’

‘Even the modest targets for extra doctors seem unrealistic’

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PAUL HERMANN

NOW A DOCTOR: Laura McManus in the estate where she grew up in Preston

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Against the odds Doctors from poorer backgrounds remain a minority, but some overcome the toughest social barriers to enter medicine. Tim Tonkin hears their stories, and why widening participation in the profession benefits everyone

‘P

eople like me don’t become doctors.’ For most of her life, these six words have governed Laura McManus’s view of herself and how her future would unfold. From an early age, the now 31-year-old had aspirations of studying medicine, yet a combination of the pressures in her personal life, discrimination, socio-economic surroundings and the attitudes of those around her, made her dream seem an impossibility. Now a foundation year one doctor, Dr McManus’s journey into medicine was not only unconventional but saw her having to overcome personal circumstances and a start in life that to many would have seemed insurmountable. Growing up in Preston, she lost her mother at the age of three and ended up living with her father in a one‘It was a joke – people bedroom flat on a council estate. Her ambition to become a doctor would literally laugh began as a young girl worrying about at the idea of me the health of her father, who has being a doctor’ hydrocephalus. ‘When I was very young, he would get headaches all the time, so I used to want to be a brain surgeon to fix him, but it became apparent that things like that don’t happen to people from my background,’ she says. ‘When you come from a background of extreme poverty, you face discrimination at every turn, it’s thedoctor | September 2019 15

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OKECHUKWU: ‘Getting through the application process by myself was probably the biggest obstacle I faced’

SIMON BOLTON

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pandemic. Teachers wrote us off as “bad kids” that would never achieve anything. They would literally laugh at the idea of me becoming a doctor.’ One well-meaning adult, hearing her career plans, suggested she should become a hairdresser instead. Dr McManus explains that she didn’t have the same educational experience as other children, and through frustration at the system, and dealing with difficult situations at home, she ultimately played up to that image. It was this that led to Dr McManus being permanently excluded from school at the age of 15 owing to poor behaviour and attendance. ‘It wasn’t that I was academically incapable, it was discrimination and the lack of support, resources and self-belief.’ Her situation was further complicated when, at 16, she became pregnant, leading to her leaving her family home and spending 18 months living in homeless hostels. She describes the relationship with her son’s father as ‘volatile’, and at 19, she ended the relationship and became a single parent. It was then, after doing a succession of jobs such as cleaning, serving in a chip shop and care work, she began to think ‘there must be more than this, I want to give my son something better than I’ve ever had’. She began to google science degrees, the idea of becoming a doctor still seemed out of reach. This is where she first learned about A-levels, ‘School had never informed me about A-levels and I had not known anyone to do them in my personal life, I ‘You need to target just didn’t know they existed.’ After approaching a local college, she people before they apply to university and from a was able to convince staff to allow her to take A-levels in chemistry, biology, and really young age’ mathematics, despite her not having the required GCSE results. After excelling in her AS year, she was asked by her biology teacher what she wanted to do in the future and mentioned dismissively how she had, as a child, wanted to become a doctor. ‘I told her the idea of me being a doctor and she just said, “well why not?”. That made me suddenly ask myself the same question.’ With the support from course tutors, Dr McManus approached universities local to her explaining that she wanted to study medicine but did not have the requisite GCSE results. Two universities responded to her and, after some negotiation, it was agreed that she could be admitted to their medical course provided Dr McManus achieved five GCSEs and another AS level in addition to the A-levels. This led to another hurdle, as a mature student only thedoctor | September 2019 17

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ED MOSS

Looking back over the obstacles Dr McManus has maths and English GCSEs were available to take through had to overcome and how things can be made easier her local colleges, so Dr McManus had to learn the for future prospective doctors, she says: ‘I would like to curriculum herself and find a local high school to allow highlight the inequalities of people from my background her to sit the GCSE exams as a private candidate. and hopefully inspire someone to In 2014 she finally secured a place to dream big and go for it, even when you study medicine at Lancaster University. feel the world is against you and that She said that learning that she would things can’t improve. be able to attend university to study ‘When I see people from my medicine had been an amazing yet ‘A career in medicine surreal moment in her life. Although, shouldn’t just be for the childhood, I am constantly told, “you must be really clever, I could never do studying medicine has not been without advantaged’ anything like that, I’m just not clever its challenges, she faced eviction, had a enough”. But it could not be further breast cancer scare and had lost several from the truth. It’s just they haven’t had family members. the same opportunities or support and ‘I didn’t have the same family instead, they have faced multiple hardships and faced situation or financial security as other students and had to use food banks several times throughout medical discrimination at every turn in their lives. school. I suffered great anxiety early on as I struggled to ‘They are clever enough and they are capable, if they are given the right support and the self-belief that they “fit in” with students from more affluent backgrounds. are able and deserving of achieving more, they can My vocabulary was very limited compared to others achieve whatever they want.’ and I found myself frequently not understanding teaching/conversations purely because of the As a career, medicine has for a long time been seen as the preserve of the financially and academically vocabulary difference. I felt I had missed out on the privileged, with statistics often lending weight to this hidden curriculum of being middle class, which seems perception. essential for studying medicine.’ A 2016 report published by the Sutton Trust on the Despite these difficulties, with the support of educational backgrounds of UK professionals found that Lancaster Medical School, Dr McManus has now while just 7 per cent of the UK population had attended completed her studies and is now working back in her independent schools, students from these institutions hometown at the Royal Preston Hospital. made up 61 per cent of the total entrants to medicine. In an effort to improve diversity of medical school candidates, the trust has called on universities to ‘contextualise admissions to study medicine, recognising that academic ability is just one crucial part of being a successful doctor’. It has also called on schools and medical colleges to collaborate to encourage pupils to take an interest in medicine and increase students’ exposure to the possibility of studying medicine at an earlier stage in their education. Improving the aspirations of students from educational and social backgrounds under-represented in medicine, and ensuring they have equality of access to medical school, are known respectively as widening participation and widening access. Dr McManus feels that, although she didn’t benefit from widening participation, her journey would have been made easier if that support were available to her. She believes that widening participation is crucial to support people into medicine, however, also believes that for CADMAN: ‘Not everyone has a people of her background many of the existing initiatives conventional route into medicine are too limited to work well. and that’s OK’ ‘Widening participation needs to be targeting people from a very young age and targeting mature students. 18 thedoctor | September 2019

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VALENTINE: ‘It’s all about building up their experience’ EMMA BROWN

By the time people turn 18, it is likely too late to make many real differences as they are likely falling into similar situations I have faced, not achieved well at school and not even considering university as a life option. ‘Like myself, it may take several years longer for life to settle down and to be in a stable enough situation to be able to plan for a career, rather than worrying about whether to spend the last few pounds on food or electricity. ‘That is why I believe targeting people in primary school or high school starters would be more effective or targeting people attending college as a mature student when they are ready to plan for a different future.’ Dr McManus feels that people like her who have managed to make it in medicine against the odds, have a responsibility to share their stories and make themselves visible in order to inspire and encourage others from disadvantaged backgrounds to consider becoming doctors. ‘There are a lot of people out there who have the skills but aren’t channelled in the right way or have all their options presented to them.’

Deprived areas Published last November, the Medical Schools Council’s selection alliance report provides insight into its efforts to got in to medicine,’ she says. ‘Neither of my parents are in the medical profession, improve widening participation. The report contained some encouraging signs such as so I didn’t have any point of contact; anyone I could speak to understand the process for applying.’ the percentage of BAME (black, Asian and minority While private schools and colleges will often host ethnic) students entering medicine having risen annually dedicated programmes to assist pupils looking to apply from 28 per cent in 2011 to 41 per cent in 2016. Less encouraging, however, is the finding that entrants for medical school, such resources were simply not on offer at Theodora’s school. to medicine from the UK’s most deprived areas, as ‘Trying to get through the application determined by the Index of Multiple process by myself was probably the Deprivation, was shown to have biggest obstacle I faced,’ she says. increased by just 5 per cent between ‘Coming into medical school and 2007 and 2016. seeing all these people whose parents The report also reveals that while ‘If a patient sees 43 per cent of those entering college someone who they think were doctors or their school had had a medical school programme that would or university had parents without they can relate to it will take them through interviews – I didn’t higher education qualifications, such make them more likely really have that.’ applicants only made up 23 per cent of to speak up’ Six people in her year applied for entrants to medicine. medicine, with Theodora and one other pupil winning places. Obstacles to applying Since becoming a medical student, she has sought to Originally from Nigeria, medical student Theodora help students in a similar position to the one she faced Okechukwu came to the UK with her family aged eight, through involvement in e-mentoring schemes and settling in Enfield. blogging about widening participation on Instagram. Attending a comprehensive school in Barnet she ‘You’d be surprised how much just knowing someone discovered a love for science subjects and decided to who’s been through the process makes such a difference become a doctor after one of her teachers suggested to you applying, and I really want to be that person for as it to her. ‘My biology teacher had so much faith in me and really many people as I can,’ she says. ‘I think for some teachers [at my school], they were helped. Without that teacher I don’t think I would have thedoctor | September 2019 19

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maybe confused about my hunger to study medicine. My AS level results were not the typical four A’s you’d expect, but I was determined that I would still apply. A lot of people would tell me that there were a lot of other subjects I could apply for with the grades I had. ‘One of my brothers attended a selective school for sixth form, and it’s completely different how students are handled there when they want to pursue something like medicine or law or go to Oxbridge.’

Patient voice

She credits her attendance at widening participation summer schools with her successful application to medical school. She feels she had had to fight a near constant battle to persuade those around her that she should be given the chance to study medicine. ‘It was constantly “you’re not going to be able to do this” or “you’re not that sort of person”,’ she says. ‘If it was not for my college, who were amazing and did everything they could to help me get there, I probably wouldn’t have gone into medicine. ‘A career in medicine shouldn’t be just for the advantaged. Not everyone has a conventional route into medicine and that’s OK – these struggles can in fact prepare you for the things you will face every day as a doctor.’

Now in her fourth year at Nottingham University, Theodora says widening participation is not just about increasing equality of opportunity for students, but ensuring that the health service better represents the patients it cares for. ‘If a patient sees someone who they think they can relate to [it] will make them more likely to speak up,’ Building confidence Recognising and giving greater support to ‘looked after she says. children’ (children in care) looking to ‘That’s really important for patient pursue a career in medicine was an care because if a patient doesn’t feel issue brought before this year’s BMA able to speak up, [as a doctor] you might ‘I’m constantly dealing annual representative meeting in miss things.’ Belfast. Bristol medical student Christine with things like Initiated by the BMA medical Cadman feels that the personal imposter syndrome; students committee, those at the adversities she has faced could help give that feeling of: “I don’t meeting emphasised how those leaving her more perspective when she comes quite belong here.”’ the care system needed to be viewed as to qualify as a doctor. of equal value to the medical profession She decided to pursue medicine as other applicants, and should receive aged 19 having spent several years in additional support and information from universities care and, at age 15, being hospitalised for a number of when applying or interviewing for medical degrees. years owing to her mental health. It also called on the association to lobby medical She had been able to take her English language and schools on the need for specific policies around ‘looked maths GCSEs while still in year nine and while in hospital after children’ as a vital means of increasing their was able to complete exams in biology, chemistry and participation in the medical profession. physics. Medical schools in the UK are required to host an She says she was inspired to go into medicine by one outreach scheme aimed at improving access to courses of the doctors she encountered while in treatment. such as medicine. ‘One of my consultants was a lovely man who always The oldest such course is the EMDP (Extended Medical said to me: “You’re so clever, you could be a doctor one Degree Programme) at King’s College London launched day,” but at the time I was just not interested,’ she says. in 2001 before such schemes became mandatory. ‘When I was getting ready to leave hospital everyone It was the first widening-participation initiative of its around me was telling me that I needed a goal, and so I kind and despite taking on just 10 students in its first year, decided I was going to try.’ now has an annual intake of 77 students, with more than Christine was discharged from hospital at 18, sent to 400 doctors having graduated from the programme since a care home and then on to an education unit where it began. she was told that it wouldn’t be possible for her to study The course is designed to provide a ‘graduated’ chemistry or biology at A-level. introduction to medical study for students coming from Through sheer determination she was able to non-selective state education or who are part of the persuade her care home to send her to a college where Realising Opportunities scheme. she could take the necessary subjects. The six-year course is structured in such a way that After completing her A-levels at the age of 20, the first year is split into two years thereby allowing she secured a place at Bristol university and is in her students to receive additional support through tutorials third year. 20 thedoctor | September 2019

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in subjects ranging from pharmacology and immunology, DAVIES: ‘Your to research skills and academic writing, offering a range background should not matter’ of formative learning opportunities to support academic development. Jane Valentine became a co-director of the EMDP in 2014 and is now the programme’s pastoral support lead. ‘I’m constantly dealing with things like imposter syndrome; that feeling of “I don’t quite belong here” or “I’m not good enough”,’ she says. ‘We have a lot of peer learning and extra pastoral support through the EMDP adviser system from day one… and we offer lots of community-based service opportunities as well. ‘It’s about building up their confidence through those small group interactions, through those peer networking events and through one-to-one discussion. The more a student progresses the more they can see that they are doing as well as everyone else.’ Students on the extended programme are integrated with those on the standard medical degree from the medicine, what challenges they faced and what options beginning, with only their formative EMDP-specific exist for those with similar aspirations. teaching done separately. Registration for a one-day training event at BMA House However, unlike some widening participation courses this October is now under way, with newly qualified in which students are shifted into the standard medical doctor Brooke Davies one of those degree after a year or so, those on looking to get involved. the EMDP remain on the initiative As the BMA medical students ‘These are students throughout the six years of their studies. committee widening participation Along with its extended degree with immense talent programme, King’s College has a and their life experience lead Dr Davies led calls for doctors and medical students to share their stories widening-participation department might give them to illustrate the range of backgrounds of which seeks to encourage students something that other people entering medicine, and increase from less-advantaged backgrounds to doctors don’t have’ awareness and engagement with consider medicine as an achievable widening participation. goal. This outreach activity begins as Having herself come from a workingearly as primary school, but with the class background and being the first member of her main focus at secondary and sixth-form levels, with family to attend university, she is now an F1 at the students from the EMDP travelling into schools to share Royal Lancaster Infirmary and says that an individual’s their stories of how they got to medical school. background should never serve as an obstacle to them ‘These are students with immense talent and their studying medicine. life experience might actually give them something that ‘Widening participation, for me, is the concept that other doctors don’t have,’ explains Dr Valentine. allows anyone to have a chance to be a doctor. Your ‘They [school pupils] can see “that person is like me, background should not matter,’ she says. why can’t I do it too?”. I don’t think there’s anything more ‘It should not matter if you have parents who are powerful than that for a student.’ doctors, parents who are not, or you don’t have parents. It should not matter if you live on a council estate, live in Inspirational stories care or live between homes. Helping school students realise their potential, or ‘It should not matter if you are white or BAME, female even just consider medicine as a possible career, is an or male. It should not matter what your faith is or what objective of a new initiative being launched this autumn you practise. It should not matter that your school was by the BMA. private or your school was a poor performer. It should Known as the Aspiring Doctors programme, the only matter that you want to study medicine and are scheme is looking for medical students and doctors who willing to work for it.’ want to try to make a difference by visiting schools and colleges with the view of talking about their route into bma.org.uk/wideningparticipation thedoctor | September 2019 21

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MATTHEW SAYWELL

New goals

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An escape from the moment, and a chance to challenge public perceptions – Peter Blackburn meets the doctors and participants at the Homeless World Cup

n the day the NHS came into being, in 1948, Nye Bevan said: ‘The eyes of the world are turning to Great Britain – we now have the moral leadership of the world.’ Some 70 years later, the life stories of the people gathered at Cardiff’s Bute Park – a short stroll from the city’s watchful statue of the man who founded the health service – might have left Bevan questioning where that moral leadership had gone. A few minutes in the company of players from the home nations’ sides revealed all kinds of personal tragedy and ill fortune – and in many cases the powers-that-be in government, and indeed the NHS, had done relatively little to provide a safety net or comfort blanket during times of serious need. It is this vacuum that the Homeless World Cup aims to help fill. Where society fails, it’s an invaluable chance to bring rough sleepers and the vulnerably housed together with charities, campaigners and those who have experienced homelessness but have managed to make better lives. Speaking to The Doctor at the tournament, actor Michael Sheen (pictured below), who funded the event, explains: ‘People come down to get involved in the football – it gives them an escape from what is going on in their lives at the moment, they form connections, they become part of a team and rather than the stigma and the judgement they are getting [in everyday life] they feel like they belong somewhere, like people actually care about them… and they get a bit of self-confidence and self-esteem as well as a bit of motivation about wellbeing.’ The World Cup is first and foremost an event: more than 500 players representing more than 50 countries, with recent experience of homelessness, all joining together to compete – and to share experiences. But the initiative itself is wider and includes 74 different projects around the world which utilise football as a ‘tool for social change’.

The tournament, and the wider projects, aim to inspire homeless people to make positive changes in their lives and brings together people who have the experiences and contacts to make changes while challenging public perceptions of homelessness. Jack Badu, manager of the England team at the event and engagement officer for the charity Centrepoint, says: ‘The biggest thing for our team is that this is an opportunity to showcase something that they can have a sense of achievement about. ‘A lot of the time the narrative based around young people at risk of homelessness is that they are a burden on society. It’s really important to give them a chance to show how brilliant they are and for them to feel like they are everyone else.’

‘A lot of the time the narrative is that they are a burden on society’

Beautiful game Players taking part in the competition feature people who have been homeless within the last year, asylum seekers, people who sell street papers and those in drug or alcohol rehabilitation. The games are four-a-side and last for two, seven-minute halves. Mireia Salinas (pictured opposite), the goalkeeper for the England women’s side, is a shining example of the power football – and charities and campaigners who act where society fails to – can have. The 41-year-old moved to Derby in her 20s from Barcelona in search of a ‘new language and culture’. Ms Salinas fell into an abusive relationship and drug addiction and after 12 years ‘trapped’ she fled – the only viable option after losing touch with her friends and family was to sleep on the streets. ‘It was horrible – you are on your own. I wasn’t asking for money or anything, I just wanted people to talk to me, to notice that I was there. I understand people sometimes think you are there because you are a druggie thedoctor | September 2019 23

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and you deserve it, but people get in very bad situations after having very bad luck in their life. ‘I have seen things with my own eyes – I have experienced horrible things. Women being raped. Young lads with a drink abusing people. I saw friends and people I care about going through horrible things. It is very, very horrible.’ But Ms Salinas found help through Derby County Community Trust’s active choices programme, which aids the recovery of substance and alcohol misusers and helps with access to accommodation – and then joined up with the scheme’s football team, which plays in a league against other similar projects. A call-up to represent the England national team at the Homeless World Cup followed, which means she has gone from sleeping in Derby’s Arboretum Park to representing her adopted country on the world stage. It might be a cliché but football truly has saved Ms Salinas’s life. ‘It has given me a purpose to wake up – I wake up with a smile on my face and I know something amazing might happen rather than waking up in a park at 7 o’clock in the morning and thinking, what now,’ she says. ‘Being able to help people now would be the very best thing ever. If I help one person that would be great.’

Pride restored Rhodri Martin, team doctor for the Welsh international football team – volunteering at the event – saw the power that Ms Salinas describes, first-hand. He says: ‘I thought it would be a worthwhile thing to do especially given I am working in football. I thought it would be beneficial to give something back to people using football to try and get their lives on the straight and narrow. ‘I’m not used to dealing with homeless people in my work – not since I was a junior doctor. It was refreshing for me to be working with other colleagues and trying to help give people a second chance in life. ‘You get a sense of the importance of the event and the pride of the individuals – they had something to be really proud of and it gave them a real sense of purpose and worth. Walking out and listening to a national anthem and representing your country was clearly a huge sense of accomplishment of the

individual. They can be superstars and that can only be beneficial.’

Maintaining hope

‘I know something amazing might happen rather than waking up in a park at 7 o’clock in the morning and thinking, what now’

While Ms Salinas’s story is one of hope, many of the 500 footballers at the tournament return to life on the streets or in temporary accommodation when the final whistle blows. Makumbi Abdallah (pictured opposite) fled Uganda last year after his father was murdered and lives in immigration hostels while his permanent right to asylum is being processed. While his future is still up in the air, Mr Abdallah – who plays for the Welsh men’s team – says the feeling of being around people with similar experiences, and those who have made better lives, is inspiring. He says: ‘At this moment I can’t even remember that I am homeless because of the huge number of people around you who like to have conversations with you – you forget the situation that goes behind your life. ‘I have not got a place to stay so I have to go back to the immigration hostels. But I don’t lose hope – in time things can change.’ The link between homelessness and health is inextricable – and it’s of growing significance. Figures collected by The Doctor through a series of Freedom of Information requests reveal that the number of recorded visits to England’s emergency departments by patients classed as having no fixed abode has nearly trebled since 2010-11. The effects are significant for patient care, workload and balance sheets. Yet when The Doctor looked to assess the provision of homeless care to tackle this growing need, services around the country were remarkably patchy: only 20 CCGs (clinical commissioning groups) reported having clinical leads for homelessness – a position of responsibility for overseeing care for homeless patients recommended by some experts; just 15 areas said they specifically hire or contract staff to work in homeless care; and in 77 CCG areas there were no specific services for homeless patients reported, whatsoever.

Care improvements needed Swansea emergency medicine consultant Katy Guy was on hand as the medical director for the tournament – and has been inspired to take her experiences back into the day job.

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MATTHEW SAYWELL

‘This has really opened my eyes,’ Dr Guy says, the sights and sounds of the festival of football echoing in the background. By day four of the tournament, Dr Guy has already had time to muse on the treatment given to homeless patients in the NHS. While life on the front line is tough – with the stress and strain of a depleted workforce and soaring demand – better care would be an improvement for patients and doctors. Dr Guy says: ‘When you are really busy and you’ve seen a patient and there’s another waiting to be seen, it’s easy not to get involved in trying to change or improve things. ‘I think we can do more than just say: here’s the number for a shelter that may not have any beds for you. It is something I would like to work on and do more to help with having met all the people here.’

Public health emergency Doctors at the BMA annual representative meeting earlier this year pledged to be ‘at the forefront’ of tackling the ‘public health emergency’ of homelessness. Doctors agreed that the association would lobby for medical schools to include the healthcare needs of homeless patients in their curriculums, NHS bodies to explore integrated models of homeless healthcare, and for hospital trusts to provide clinical staff with clear admission and discharge guidelines and procedures. The motion also urged action from

ON THE BALL: Makumbi Abdallah raises his game

GUY: On hand as medical director for the tournament

‘I think we can do more than just say: here’s the number for a shelter that may not have any beds for you’

the governments of the UK – calling for additional resources to support the primary medical care of these vulnerable people and to ensure that no person completing a prison sentence is released without having somewhere to live. For Ms Salinas, who has come through so much and can be a beacon of hope to many, this is the crux: those in charge of policy and purse strings need to step up. She says: ‘These things [the support and guidance provided by events such as the Homeless World Cup] are amazing but they should be provided by the Government. I know it’s a lot of money and it’s a lot of time – but we are people, we are humans. ‘I have met the smartest, the sweetest and the most amazing people in the streets and they are capable of doing amazing things with the right help and the right push. There are smart people, there are writers, these people can do something. If the Government could care a tiny bit more about us it would make so much difference.’ thedoctor | September 2019 25

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EMMA BROWN

UNDER PRESSURE: Young people in east London learn how to apply pressure to a wound

‘People end up in situations where they witness a shooting or stabbing and don’t know what to do’ PIERRE: ‘StreetDoctors helps young people gain confidence’

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Witnesses of knife crime may often flee the scene but doctors and medical students are volunteering to educate people on how to react to and contain violence. Keith Cooper reports

The sharp end R TRAINING: New volunteers acquire the skills they will go on to teach

ochelle Pierre signed up as a ‘streetdoctor’ back in 2011, her first year at Barts and The London medical school. ‘An email came around, looking for volunteers. I grew up in Hackney around a lot of youth violence,’ says Dr Pierre, now a core trainee 1 in anaesthetics. ‘Somebody close to me had been shot. They weren’t involved in a gang, it was a case of mistaken identity. I knew to call an ambulance but I didn’t know much first aid. I wanted to get involved.’ Back then, StreetDoctors, now a growing charity run from a London office, was known as the Liverpool Project. Set up by two medical students and a senior youth practitioner from a youth-offending team in 2008, it helps young people explore the consequences of violent crime and teaches at-the-scene basic first aid in short, informal sessions. It’s funded by an assortment of charitable trusts and Government bodies, including BMA Giving, a charitable arm of the association. ‘Lots of people end up in situations where they witness a shooting or stabbing and don’t know what to do. They end up not helping out of fear of not knowing what to do,’ says Dr Pierre, now a trustee for the charity, helping to steer its future course. ‘StreetDoctors helps young people gain confidence in those situations, when your fight or flight kicks in. When you don’t know what to do, a lot of people are going to run away.’ The charity has 20 teams across 16 UK cities and big plans to expand as public concern about violent crime rises and recorded knife crimes reach record levels. Knife crime is now the biggest concern among young people, according to a UK-wide ballot of more than one million 11- to 18-year-olds. It’s no longer considered just a law-and-order problem for the police to deal with. ‘This is not just an issue for the Government. This is not just an issue for the police. This is an issue for all of us,’ Cardiff medical student Adanna Anomneze-Collins told thedoctor | September 2019 27

PAUL HERMANN

ANOMNEZECOLLINS: ‘This is an issue for all of us’

‘Gang culture can be quite difficult to deal with. I haven’t been brought up with that kind of culture’

the BMA annual representative meeting in Belfast this year. ‘We all have a role to play. We can all play a part. We need to break the cycle and to be aware of social impacts,’ she added, calling for a public health approach to tackling knife crime. The issue had been raised earlier in the year at the BMA medical students conference, put forward by fellow Cardiff medical student, and StreetDoctors volunteer, Omolara Akinnawonu, who was named best speaker at the conference after her impassioned address. This approach is defined by the Mayor of London’s office as, ‘looking at violence not as isolated incidents [but]… as a preventable consequence of a range of factors such as adverse early-life experiences, or harmful social or community experiences and influences’.

Ribena standing in for blood StreetDoctors fully endorses this public health approach and sees its work as part of it. ‘Stabbings and shootings are not inevitable,’ its volunteer and engagement manager Rebecca Long says. ‘They are preventable and we can play a part in that.’ Dr Long has taken a career break from training to work full-time for the charity, after almost eight years as a volunteer. ‘As much as I respect and love the NHS, I am enjoying the opportunity of working in the third sector. My medical training has put me in a unique position to bridge that gap between healthcare, the third sector and public health. It has really broadened my horizons. The young people we meet have seen things I’ll never see.’ Simon Smith, about to start his final year at Newcastle medical school, is also persuaded about the public health approach, after three years volunteering. 28 thedoctor | September 2019

NASSER: ‘There is no excuse not to call an ambulance’

‘You can compare youth violence to infection,’ he says. ‘Both are contagious, both spread and both can be contained. It is easy in medicine to concentrate only on diagnosis and treatment. What gets overshadowed is the impact of society on people; medicine is just one of the pieces in a larger jigsaw.’ He’s now an impact specialist for the StreetDoctors Newcastle team, collecting and analysing data and feedback from attendees. Last year’s impact study showed volunteers had taught more than 4,000 young people in more than 800 sessions. StreetDoctors’ teaching sessions are informal and interactive. Volunteers arrange sessions and funding with local agencies, such as youth groups, young offender institutes and pupil referral units. Cups of Ribena, standing in for blood, are poured into washing up bowls to prompt conversations about blood loss. Young people learn, ‘for one pint, you get weaker, start breathing really quickly… five pints of blood, you’ll definitely be dead’. Attendees are invited – but not pressured – to share experiences. ‘My friend got literally stabbed through the cheek,’ one says in a taped session. ‘He took off his T-shirt, wrapped it around his face and walked to hospital.’ Opening up like this can, of course, be traumatic in itself. ‘Sometimes they don’t want to talk about it, which we totally understand,’ Dr Pierre says. Then there’s myth-busting. ‘Isaiah thinks it’s safe to stab someone in the bum or the cheek,’ one volunteer says. ‘But there’s a lot of muscle in your bum. There are a lot of important blood vessels, some as thick as your thumb. A little cut in there? You can lose a lot of blood.’

MATTHEW SAYWELL

ASHLEYNORMAN: It is quite common for people in their 20s to know someone who has been stabbed

‘We are not authority figures; we don’t talk down to them’

PRESSURE POINTS: The StreetDoctors Leeds team teaches resuscitation skills

This informality helps volunteers collect and share up to this party. It was more of a scuffle at a party of drunk data on young people’s experiences, giving them voices teenagers. But obviously they were all really upset. The which are often not heard, says Mr Smith. ‘Everyone is whole day was quite moving. It was all quite fresh, the grief, equal in the classroom. We are not authority figures; for those kids,’ she says. we don’t talk down to them. These young people are smart and intelligent.’ Encouraging empathy To extend its reach, the charity has started StepWise – a Working with young people from very different programme to help young people complete an accredited backgrounds can be challenging, too. course in first aid at work and even go on to take part in Manchester medical student Adnan Nasser recalls co-delivering StreetDoctors sessions teaching his first session in Moss Side, alongside volunteers. Leeds medical an inner-city area, still home to gang student Tabitha Ashley-Norman is the violence and gun crimes, despite largely team leader for StreetDoctors Leeds, ‘Empower young people shaking off the name ‘Gunchester’ it one area piloting Stepwise. to act. We see young earned in the ’80s. ‘We go to Wetherby, a young offender people as part of the ‘Gang culture can be quite difficult institute, to take the young people there solution rather than to deal with,’ he says. ‘I didn’t fully through a six-week course,’ she says. ‘It the problem’ understand it. I haven’t been brought up has been quite memorable because you with that kind of culture. But when you’re get that continuity of having a cohort of brought up with it, it’s all you know. kids in prison. They really like any change Young people will ask, why should I help in their routine so are really engaged, more engaged than someone from a different gang? You can say, I understand, some of the other young people we teach.’ then you discuss it, accept their views, and encourage empathy. How will the victim’s mum feel? There really is no Fresh grief excuse not to call an ambulance.’ Most of the volunteers The Doctor spoke to had little The questions and attitudes they face can be testing. direct experience of street violence but all knew people But StreetDoctors say they aren’t there to lecture, lay who had. ‘In Leeds, somebody I knew quite well got blame, or demonise the young people who attend stabbed in a scuffle in a nightclub. I wasn’t there but sessions, and sometimes admit to violence themselves. he was hospitalised. He had a punctured lung,’ says Ms ‘We aim instead to empower young people to act. Ashley-Norman. ‘Sadly, it’s quite a common thing for We see young people as part of the solution rather than people in their 20s.’ the problem,’ Dr Pierre says. ‘Some people seem to forget She recalls an event, which StreetDoctors Leeds took It can happen to anyone.’ part in, at a knife awareness day, held after a teenager died bma.org.uk/charitablegiving from a stabbing. ‘Kids who were not invited had rocked streetdoctors.org thedoctor | September 2019 29

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

Junior doctors can all too easily miss out on their breaks, but their representatives at one trust have negotiated a new system which could be a model for others Junior doctors have a to sustain our concentration contractual right to breaks and efficiency, provide space but frequently they are to refuel and recharge, and unable to take them. This is are essential for our health a priority for the BMA. and wellbeing.’ The BMA produced the Dr Davies says that she Fatigue and Facilities Charter believes the success of the last year and it negotiated scheme could be replicated better rest limits as part of at other trusts provided a wellimprovements to the junior considered set of guidelines doctor contract in England, were agreed alongside good which were agreed in a communication channels referendum in June. and support from senior Local action can also make colleagues. a big difference, as Brighton ‘Juniors felt the rostered foundation year 2 and BMA break times enabled them to DAVIES: ‘Breaks need to be embedded into our working culture’ junior doctor representative take breaks when they may Emma Davies has shown at not have done previously and Brighton and Sussex University Hospitals they enjoyed taking breaks together to enhance NHS Trust. team working,’ she says. Working with senior consultant ‘Breaks need to be embedded into our colleagues and BMA staff, she was able working culture in such a demanding profession. to develop a standard policy across the Acknowledgement of the importance of breaks, department of medicine prioritising rostered whilst taking responsibility at an individual, breaks. The policy set out specific guidance departmental and ward level can help to on how break times could be properly observed. make this happen.’ This included ensuring that breaks started She was assisted in implementing the pilot by and ended at the pre-scheduled times and senior consultant colleagues and BMA industrial making sure that other department staff such as relations officer Cathy Taylor, who outlined the nurses be made aware of doctors’ break times importance of the initiative. and know not to bleep them during this period. ‘Breaks are contractual but in reality can Only medical emergencies and cardiac arrests be hard for doctors in training to take,’ says should prevent a break from being taken. Ms Taylor. ‘A survey of junior doctors highlighted ‘Dr Davies worked really hard, with the rostered breaks as one of the top three things support of the trust, to ensure doctors in which would improve their working lives,’ training could actually take the breaks they says Dr Davies. are entitled to. The success of this pilot ‘However, in many departments there was no was a great example of the real difference system in place for juniors to take their entitled BMA reps can make to improve working lives breaks, so they were taking breaks as and when for doctors.’ they could, dependent on workload. BMA member relations staff urge junior ‘I felt that helping doctors to take their doctors to exception report if breaks are missed entitled breaks was important, not only because – and to raise it with the association or at junior they are contractual but because they are vital doctor forums if it happens regularly.

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what’s on September 27 Planning for retirement – delivered by the BMA, Leeds, 9am to 4pm

October 02 Critical appraisal workshop – part 1, London, 9am to 4pm 04 Clinical pharmacists in general practice masterclass, London 04 Dermatology masterclass, London, 8am to 5pm

05 Care of an older person masterclass, London, 8am to 5pm 11 Planning for retirement – delivered by the BMA, London, 9am to 4pm 14 CESR seminars for SAS doctors, Manchester, 9am to 12.15pm 16 Practical skills... time management and taking control, Manchester, 9am to 5pm

November 08 BMA wellbeing day 2019, London, 9.30am to 4.30pm 15 SAS: Your wellbeing matters, Templepatrick, County Antrim, 9am to 4.30pm 19 Practical skills for improving personal leadership, London, 9am to 5pm

22 Critical appraisal workshop – part 2, London, 9am to 4pm

20 Practical skills... leadership and management for doctors, London, 9am to 5pm

28 Trainee doctor LNC representatives conference 2019, London, 10am to 5pm

29 Planning for retirement – delivered by the BMA, Oxford, 9am to 4pm

04-05 BMJ Live, London 05 Neurology masterclass, London

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

Keep learning at every stage of your career 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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