The Doctor (January, issue 17) by The BMA

The magazine for BMA members

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Issue 17 | January 2020

Our loss Doctors driven out of the UK by callous visa rules which separate families

‘Be resilient’ Are these the most patronising words you hear?

Big data Its uses and abuses

Hollow promises The strain felt by mental health staff and the broken pledges for new recruits

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

Email thedoctor@bma.org.uk

Editor Neil Hallows (020) 7383 6321

Call a BMA adviser

Chief sub-editor Chris Patterson (020) 7383 6978

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 Philippe Desveaux

The Doctor is a supplement of BMJ vol: 368 no: 8229 ISSN 2631-6412

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In this issue 4-5 Briefing

The BMA sets out urgent priorities for the new Government

6-9

A digital dilemma

Harnessing the benefits of mass patient data without putting people at risk

10-13

Welcome Chaand Nagpaul, BMA council chair Happy New Year and welcome to the first issue of The Doctor magazine of 2020. With a new Government elected and the beginning of a decade it is the perfect time to make it clear that, when it comes to the health service, politicians need to do much better. For too long the NHS has been the subject of false political promises, with so much pledged but so little delivered. A piece on the mental health workforce in this issue of The Doctor highlights the gap between rhetoric and reality. BMA research shows promises of more staff and delivery of funding to the front line have demonstrated precious little progress. In fact, as BMA mental health policy lead Andrew Molodynski says: ‘There are longer waiting lists, increasing out-of-area placements, slimmed down services that cannot cope with demand and, most worryingly, a rising suicide rate for the first time in decades.’ Our asks for politicians and from this new Government are quite simple – but they cannot be ignored if the NHS and social care are to survive. We need investment in services and the workforce, a comprehensive Brexit deal that does not threaten the future of the NHS and legislative change to remove the vast inefficiency of the competition of the internal market. It is also a poignant time to ask whether this country’s immigration policy is doing everything it can to retain international doctors. The story of the Warikoo family, featured in this edition, suggests it is not. Families are being broken up, the NHS is losing talented staff and services will suffer as a result. Our investigations into homelessness and health continue – this time looking at the plight of patients and frontline staff in Brighton. Homelessness is a stain on a society and we cannot afford to ignore the lessons doctors in areas such as Brighton provide. Also in this edition of the magazine we look at the potential effect of big data on the NHS and question the use of the term ‘resilience’ – an often-heard buzzword when talking about doctors working in a remarkably pressurised environment.

A service run ragged

Mental health staff face unmanageable workloads, while government promises of new recruits sound ever less likely

14-17

On the front foot

For those passionate about their teams, but apathetic about health, a bond between doctor and club is the answer

18-23

No place like homelessness The GP and his team providing care with inadequate resources to the homeless

24-27

Under and out

Doctors are being driven out of the UK by a change in visa rules

28-29

Don’t talk to me about resilience...

Hollow words about coping are not only patronising but make doctors who face unsustainable pressures feel it is their fault if they are struggling

On the ground

BMA staff help a doctor whose employer said she was overpaid, and ensure toll fees are reimbursed for trainees

What’s on Keep on top of events

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briefing

Dear prime minister: turn pledges into progress

Current issues facing doctors

‘It’s vital the Government starts to make a difference on the front line’

There were no shortages of promises about the NHS made during the election campaign, and now doctors are determined they be turned into action. In a letter to prime minister Boris Johnson (pictured below), BMA council chair Chaand Nagpaul (pictured left) has called for the ‘Government to turn its rhetoric about the NHS delivered on the campaign trail into decisive action that will deliver a health service that’s safe for patients and supportive to staff’. Dr Nagpaul added: ‘We know the NHS is in crisis – hospital bed numbers are at a record low, waiting lists the highest since records began and staff are working in an intolerable climate of stress. ‘It’s vital the Government starts today to make a difference on the front line – especially as we head into the busiest time of the year. The challenges are huge, which is why the BMA calls upon the Government to act immediately to halt the decline in our NHS.’

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Three areas where the BMA is calling for urgent action: 1 Tackle the pensions crisis The idea of a tax bill being higher than an entire year of earnings should be a ridiculous prospect – but this is the reality doctors face thanks to a punitive pension tax system, which the Government has failed to address. It is a situation forcing doctors to remortgage their houses or raid pension funds – and hospitals across the country are being left without vital cover as staﬀ

are forced to cut down hours to avoid huge bills. It is the ‘greatest immediate threat’ to capacity and patient services. On the campaign trail Mr Johnson said he intended to hold a review of the pensions ‘taper problem’ – but plans for immediate reform would have been more useful. Dr Nagpaul says: ‘The review, which the BMA expects to be involved in, must focus on action

by the Treasury to address the cumulative impact of the taper, annual allowance and lifetime allowance. ‘The BMA is absolutely clear that the only solution to the current unjustifiable problem impacting doctors and ultimately patient waiting times, is removal of the taper and annual allowance for defined benefit schemes such as the NHS pension scheme.’

2 Increase health spending ‘Absolutely brutal’ is not a description beﬁtting of any workplace – let alone a hospital where doctors are trying to treat patients with care and compassion. But, last year, the winter pressures didn’t end with the changing of the clocks, and across the country wards felt more like battleﬁelds than institutions of care. One specialty trainee in emergency medicine told The Doctor of bays in his emergency department being split into two – with 56 patients squeezed into a

department designed for 16 and some bays having to be turned into toileting areas or drinks stations. GPs also report seemingly endless demand on services as the whole health system shudders under the weight of rocketing need from the public, with little resource to cope. Mr Johnson claimed to be addressing these issues in pledges made on the election trail – but his promises fall short, oﬀering real-terms increases in total health spending of 3.1 per cent per year

between 2019/20 and 2023/24, which would lead to a shortfall of £6.2bn. It is in the face of this crisis that the BMA has called for annual increases of 4.1 per cent for the NHS, based on the Institute for Fiscal Studies assessment on what the NHS needs. Addressing the prime minister, Dr Nagpaul says: ‘Adequate investment in the NHS and its workforce is vital, and without it we risk patients being let down by the services they and their families depend on.’

3 Mitigate threat posed by Brexit There are 135,000 NHS staﬀ who are nationals of a country outside the UK. The future of the NHS could hardly be more linked to the Brexit debate and the negotiations on the future relationship between the UK and the EU. As such, the BMA has been a leading voice on the threats of Brexit – and, particularly, a no-deal

Keep in touch with the BMA online at

Brexit – to the NHS. For years the association has urged successive governments to guarantee permanent residence for EU doctors and medical researchers in the UK, to continue free movement for healthcare and medical research staﬀ and protect mutual recognition of professional qualiﬁcations. Dr Nagpaul says: ‘Brexit will be at

instagram.com/thebma

the forefront of the Government’s agenda, and the BMA has warned of the damage that leaving the EU could inﬂict on the NHS, its staﬀ and patients, especially if this is without a deal. It is vital the Government takes all possible steps to mitigate the threats Brexit poses to the health service, the profession and the public’s health.’

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‘B

ig data’ might not have many friends beyond the glass palaces of Silicon Valley. As the popular view of tech giants has shifted from a position of awe, to routine convenience, to hostility at their power and tax practices, many think we have given too much of ourselves to people we shouldn’t trust. The NHS collects a huge amount of data, and for it to fall into the wrong hands would lay bare the most intimate details of the entire population. So, it’s not surprising the NHS patient-safety strategy, brought out earlier this year, warns that ‘failure, design flaws or incorrect use’ of IT systems has the potential to cause patient harm. However, reading the strategy, this feels like a caveat. Generally, it sees data as a way of improving, and not threatening, safety. For example, the NHS needs to ‘improve understanding of safety across the whole system by drawing intelligence from multiple sources of patientsafety information’. It’s not only self-evidently true that mass patient data could help the health service but that large parts of it could not function or advance

without it. Discovering the link between smoking and cancer would not have been possible without whatever ‘big data’ was called back then, and nor would virtually any other epidemiological research.

Learning from patients So how can the NHS harness the benefits without patients coming to harm? Imperial College Healthcare NHS Trust in London is attempting to analyse and learn from a vast and previously under-utilised source of data. Each month, Imperial sees thousands of records generated via the NHS’s Friends and Family Test – a feedback platform that allows those who have used the trust’s services to comment on their experiences. Determined to learn from this data, the multidisciplinary team spent more than a year devising an algorithm able to analyse the free-text elements of the Friends and Family Test feedback, giving particular focus to what had been done well and what could have been done better. Consultant urological surgeon Erik Mayer, who has been involved in the project,

said through the algorithm patient data could now be processed in near real time and – thanks to an associated dashboard – be accessed by staff across the trust. Speaking at a conference on patient safety hosted by the Westminster Health Forum last year, Mr Mayer said the algorithm had enabled clinical benefits through its analysis, which would not have been possible to achieve manually. ‘We get 20,000 comments a month at Imperial; no one can get through all those and use them for quality improvement,’ he explained. ‘What we’ve done is trained an algorithm to analyse these comments in near real time for us, so we’re getting through these comments as they’re submitted – be that electronically or manually – then uploaded on to the system to assign a domain and a sentiment, where it’s positive, negative or neutral.’

Driving up standards He said that the system had led to technical efficiencies in the way staff worked, saving time and identifying patient-derived improvement opportunities; from simple things such

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‘Big data’ can give new insights into population health and provide doctors with decision-making tools. It can also, if handled badly, lead to catastrophic breaches of privacy and shatter patient trust. Tim Tonkin assesses some of its successes and shortcomings, and how doctors can best navigate the digital future

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‘We’ve trained an algorithm to analyse these comments in near real time for us’

as taking steps to improve signage in wards to introducing a discharge checklist, saving patients from having to repeat information to different members of staff. He said: ‘This is fully open to the whole organisation, so any ward Sister can look at [the performance] of another ward and try to understand why they are doing well or doing badly compared with their peers.’ Clinical senior lecturer honorary consultant and BMA medical academic staff committee co-chair David Strain says that big data is likely to play a role in the way healthcare is delivered and safety standards improved. Spending half of his time in academic research and the other in clinical practice, Dr Strain has conducted research into healthcare for frail and older patients – a group often bypassed by pharmaceutical and charitable research sectors. During a study into the use of proton pump inhibitors – medications that are generally safe and effective in younger patients – he was able to demonstrate their use in older adults increased the risk of pneumonia and fractures. ‘Frail, older adults are never included in clinical trials,’ he says. ‘There are databases such as Clinical Practice Research Datalink that include anonymised patient data from across the country. From that data you can identify populations that wouldn’t normally be included in clinical trials. Using a prior-event rate-ratio analysis, we can then determine what effects drugs that are commonly

MATTHEW SAYWELL

‘We are going to require either a whole series of new specialists that don’t exist today or AIsupported physicians’

PRIORITIES: David Strain says ensuring privacy and transparency with patients is vital

used in younger populations have on older populations. A lot of medicine is very target driven, particularly chronic disease management [and] those targets were derived from studies done 30 years ago. [Since then] medicine has changed, the population has changed, and the drugs have changed so we now re-evaluate those targets in model patient populations. ‘As medicine becomes more complex and with patients with multiple comorbidities, we are going to require either a whole series of new specialists that don’t exist today or AI [artificial intelligence]-supported physicians.’ Dr Strain says that ensuring patient data is handled with the utmost levels of privacy and security is essential with big-data enterprises. He adds that transparency with patients about how their data is used is critical, as is ensuring the result of data research is for the benefit of patients. The track record of bigdata ventures in healthcare, however, is far from unblemished or without controversy. Six years ago NHS England announced its care. data programme. It was an

ambitious plan that sought to collect patient data from GPs in England. The intention was to link GP data with hospital data sets within a central database. The data would be held in pseudonymised form and the plan was for the database to provide a valuable resource which researchers could apply to access. Despite its stated intentions, however, the project was regarded with suspicion by many doctors, primarily because patients had not been adequately informed about how the data would be used, who might have access to it and how rights of optout could be meaningfully exercised. These concerns were further compounded by confusion surrounding whether data could be shared with third parties for commercial purposes. Three years after its launch and following a review of data security by Dame Fiona Caldicott, care.data was cancelled. Concerns about the protection of patient data were also raised around a big-data partnership between the Royal Free hospital in London and Google-owned technology

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Key principles In July this year, the Department of Health published a framework to help ensure clinical innovations underpinned by data research are beneficial to patients, with five principles at its centre. These include a requirement that any use of

NHS data unobtainable in the public domain must be explicitly for the purpose of improving the health and welfare of patients. Other principles include NHS organisations entering into arrangements involving their data must do so on ‘fair terms’ and be communicated clearly to the public to ensure transparency and, by extension, trust and confidence in the health service. The health service will also need to consider possible unintended consequences of big data in healthcare; namely who will ultimately own NHS patient information that will power healthcare apps, and the potential financial costs posed by an increasing reliance on AI algorithms developed by the private sector. Dr Strain says, irrespective of the potential in big data, AI is not a magic bullet capable of compensating for all the other challenges facing the health service such as under-staffing and a lack of resources. He adds that big data and the AI applications that can be derived from it are not infallible. ‘Big data offers an opportunity to do research much cheaper and for creating decision-support tools, but no algorithm or computer system can replace the actual direct face-to-face contact between doctor and patient. ‘One of the biggest problems with AI development is the information that is put in. ‘The same term can mean different things to different people. A great example would be the term “chronic pain”, to one patient it means severe

pain, to another it means pain that has been going on for a long time. ‘All of these [big data] systems are only as good as the information that’s put in. ‘Apps get it wrong, and when apps do get it wrong, they do so big style. Having the AI supporting the doctor can work perfectly well.’ It’s indisputable that patient data is a valuable commodity, with enormous potential. The challenge in future years is less likely to be one of technology, than in safeguarding whose commodity it is, and whose potential it serves.

Ethics consultant Susan Liautaud addresses a BMA event on AI MATTHEW SAYWELL

company DeepMind. In 2015, the Royal Free and DeepMind formed an agreement that saw the latter process around 1.6 million partial records containing patient-identifiable information, for the purpose of developing and safety testing an app for detecting and diagnosing acute kidney injury. The collaboration eventually led to the development of a mobilebased platform known as Streams, which was launched in early 2017. However, an investigation by the ICO (Information Commissioner’s Office) published in July that year highlighted concerns around the development of the app. The ICO demonstrated how patients had not been adequately informed that their data was being used as part of the clinical testing of the Streams app. It concluded that, in its partnership with DeepMind, the Royal Free had not fully complied with the requirements of the Data Protection Act. Information commissioner Elizabeth Denham stated that, while the use of data had clear potential for clinical improvements and patient care, ‘the price of innovation does not need to be the erosion of fundamental privacy rights’.

The BMA has held a number of events looking at the issue of AI and the role that it is likely to play in the future of healthcare. While welcoming the potential of big data-driven AI, the association has made clear that the profession must be alert to the possible risks and harms of new technologies, and has previously highlighted the considerations that should be made when using patient data in treatment and research. The BMA is calling for digital healthcare to become a core element of medical and clinical training and is seeking to develop an ethical-framework checklist enabling doctors to assess the benefits of new healthcare technologies.

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MISSING OUT: Care is being compromised because of a depleted workforce

A service run ragged B Mental health staff face unmanageable workloads, depleted teams and poor access to training, BMA research finds – with government promises of new recruits sounding ever more hollow. Keith Cooper reports

old pledges to recruit vastly more members of staff, as a means of easing the pressure in mental healthcare, are often deployed with aplomb by politicians. More than 10,000 extra would be recruited this year, said the Conservative manifesto in May 2017. Its opponents back then believed it was based on ‘thin air’, they told the BBC. Two months later, the Government’s official plan, Stepping Forward to 2021, pushed the figure up to 19,000 additional staff.

Leap forward to 2019 for an even more ambitious scheme. The NHS England Mental Health Implementation Plan called for a further 27,000 staff, a mix of psychologists, psychiatrists, nurses, social and peer and other support staff, to make up the ‘multidisciplinary’ approach it envisioned. An influx of new staff into mental health would certainly help the patients who suffer the traumatic, sometimes tragic, consequences of shortfalls and those in the service who struggle to cope with everrising demand. However, such pledges,

‘There are longer waiting lists, increasing out-ofarea placements, slimmed-down services that cannot cope with demand’

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alongside parallel ones to improve services by funding the front line, are yet to make a significant mark, says BMA mental health policy lead and consultant psychiatrist Andrew Molodynski. ‘The opposite has happened,’ he adds. ‘There are longer waiting lists, increasing out-of-area placements, slimmed-down services that cannot cope with demand, and most worryingly, a rising suicide rate for the first time in decades. ‘Why, in the fifth-richest country in the world, do we allow this situation to continue and indeed worsen?’ (see panel on page 13).

‘Not on track’ So just how far have these pledges travelled in driving recruitment? Is ambition enough to improve care and conditions in the NHS? The answer is a clear ‘no’, according to BMA analysis of workforce figures and a survey of more than 1,000 doctors, psychologists and mental-health nurses, carried out with the Royal College of Nursing and the Association of Clinical Psychologists UK. The NHS is ‘not on track’ across multiple measures of workforce, its treatment of staff, and employers’ commitment to their wellbeing – an even more essential element, given the pressures. Measuring Progress: Commitments to Support and Expand the Mental Health Workforce finds that many staff groups have stayed static in numbers or fallen during the past decade. The number of doctors, 9,000, has barely budged, despite the

The Government’s repeated, growing – and unmet – pledges to recruit more mental health staff

May 2017 10,000

July 2017 19,000

rhetoric, pledges and plans. More than 7,000 nurses, health visitors and midwives have left the NHS since 2009. Vacancy rates for psychiatry posts in England have doubled since 2013 to nigh on one in 10. They’re even higher in clinical psychology and nursing. Meanwhile, work pressure on this diminishing and depleted workforce rises, according to figures.

Toll on staff The effect on staff is revealed in the survey findings: –– almost seven out of 10 respondents work in teams with vital members of staff missing most or all of the time –– nearly half (47 per cent) of doctors work shifts in which they are down at least one medical colleague –– four in 10 found workloads ‘unmanageable’ or ‘mostly unmanageable’, according to respondents from all three professions –– half said access to training had worsened or greatly worsened –– while positive improvements were reported by most working with multidisciplinary teams, many lacked access to the

July 2019 27,000

support staff they needed to take part fully. The pressures on staff from all this takes an obvious toll. A consultant psychiatrist, who asked not to be named, says he recently decided to quit his job after the struggle of running an inpatient service for years, caring for people who are acutely unwell. ‘Inpatient services are seen as the most expensive resource and the bottleneck in the service,’ he says. ‘The level of bureaucracy and scrutiny is relentless whenever something doesn’t go well. It inevitably results in another layer of process added on.’ The desire, as a psychiatrist, to provide good patient care is constantly in tension with the need to take complete breaks from work, he adds. ‘It is difficult to get much sense of a break from work, certainly not enough of a consistent one. Nursing staff are probably hit more than doctors but nonetheless it does affect us as well.’

‘The level of bureaucracy and scrutiny is relentless whenever something doesn’t go well’

‘It is difficult to get much sense of a break from work’

Can’t carry on Manchester consultant child and adolescent psychiatrist thedoctor | January 2020 11

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GAMBLE: ‘Chronic workforce shortages have plagued our profession’

DUNKERLEY: ‘Massive’ increase in demand for services

Alison Dunkerley says she’s seen a ‘massive increase’ in demand for her services without any increase in resource. ‘It is sometimes really hard to recruit and retain staff,’ she says. ‘I am lucky enough to be able to retire soon. I never thought I would at 55. I actually enjoy my job in some ways but I’ve realised that I cannot carry on

working the way I am.’ Royal College of Nursing professional lead for mental health Catherine Gamble says the survey shows staff are consistently held back by unfillable vacancies and the ‘e-rostering system’, which made agency work more attractive than full-time posts. ‘The clear majority of nursing staff felt the absence

of one of their own on their last shifts. This hammers home the reality of the chronic workforce shortages that have plagued our profession,’ she adds. ‘Unless there is urgent investment in growing the nursing workforce the pressures will continue to grow to the point where it will no longer be possible to attract nurses to work in the NHS, and parity of esteem for physical and mental health remains a goal yet to be realised.’ Dr Molodynski calls for a ‘real parity’ in mental healthcare, a parity of resources, access, and outcomes – not just ‘esteem’. The BMA has set out a series of recommendations to achieve real parity, including calls for extra ‘standards’ to keep tabs on access to services, a fairer share of resources, and a ‘realistic and measurable’ set of commitments on workforce (see panel opposite).

‘I enjoy my job but I’ve realised I cannot carry on working the way I am’

The state of mental healthcare in England

13.8 £2.3bn

Extra funding planned for mental health by 2024

Proportion of CCG budgets spent on mental health

Less than a third Children with mental ill health able to access care they need

Sources: NHS England and House of Commons Public Accounts Committee

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Why do we allow our mental health services to be like this? Mental health has been high on the political agenda for some years now, with bold promises from Government in recent times: more staff, more services, more funding, no patients being sent around the country for care, reduced waiting lists, fewer suicides. However, what we have seen outlined in this article and numerous academic and mainstream publications is essentially the opposite: longer waiting lists; increasing out-of-area placements; slimmed-down services that cannot cope with demand; and most worryingly a rising suicide rate for the first time in decades. In microcosm, my own team (a general community team for people like you and me with mental health problems) has recently been audited as having 50 per cent too few staff. We knew that already. Will things be put right? Almost certainly not. If we were an oncology or paediatric team would they? Almost certainly yes. Why, in the fifth-richest country in the world, a liberal democracy with a national health service ‘free at the point of use for all’, do we allow this situation to continue and indeed worsen? The reasons are not clear. The public is more supportive of the need to provide treatment for people suffering with mental health problems than ever, health workers are all aware of the need, and other services such as the police are crying out for things to improve. Twenty years ago, there were similar calls for change, and these were answered – by a national service framework for mental health services and the necessary funding to enhance and transform services. It worked. We need something similar now. The era of parity of esteem has seen a worsening of care standards overall. We at the BMA call loudly for real parity – parity of resources, access and outcomes. If the Government will commit to achieving that over the period of the 10-year plan then their promises may come good and there will be fewer lives shattered or ended by the current shameful underinvestment. Fewer people languishing on wait lists for desperately needed therapy, fewer people being shipped around the country in the night for want of a bed, fewer children having their life chances ruined by waiting years (yes years) for treatment they need, fewer people taking the tragic final steps to end their lives because help and hope have gone. Real parity, 25 per cent of NHS funding for mental health care across primary and secondary care, is not a choice – it’s a necessity. Andrew Molodynski is the BMA consultants committee mental health lead

BMA recommendations on parity of resources, access and outcomes – what does it look like?

On funding: Clinical commissioning groups should double expenditure on mental healthcare. More should be spent on mental health wards, research, and in primary care and public health.

On access: Standards for access to services which are fully funded. Reviews of all trusts who place high numbers of patients in beds far from their homes.

On workforce: Realistic and measurable workforce goals. Targeted recruitment campaigns for the hardest-torecruit sub-specialties, such as old-age psychiatry and learning-disability psychiatry.

On prevention: A crossgovernment body established to draw up a joint strategy on public mental health. National and local Government adopt a ‘mental-health in-all policy’; mental health impact assessments for all new policy proposals. thedoctor | January 2020 13

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DAVE NELSON

PRITCHARD: Football clubs have the ability to reach parts of the community that healthcare professionals cannot 16 thedoctor | January 2020

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On the front foot Doctors are harnessing the powerful bond between sports clubs and their supporters to reach people who often have little contact with the NHS. Tim Tonkin reports

ootball stadiums resemble fortresses of unimaginable wealth, with their great, gleaming corporate backs turned against the terraced streets below. The contrast between them and the working-class communities where they were planted a century ago, and often remain, can be stark. Thanks to the efforts of doctors – and some imaginative outreach work – the clubs are providing more than just a weekly diet of triumph or woe to their fans. GP Chris Pritchard works one day a week with Everton in the Community, which aims to focus on three areas affecting the local community: health and wellbeing, disability

and employment. He says the deep and powerful connection between fans and their team means football clubs have an almost unique ability to help the NHS engage with potentially hard-to-reach sections of the patient population. ‘A lot of what Everton in the Community does is try to engage those people who don’t necessarily seek normal healthcare routes,’ he says. ‘Where I am based is known as the L4 area of Liverpool – one of the most socially deprived areas of the city and probably the country. Some of the greatest health inequalities in Liverpool are found here, issues relating to public health and long-term health conditions which aren’t thedoctor | January 2020 15

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PUSHING THE BOUNDARY: Dr Trivedy uses cricket to reach patients from ethnic minorities

BEAT THE BLUES: Every club should have such a scheme, believes Dr Pritchard

being met properly.’ The club recently provided pre-match HbA1c screening tests by NHS nurses to supporters, to coincide with Diabetes Awareness Month. Dr Pritchard says the club’s community outreach work involves a range of projects, such as ‘tackling the blues’, which engages with pupils at 150 local schools on physical activity and wellbeing, and ‘active blues’, which is aimed at men aged 35 to 50 struggling with mental health problems. ‘We go into schools and we use the Everton badge,’ he says.

‘People recognise that, and they feel more comfortable speaking to someone who is wearing an Everton shirt than they would someone in a shirt and tie. ‘I think if every Premier League football club, every cricket and rugby club was to engage with its community, healthcare professionals could tap into hundreds of thousands of potentially new patients who wouldn’t otherwise see healthcare services. ‘Hopefully in the next 10 years every club will aim to have this sort of thing on board.’

DAVE NELSON

Check-up service Brighton emergency medicine consultant Chetan Trivedy, meanwhile, sees cricket as a way of reaching patients from ethnic minorities who may be reluctant to present to health services. Dr Trivedy founded Boundaries for Life, which offers a number of free health check-ups to spectators and staff at cricket grounds in England and Wales. The consortium, which includes healthcare providers and the voluntary sector, helps assess blood pressure,

cholesterol levels and alcohol consumption, as well as checking for oral cancers and early indicators of diabetes. He says: ‘Cricket is the only sport that’s followed by a significant number of those from ethnic minorities: Indian, Pakistani, Bangladeshi, Sri Lankan, and those from the West Indies and South Africa. ‘We ask a lot of the people that come to us whether they’ve been [to get their health checked] before, and they haven’t; they only go to the doctor when they are ill as opposed to for prevention.’ In its nine years, the organisation has helped deliver more than 5,000 free health checks but Dr Trivedy says the potential for sports organisations to improve the health of the wider public is still largely untapped. ‘The Oval [cricket ground in south London] has a capacity of about 20,000 to 25,000. If you’ve got people who are a captive audience, there’s an opportunity to reach out to communities who may not see their GP. ‘On a good day we can see 40 to 50 people, we have people queuing up because the checks are free and the results are instant.’

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The initiatives come as local authorities, traditionally the main source of funding for leisure activities, are under a tremendous squeeze.

Spending cuts Liverpool University senior lecturer in sport business Dan Parnell was part of a team which found a significant reduction in participation rates in sport among women, people aged between 14 and 29 and those from black and minority ethnic backgrounds, between the years 2008 and 2013. Overlapping with this period, the Institute for Fiscal Studies found a cut of more than 40 per cent in spending by English local authorities on leisure services between 2009-10 and 2017-18, and separate figures show the number of council-owned football pitches fell by 710 in the same period. Dr Parnell says there should be much greater investment. ‘We know physical activity works, we know that football works we know it’s value for money. ‘Let’s stop messing around and put some large community-based interventions in place so that we can evaluate and start to

deliver [on improving health].’ The BMA, in a briefing published last October, raised concerns about the effect of funding cuts on local authorities, which have in many cases forced the sale of leisure facilities. BMA public health medicine committee chair Peter English says: ‘While encouraging people to take part in more sport and exercise is an increasingly important component in social prescribing, our analysis shows that the importance of this is not being prioritised in current policy decisions. ‘If the Government is to make any progress in improving the health of the nation and reducing inequalities, much greater investment into sporting and recreation facilities is one of the most central changes that must occur over the years ahead.’ The latest Health Survey for England gives an insight into the challenge. It found that 67 per cent of men and 60 per cent of women were classed as either overweight or obese in 2018, with 28 per cent of children aged two to 15 also falling into these categories.

PARNELL: Physical activity provides value for money

The survey also found that rates of obesity were linked to socio-economic factors, with 20 per cent of adults living in the leastdeprived areas classed as obese compared with 36 per cent of adults living in the most deprived regions. Watching football on the TV – and without wishing to sound judgemental – the crowd and players may be wearing the same shirts but there is an almighty contrast in the bodies underneath them. This might sound obvious but a century ago, it would have actually been hard to tell the difference between 11 randomly selected, almost universally lean football fans, and the players who were stocky but rarely athletic, and would have thought a hamstring a kind of novelty pie. The gap between the waistlines of those who play sports at the highest level and those who cheer them on has become not quite as great as the gap in their respective salaries but is still a matter for concern and alarm. The most ardent fans say they would do anything for their teams. Let’s see if this includes exercise.

TRIVEDY: ‘An opportunity to reach out to communities who may not see their GP’

‘Greater investment into sporting facilities must occur’

‘People feel more comfortable speaking to someone wearing [their club] shirt’

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EMMA BROWN

No place like homelessness An acute housing crisis has left people living in flimsy tents in one of our wealthiest cities. Peter Blackburn meets the GP and his team trying to offer them care, with woefully inadequate resources

utside the window of the cramped single bedroom, autumnal seaside winds howl, steadily picking the peeling paint away from the exterior of a once-grand Georgian town house. There is no grandeur inside. A tiny yellowed fridge buzzes, door hanging open, as if it has been so forever; a single hotplate sits uselessly next to a muffled radio and disorganised tumbles of stained clothes. A man stares at the ceiling – lying fully dressed, unmoving, on a crumpled mattress; his feet wrapped in an uncovered duvet. Sometimes he responds to questions from his visitors, managing a barely audible ‘yes’ or ‘no’. Sometimes he is unable to muster a response. Plans for a future GP appointment and another visit are discussed. The likelihood of any sort of movement is unclear but the visitors will continue to try, regardless. Just months ago, this man had the sort of life most people would call normal. He had a job and a wife. But now, emergency accommodation in Brighton – dark and gloomy corridors with endless brown doors hiding barely habitable rooms – and visits from GPs, nurses and charity workers are his daily existence. In Brighton, just like much of austerity Britain, even those living ‘normal’ lives can be just a hint of misfortune away – the death of a loved one or the loss of a job – from becoming another statistic in the hurtling growth of the thedoctor | January 2020 19

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EMMA BROWN EMMA BROWN

SARGEANT: ‘It’s a case of celebrating your victories’

homeless community. Just hundreds of yards away, on the pebbles of the beach front, a tiny sky-blue tent, guy ropes clinging to a fence, flutters in the wind (pictured right). The tent remained, steadfast, during two visits from The Doctor, nearly two months apart. Behind it, in vibrant, dancing, multi-coloured font, the words exclaim: ‘Visit Brighton.’ Tents, worth as little as £20 or £30, as permanent accommodation for human beings are common here, as in many parts of the country, as the number of people falling into homelessness, and then struggling to find their feet again, grows endlessly – a never-ending incline on the grimmest of graphs.

Desperate shortage

‘The delay in getting help to people and services around them is just huge’

The Doctor was visiting Brighton to witness the struggles of staff, patients and the system, shadowing the work of GP Chris Sargeant and clinical services manager for the local homeless team Caterina Speight. The duo visited as many patients who were treated in hospital and then found accommodation, of one kind or another, as possible. There are around 10 emergency accommodation sites in Brighton – three of which The Doctor visited in the latter part of 2019. The staff were well meaning and pleasant but the properties were shabby and dark and were hardly suitable for the average person, let alone the most vulnerable and unwell patients outside of hospital. ‘It’s not ideal, at all,’ Ms Speight says, ‘but it is better than nothing.’ This is the crux of the issue in most towns and cities in England. Housing is becoming near-impossible in most circumstances. Few houses have been built, therefore all the

levels of supported accommodation, usually graduated through with a view to patients moving into their own places eventually, are clogged up. Simon Gale, operations and hub manager for Justlife, a homeless charity which runs an outreach service in Brighton, says: ‘These old buildings were probably suitable 10 years ago when people were going into emergency accommodation and it was just as an emergency, and they would be moved on to something more appropriate. But over the seven or eight years we’ve worked, the people now end up staying there for months or a couple of years – it’s a real log jam in the system.’

Forging relationships When The Doctor visited Brighton, an 18-year-old woman had been kicked out of her house by her parents. Doctors had been told that the local housing department said she was not more vulnerable than the average homeless person and would have to sleep on the streets that night, for the first time ever: alone and at risk. On the way from one location to the next Dr Sargeant and Ms Speight receive calls about patients on their list and try to tie their care together as much as possible. Considering the amount spent in acute care each day it is quite amazing to see two frontline staff trying to do so much for so many while working from a Nissan Micra; patients have been raped, have

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EMMA BROWN

SPEIGHT: Services are chronically underfunded

‘Homelessness is a public health emergency’

EXPOSED: A rough sleeper’s tent in Brighton

infected wounds, chronic substance misuse and are in sex work. Complex does not even begin to cover it. Between them they forge hard-fought-for relationships – these patients can ‘take a long time to give you their trust’, Ms Speight says – to encourage patients to go to hospital, make GP appointments and engage with other services. In many cases engaging with other services is far easier said than done, however – and is becoming increasingly difficult as austerity continues to bite. ‘They are chronically underfunded – they are just not there to access,’ Ms Speight says, when asked how austerity politics has affected the ability of health professionals to access support services such as substance misuse services, social care and, particularly,

mental health services. ‘We can identify immediate need but the delay in getting help to people and services around them is just huge. It comes down to people like us to try and cope with patients who need this kind of specialist help – it’s work we shouldn’t be doing and it has an impact.’ This sort of strain is clearly problematic for patients – but it is hard for professionals, too. How do staff cope with the complexity, tragedy and emotion involved in such difficult cases? ‘It’s a case of celebrating your victories and not just dwelling on the times when you aren’t able to do anything,’ Dr Sargeant says.

Care blueprint

EMMA BROWN

The homelessness crisis is a situation the BMA declared a public health emergency at its annual representative meeting last year. Last month, BMA emergency medicine lead Simon Walsh said rising homelessness was ‘souldestroying’ and that the needs of homeless people continue to be ignored. On a national level, Dr Walsh is right. But here in Brighton, and in a handful of other cities, there is a blueprint which attempts to fill the gaps and wrap care around homeless patients – it may not be enough but it is something. The Pathway model here comprises the Arch surgery on Morley Street and a team based in the local hospital. The team has urged commissioners to fund a step-down facility, where people who are fit to leave hospital but still need support or time to put plans in place, can go – but money has not been found. Nestled between floors three and four of the Royal Sussex County Hospital, the small Brighton pathway team, comprising Dr Sargeant, in-reach nurse Gregg Lock and thedoctor | January 2020 21

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EMMA BROWN

TEAM PLAYERS: The Brighton pathway team, consisting of (from left) Gregg Lock, Katie Carter, Caterina Speight and Chris Sargeant

‘Cuts to youth provision means I worry we will increase the number of people who end up homeless’

WALSH: Homelessness is ‘soul destroying’

advocacy and discharge coordinator Katie Carter, are on hand every time a patient who is homeless or vulnerably housed is identified. They are ready to meet patients, find out about their history and try to give them any support they need. On the day The Doctor visits, patients are worried the weather is turning more wintry – and the staff are struggling under the pressure of rising demand which leaves more patients needing help but fewer beds in which to treat them. Rushing the process is counter-productive, however. Discharging patients to the streets is short-sighted because they will end up back in hospital with further complications. Many would suggest it to be unethical, too. ‘Most people don’t come into the NHS to put people out on the streets,’ Dr Sargeant says. ‘But if the system is under extreme strain that can have an impact. And there is an understanding that elderly people have to wait on a ward for a nursing bed or care package – but that isn’t the same for homeless patients even though they have

many of the same, or worse, frailties.’ The system in Brighton, originally described as Pathway Plus, is now commissioned by the local clinical commissioning group. Once people leave the hospital they are fortunate enough to be visited by a floating team of non-clinical support workers, as well as being registered with homeless GP practice Arch, or another local GP. This service, commissioned as part of Pathway plus, is run by the Justlife charity. Simon (not his real name) was forced to flee to the Brighton area from a different part of the country after being the victim of an acid attack which left him nearly blind and fearing future violence. Simon was helped with somewhere to live and was supported to overcome his fears – eventually gaining access to financial support and medical appointments. Mr Gale says: ‘We are still able to intervene and help people. We take a committed, long-term approach and don’t limit how long we work with people. But no matter how hard you try there are some cases where you can’t help – some people die prematurely. The frustration is we could double our team and still not really feel we are reaching all the people who need support.’ Looking to the future is a concern too. One life experience that ties so many homeless people together is early childhood trauma – and the potential effect of austerity policies in this area is a serious worry. Mr Gale adds: ‘The cuts to things like children’s centres and that sort of youth provision means I worry we will increase the number of people who end up homeless.’ The effectiveness of teams such as Pathway Plus and the work they do should not be measured by the basic statistics NHS commissioners and managers favour, such as emergency care attendances and financial effects – demand is continually going up and complex cases do not fit into basic metrics. But that said, the project here, now running for seven years in total, is making a difference. Many similar projects would not be able to demonstrate such obvious effects as those illustrated in the box, ‘On the right path’ (right). The rising demand and complexity are too much. The Doctor understands around 10 more hospital trusts are in discussions with

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EMMA BROWN

ROUGH TREATMENT: The only available shelter for some Brighton residents

‘We could double our team and still not really feel we are reaching all the people who need support’

Pathway about introducing teams but many are citing the need for a demonstration of cost savings as a basic requirement.

Funding targets In an NHS where the only thing going down is performance against targets, this seems totally unrealistic. Only 11 hospital trusts have a Pathway team, which could cost as little as £100,000 to £200,000 a year, in place. A senior leader in a homelessness charity says, ‘the financial lens has become dominant in our healthcare system’. He adds: ‘If there really is significant new funding coming after

On the right path In 2018/19, compared with the previous financial year, measuring patients registered at the homeless GP surgery, the Pathway team demonstrated a:

6.1 %

reduction in emergency care attendance

26.1 %

35.4 %

reduction in unplanned admissions

reduction in readmissions within 30 days

the election… if it’s all only to be invested in things that save money or deliver efficiency savings lots of it will miss the needs in the population.’ A different type of evaluation is required. And, according to local experts in Brighton, other changes are needed too: more understanding of the value of step-down facilities investment in housing and longer NHS contracts for teams so they can get on and do work without looking over their shoulders. Dr Sargeant says: ‘We’re not asking for the world, but you would be surprised how hard it is to get what we have got now and to get more. It’s not just getting it, it’s keeping it.’ The only thing as striking as the scale, complexity and tragedy of homelessness in Brighton is the commitment, care and compassion shown to the homeless. So often society forgets these patients but not if these staff can help it. At the fortnightly multi-agency meeting, hosted by the Arch GP surgery, where all the local organisations trying to tackle this desperate issue trace the journeys of their patients and discuss their needs and next steps, that commitment, care and compassion could not be any more obvious. It is driven home most powerfully when the solemn faces around the table begin to realise they have done all they can for one patient who has no recourse to public funds and will not be helped by the existing structures of society in this country. Consoling the charity workers and healthcare staff who have spent weeks trying to give the man a second opportunity, Arch GP Tim Worthley says: ‘Thank you for everything you are doing for him. You are not missing anything, you are not failing. All we can do is try.’ thedoctor | January 2020 23

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Under and out Doctors are being driven out of the UK by a change in visa rules that keeps families apart. Jennifer Trueland speaks to a consultant from a shortage specialty who has recently moved to Australia because of Home Office inflexibility

n the face of it, Nishchint Warikoo is beginning an exciting new chapter of his life. He moved from the UK to Australia on 5 December to take up a post as a consultant child psychiatrist at Sydney Children’s Hospital. Although the job is going well so far, it wasn’t the positive career move it might look on paper. Rather, he felt driven to it by frustration at the Home Office’s refusal to allow his mother to live with him and his family in the UK. ‘It’s a nice place to work,’ he says of his new post. ‘Work

wise, there are nice people and a good group of staff. Pay wise, it’s much better than I was getting in the UK. The weather is great. But it’s not home; not yet.’ Dr Warikoo is one of what is believed to be a growing number of doctors from overseas who chose to make their careers in the UK but have found themselves on the wrong side of immigration policy. Having moved to the UK at a time when there was a reasonable expectation that he would be able to bring his mother to live with him, these best-laid plans were

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ROSE TEANBY

PHILIPPE DESVEAUX

SOOD: Successful applications to bring dependants to the UK have plummeted

NEW LIFE: Dr Warikoo looks out over Sydney Harbour

‘We have many doctors – hundreds of them – whose parents have no one to look after them back home’

scuppered by a rule change in 2012. Since then, it has become nigh on impossible for people to bring older dependants to come to live with them, even if – as in the case of the Warikoo family – they undertake to pay for all health and social care needs that might arise.

Settled status The effect on individuals is immense – but it also means the NHS is losing muchneeded medical staff. ‘This is a major issue,’ says Ramesh Mehta, president of BAPIO (British Association of Physicians of Indian Origin). ‘We have many doctors – hundreds of them – whose parents have no one to look after them back home. It’s a

big issue for these doctors because they’re settled here, working for the NHS, their children are growing up and going to school here, so it’s very difficult for them to leave the country.’ Dr Warikoo, who was born in India, has worked in the NHS for around 15 years, taking UK citizenship in 2014. When he first moved to the UK, his mother Phoola used sixmonth visitor’s visas to spend half the year with him, his wife, and later, their daughter Soham, who is now 13. The idea had been to apply for a dependant’s visa to allow her to stay indefinitely when Phoola was 65 but the rules changed when she was six months short of that age. ‘All our plans went out the window,’ he says. ‘It was a major shock. We started taking legal advice, and it has been a very long and stressful process.’ Under the new rules, people must show a much greater level of dependency before they are granted the right to stay. ‘I’d call it almost draconian,’ he says, adding that the process has also been hampered by incompetence. For example, the Home Office denied at one stage that it

had his mother’s passport, only later conceding that it had gone missing, then found and sent to the Indian High Commission. They have also not been officially told the outcome of their latest appeal, leaving them in legal limbo.

Further afield When it seemed as though it was unlikely the application would ever be successful, Dr Warikoo explored moving to Australia, where he was promised immediate permanent residency for himself, his wife and their daughter, and a visa granting his mother the right to stay there. He went ahead and began that post on 5 December, and has gone on ahead, leaving the rest of the family in the UK for now. In his old job, as well as being a consultant child psychiatrist, he was also associate medical director. Ironically, one of his responsibilities was supporting the trust’s recruitment and retention efforts. ‘I recruited many psychiatrists from abroad, but I couldn’t retain my own post,’ he says, sadly. Given the UK has a dire shortage of child psychiatrists, thedoctor | January 2020 25

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JOHN: ‘If we lose any more doctors this way it will be a loss to the UK’

MEHTA: ‘The psychological impact is really bad’

‘They are distraught at the thought of either abandoning their careers, or having to abandon their parents’

you would think that ministers would be bending over backwards to keep the likes of Dr Warikoo working in the NHS. ‘That’s what you’d think, but I tweeted Boris Johnson and the home secretary and neither of them responded,’ he says. ‘My trust wrote to the health secretary. This has not just been my effort – the trust executives, colleagues, most of my patients and their parents have written to their local MPs. One parent got 500 people to sign a letter to the Home Office. I was amazed and really grateful for the support I got.’

Heart-wrenching decisions Human rights barrister Usha Sood says successful applications to bring adult dependants to the UK have plummeted since the new rules (which she calls arbitrary and discriminatory) were introduced. She represents around 30 families in similar situations per year, and

says while applications can be successful, it requires imaginative use of legal processes, and takes an enormous emotional toll. ‘The clients are extremely, extremely distraught,’ she says. ‘That’s the only phrase that comes to mind. They are distraught at the thought of either abandoning their careers, or having to abandon their parents. ‘They don’t think they should be made to have that choice. They want their parents to be looked after by them in their twilight years – many of them talk of the sacrifice and effort with which their parents have raised them, and have facilitated their careers and their lives. ‘And when it comes to them being able to do their filial duty – and some also believe their religious duty binds them – they are being told “put them in a home” or “get domestic people to help” – to abandon them, basically, then it’s very hard for them.’ She points out that there is no guarantee of quality care for older people in some countries, with residential or domestic services staffed by unqualified people, and not subject to regulation by

a Care Quality Commission equivalent. ‘Many [homes] do not have fire certificates or fire drills – would you put your parent in a place where if there was a Grenfell-like situation they wouldn’t survive? You wouldn’t, would you?’ says Ms Sood. The strain of having a dependent parent in a different country also potentially has an effect on doctors’ work, she adds. ‘The panic that arises in individuals I’ve been talking to, who have been dragged away from operating theatres, from quite critical events that they are tending to, and having to rush off because they know that their parents need them, but also that their patients need them, is immense.’

Haemorrhaging talent She warns the UK is losing highly skilled doctors because of this, a shortsighted policy that shows one part of the Government (the Home Office) is acting counter to the needs of another (such as the Department of Health and Social Care). ‘We are potentially sacrificing enormous talent,’ she says.

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‘We are potentially sacrificing enormous talent’

‘We are deeply concerned that doctors would be forced to relocate their families to look after their parents’

PHILIPPE DESVEAUX

MUG SHOT: Dr Warikoo helped run his NHS trust’s recruitment programme

BMA international committee chair Terry John says. ‘We urge the Government to do everything it can to retain international doctors who play a vital role in helping the NHS meet the country’s health needs, including implementing a more flexible approach to applying the immigration rules,’ he says. ‘We are deeply concerned that doctors settled in the UK, who had trained and worked here and made their lives here, and had contributed so much to the UK, would be forced to relocate their families so they could look after their parents or grandparents. If we lose any more doctors in this way it will be a loss to the UK and its taxpayers, of doctors it desperately needs.’ Dr Mehta says that, unless immigration rules are relaxed, the issue will only become more acute as more doctors become affected; BAPIO is continuing to campaign for it to be effectively addressed. ‘The situation hasn’t really changed – it’s been the same for years and years, but now that these doctors who came to the UK to work in the NHS as young doctors, when their

parents were not too old, are getting older themselves, obviously their parents are getting older too. And when there is nobody else in the family to look after them in their country of origin, when things get really bad, I’ve noticed the psychological impact is really bad. These doctors are under pressure, they feel quite depressed and there is a risk that they can’t concentrate on the quality of patient care as well as they want to because of the intense feeling of guilt.’

Duty-bound This situation is leading to some doctors taking what might be seen as drastic steps. He describes the situation of one medical couple in East Anglia, a paediatrician and a public health doctor. ‘Both parents are quite disabled and ill now and are in Mumbai,’ he says. ‘He has to go every six weeks for at least a week to look after them. Yes, they could have some paid people to look after them, but that’s not good enough. Children want to look after their elderly parents, who need their help, and they feel very guilty if they can’t do

that. It’s not just an economic drain on the doctors – it has a huge psychological impact on them.’ He utterly refutes any idea that bringing older dependants to the UK would be an economic burden on already stretched health and social care systems. ‘It’s a stupid argument because almost all the doctors who want their parents to come in have said they are prepared to write a bond to say that this will not be a drain on the UK Treasury. But despite this, the Home Office is not willing to be helpful.’ It’s been a difficult time for the Warikoo family on a personal level, not least for Dr Warikoo’s mother, who, he says, feels guilty about being a ‘burden’ on her son’s family, and his daughter, who has faced the prospect of being parted from a much-loved grandmother. And it’s not all roses for Dr Warikoo either, despite the excitement of a new job. ‘It’s feeling a bit lonely here. It’s the first time I’ve been to Australia, so it’s all new. I miss my family, and I miss my home.’ bma.org.uk/immigration thedoctor | January 2020 27

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Don’t talk to me about resilience ...

I ‘I don’t believe you should have to walk away from your job’

arrived for my on-call, parked, sat in my car and realised I couldn’t get out. This wasn’t a bad day, bad week, or even a bad month. I simply didn’t want to be a doctor any more. I wanted it all to stop. I had been an emergency medicine consultant for nearly seven years. As with my colleagues, I was willing to work hard, to put in the long hours and to sacrifice time with friends and family. My father, a first-generation Bangladeshi immigrant, had instilled in me the belief that every problem could be overcome if you put in the right amount of time and effort. However, after 20 years as a doctor, I had had enough; enough of the hostile conversations, the unrelenting pressure, the unsafe and chaotic working environment. I got through the day, hanging on by my fingernails.

Hollow words about coping and resilience are not only patronising but make doctors who face unsustainable pressures feel it is their fault if they are struggling, says emergency medicine consultant Shewli Rahman

A few weeks later I resigned my consultant post and walked away from my job.

Overwhelming pressures I came back after three years. I would like to say my working life has become more manageable. It hasn’t but I think I have learned a thing or two. I don’t believe you should have to walk away from your job, or go off sick to cope with it. I don’t believe we should be made to feel ashamed, inadequate or not tough enough when we find our workload overwhelming. Often, I have been told to be more resilient and I’ve said it to others, too. On the face of it, it seems harmless. Resilience is about recovering quickly from difficulties, adapting well in the face of trauma and adversity. Who doesn’t want or need to do that? But there are

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ED MOSS

Finite capacity So now I believe it is wrong to tell staff in the most pressured, conflict-ridden, inhospitable environments they should learn to deal with it. It is patronising. It makes people feel it is their fault if they can’t cope – they just need to be a little bit stronger. We all have our limits. It is normal to feel overwhelmed by the work, the barrage of questions and the never-ending decisions – when our means to cope with the world around us is steadily eaten away by tiredness, hunger, rudeness and stress. Our ability to care for others is vast. However, it is also finite. There are days when you just cannot give any more. It is not a weakness. We need to be kinder to ourselves. And that is not a weakness either. If you tell people they need to be resilient, you’re making it their job, and their job alone. However, it is a whole team which needs to be resilient. Healthcare is a team game; resilience is a team game.

Civility and compassion

RAHMAN: ‘I have been told to be more resilient and I’ve said it to others, too’

‘We are already the epitome of resilience’

real problems in just bandying the word around. The thing is, we are already the epitome of resilience. Every single day we share the joy and triumphs of those we come into contact with, we share their grief and loss, and sometimes, despite our best efforts, our patients die in front of us. Then we turn up the next day and do it all over again. We, in healthcare, do an incredible job and we don’t even recognise it. We should not let those who have not walked in our shoes say the solution to intolerable pressure comes from within us because this shifts the responsibility from those who could do something about the environment, to those who have to exist within it. This is simply wrong.

Our teams grow better and stronger when we treat each other with respect. The Civility Saves Lives movement shows rudeness substantially reduces the cognitive capacity not just of those on the receiving end but of onlookers, too. Staff exposed to or just witnessing rudeness are more likely to make errors and much less likely to be helpful to the next person in need. What a devastating effect on an already stressed team. Rudeness destroys innovation and creativity. The exact opposite of incivility is compassionate leadership. Remembering to say thank you, to ask people how they are and to care about their answers. King’s Fund senior fellow Michael West’s research has shown compassionate leadership equals reductions in mortality as well as improvements in staff morale. This winter is going to be tough. NHS staff are already hardened. What have I learnt about resilience? Treating staff with civility and respect is part of the answer. Hectoring them to be even tougher and implicitly blaming them for a service facing unsustainable pressures is no part of the solution at all. Contact the BMA’s Wellbeing support services on 0330 123 1245 or visit bma.org.uk/yourwellbeing thedoctor | January 2020 29

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

An employer insists, wrongly, that a doctor has been overpaid, and toll fees are reimbursed for trainees – recent issues BMA staff have helped resolve Employer loses touch with GP’s worth How well does your employer know what you do? Not just appreciate what you do, but actually knows what happens, day in, day out? It’s not just a matter of empathy – there is a practical reason, too. A GP was working for her local NHS organisation. One day she received notification that she had been overpaid more than £20,000, and some of her salary was going to be withheld until the overpayment was recovered. In fact, there was no overpayment. The problem was caused by the employer being out of touch with the GP’s duties, and making a mistake with her working hours. So, it sprang a double whammy on the GP, giving her the unwelcome (and unjustified) news that she owed a large sum of money but also that her salary would be reduced until it was ‘repaid’. The GP called in the BMA, whose employment adviser quickly got up to speed with the documentation, identified where the errors had occurred, and drafted an email in the doctor’s name, which explained why there was no overpayment. The employer agreed and repaid several thousand pounds in salary it had already held back. The BMA adviser was ready to escalate the matter but fortunately it was not required. She comments that in such cases it could easily lead to a resignation or acrimonious legal challenge. The NHS hardly needs more of either. This is why it’s important for NHS payroll departments to be at least open to the possibility that they make mistakes, as there are similar cases that have rumbled on for months or years. The GP thanked the employment adviser for her ‘prompt and clear advice on this matter, which was invaluable in helping me challenge the decisions that had been made’.

Commuting takes its toll It might be the ‘ferry cross the Mersey’ which hauls in the tourists to Liverpool but for those who work in the area, it tends to be the bridges or tunnels which are more useful. And for trainees travelling from home to base as part of their training, the tolls add up – generally about £1.80 per trip in either of the two tunnels or two bridges. Given that employers tend to pay excess mileage costs associated with work, it was strange not to be reimbursed for the tolls. It is not like there is an alternative. After consistent pressure during a period of years from BMA member relations staff and the lead employer local negotiating committee, which represents thousands of trainees, Health Education England North West has agreed to reimburse the tolls, dated back to last November. The reimbursement applies to the Runcorn and Mersey Gateway bridges, the tunnels at Birkenhead and Wallasey, and also the Warburton Bridge near Warrington and Cartford Bridge near Preston. It covers all applicable trainees, no matter where they live, if they have to pay a toll as part of workrelated travel. Toll fees associated with home-to-base expenses, unlike mileage expenses, are not part of a national agreement and so the deal reached in the north-west might have a positive effect on negotiations in other parts of the country, too.

30 thedoctor | January 2020

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S RRY…

thebma writing competition 2020

‘Sorry’ has been called the most over-used word in the English language. It can seem like a verbal tic. We say it for the smallest reason, or for no reason at all.

#writeBMA

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Terms and conditions online

For this year’s writing competition, we’d like you to reflect on this word. When do you most remember saying it, hearing it or needing it? It might have been when you made or witnessed a mistake. Or when you had a disagreement with a patient or colleague. It might be something that happened last week or many years ago. This is inherently sensitive, and you might find it necessary to

change some identifiable details. As with our previous competitions, what matters most is that the piece is vivid and engaging. Our webpage bma.org.uk/writingcompetition has last year’s winner and runnersup to give you some inspiration. We need 700 words, and the deadline is 25 January 2020. Email your entry to thedoctor@bma.org.uk with ‘Writing competition’ in the subject line.

January

March

24 Planning for retirement – delivered by the BMA, York, 9am to 4pm

03 Practical skills... time management and taking control, London, 9am to 5pm

23 CESR seminar for SAS grade doctors, London, 1.30pm to 4.45pm

30 PCN masterclass, Leeds, 9am to 4pm

04 UK consultants conference 2020, London, 9am to 5pm

25 Armed forces conference 2020, London, 9.30am to 4.45pm

February 1-2 BMA junior members forum 2020, London, 9am to 7pm 07 Planning for retirement – delivered by the BMA, Edinburgh, 9am to 4pm 08 Primary care networks... what’s next? Birmingham, 10am to 5pm 19 London and Southern Regional SAS Assembly, London, 3.30pm to 6.30pm

06 Planning for retirement – delivered by the BMA, Cardiff, 9am to 4pm

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

10 Practical skills... for effective communication, Cardiff, 8.45am to 4.15pm

27 Medico-legal conference 2020, London, 9.15am to 4.45pm

17 Joint regional council (Eastern, London, South East Coast and South Central) on climate change, London, 6.30pm to 8.30pm 20 Retired members conference, London, 9.30am to 4.45pm

26 Public Health Medicine Conference 2020, London, 9.30am to 6pm

Visit bma.org.uk/events for full details Download the BMA events app at bma.org.uk/eventsapp thedoctor | January 2020 31

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GET INFORMED HAVE YOUR SAY Physician-assisted dying 2020 BMA member survey Are you a BMA member? If so, we want to hear from you on the issue of physician-assisted dying. We are asking our members for their views on what the BMA’s position on physician-assisted dying should be. We will be contacting all BMA members in February 2020 with information about how to take part. To make sure you don’t miss out, please check that your contact details are up to date (including your preferred email address) and that you have ‘opted in’ to receive membership updates from the BMA. You can find out how to do this at the address below.

The survey results will not determine policy – but they will be published ahead of this year’s annual representative meeting and provided to those attending to help them make an informed decision about the BMA’s policy position. Before you participate, get informed by accessing our briefing materials online at bma.org.uk/PAD This is your chance to tell us what you think and play a role in shaping our policy on this crucial issue.

Get informed. Have your say. bma.org.uk/PAD

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