The Doctor – issue 40, February 2022 by The BMA

The magazine for BMA members

thedoctor

Issue 40

February 2022

Sexism in surgery Why equality seems out of reach

A right to protection Doctors push for better PPE

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Detox deficit The shameful lack of alcohol treatment services

Artificial intelligence The continuing need for the human touch

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In this issue 3 In the news Errors found in CEA payments

4-5 The human touch As the experience of radiologists shows, technology must never be at the expense of professional judgement

6-9 Sexism and surgery New research into sexual assault has a profound effect

10-11 A right to protection Those setting the pace on defending their doctors against COVID

12-15 The lifeline A successful detox unit highlights the glaring lack of such services across the country

16-17 Step up for the planet Globally recognised public health expert Mala Rao

18-19 Bone structure The retired GP who swapped his patients for dinosaurs, with huge success

20-23 Life experience Calls for the return of white coats, a doctor with long COVID unfairly pressured back to work and plans for this year’s annual representative meeting

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Welcome Chaand Nagpaul, BMA council chair The 2012 Health and Social Care Act had a destructive effect on many areas of the health and care system. Working on the front line in the NHS we see it every day, with patients passed from pillar to post owing to fragmented service delivery organised by a vast and wasteful bureaucracy. The decimation of public health and its workforce, which were moved to local authorities, and then left victim to cruel cuts, has seen the reversal of decades of progress, and life expectancy stall for the first time in more than 100 years. A feature in this issue of The Doctor perfectly illustrates the horrendous effects of the 2012 act, looking at the parlous state of alcohol and addiction services in this country. Those services were also ravaged by austerity politics and centrally imposed cuts in budgets, which the BMA campaigned vigorously against. The results are a demoralised and dwindling workforce and a tragic vacuum in support for some of the most vulnerable people in our society. In Nottingham, doctors and other health professionals are working hard to bring services back together but they are doing so in spite of the system, not because of it, and the demand they are coping with. The successes they are having further demonstrate how important it is the Government restores the public health grant to at least 2015/16 levels to address this absolute crisis in care. Also in this issue of the magazine we discuss sexism in surgery, after a paper by surgeons Becky Fisher and Simon Fleming detailed instances of sexual harassment and rape in the specialty. The paper has had a profound effect leading to many doctors, mostly women, sharing their experiences. This is a hard-hitting piece on an issue of fundamental importance. As Miss Fisher says, hopefully this focus will at the very least ‘make people feel less alone’. In this February edition we consider radiology’s uneasy relationship with technology, with the help of consultant radiologist and former chair of the Informatics Committee of the Royal College of Radiologists Neelam Dugar. Elsewhere, we speak to professor Mala Rao, a globally recognised champion of public health, about the lessons of the COVID-19 pandemic, health inequalities and why doctors in the NHS should play a leading role in averting climate disaster. Read the latest news and features online at bma.org.uk/thedoctor Keep in touch with the BMA online at twitter.com/TheBMA

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IN THE NEWS

BMA spots error in excellence awards Thousands of consultants are in line for extra pay after the BMA discovered a significant error in CEA (clinical excellence award) payments in England. The BMA consultants negotiations team have uncovered a significant shortfall in the amount spent on local CEAs in England. This is estimated to be as much as £30m nationally. Experience locally has confirmed this. BMA industrial relations officer Andrew Jordan has established that in five trusts in the West Midlands an underspend of more than £1.7m has been made on LCEAs (local clinical excellence awards). Consultants in four of these five trusts have been promised an average of around £2,700 in back pay each. BMA IROs are examining how many trusts in other parts of England have made the same error. It is ‘inevitable’ that others are affected, and members will be contacted once investigations are completed.

Cumulative funds Following pressure from the BMA consultants committee, NHS Employers has also released clarification about how CEAs are calculated. The error arose primarily because the trusts failed to apply the correct investment to LCEAs, which form part of consultants’ terms and conditions. Investment in LCEAs is calculated in each English trust by multiplying the headcount number of eligible consultants by the year’s LCEA award, and then multiplied by a ratio. Following renegotiation of LCEAs in 2018, these tended to be applied correctly in the first year 2018/19. But some trusts failed to take account of the crucial fact that funding was cumulative; SHARMA: Errors investment from previous years needed to widespread be reinvested, in addition to the new sum identified by the formula in subsequent years. BMA consultants committee chair Vishal Sharma said: ‘The discovery of the error is a highly significant development, which has arisen through the diligence, experience and professionalism of the BMA consultants committee and our member relations staff. ‘While it is regrettably rather common that trusts make errors with the individual pay of doctors, it is unusual to discover errors such as this which are widespread and happening across the whole country. ‘Our priority now is to establish trust by trust who is affected, and to ensure that consultants are given their due reward for the work they do.’ bma.org.uk/thedoctor

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COUNCIL ELECTIONS

Voting for the newlook BMA council – the principal executive committee of the BMA – starts next month. Ballot papers and instructions on how to vote will be posted to members on 16 March and voting will close on 19 April. Results will be announced at the end of April. Following a review some key changes have been made for this round of elections, which include a singlegrid ballot paper, which will make the process of voting for members simpler as well as changes to the make up of voting members on council to ensure fairer gender and ethnic minority representation. BMA council sets the strategic direction of the organisation in line with policy decided by the representative body. It is responsible for formulation and implementation of policy throughout the year between annual representative meetings.

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NEIL HODGE

DUGAR: ‘I find it very hard when I see how long people are waiting’

Radiologists face unprecedented demands. Technology offers some solutions, but doctors warn that it must never be at the expense of professional judgement. Seren Boyd reports

The human touch N

eelam Dugar champions technology, embraces its advances, is excited by its potential. Alongside colleagues, she oversaw the digitisation of her own radiology department in Doncaster and until September, she chaired the informatics committee of the RCR (Royal College of Radiologists). The interplay between tech and technician, between artificial and human intelligence, is central to her specialty. But in recent years, that relationship has become uneasy. An acute national shortage of radiologists coupled with ever-rising demand for diagnostic imaging has meant increased reliance on technological solutions, not least to tackle mounting backlogs. Some fear this move could further undermine a specialty already in crisis. 04

Dr Dugar, a consultant radiologist, is no Luddite. But she warns technology’s potential to revolutionise imaging is being overstated. Humans with specialist medical training will always be needed – and their role needs to be better understood. ‘I love technology and I’m always pushing at its boundaries to improve patient care – but you still need a human arbitrator,’ she says.

System pressures The shift to virtual consulting owing to COVID has piled on the pressure for already hardpressed radiologists. At times during the pandemic, the number of patients waiting for MRI scans in Dr Dugar’s trust rose to 2,000 to 3,000, excluding those who had been given an appointment. That range is 10 times higher than prepandemic levels. The waiting

list for ultrasounds is even longer: 7,000 to 8,000 patients, at the time of writing. The latest NHS England statistics for imaging waiting times, published in January, showed 20.7 per cent of patients were waiting six weeks or more from referral. ‘I find it very hard when I see how long people are waiting because I know, among them, there’ll be unsuspected cancer cases,’ says Dr Dugar. But the demands on radiology departments have been rising for years, with an increasing number of NICE (National Institute for Health and Care Excellence) guidelines recommending imaging for its diagnostic strengths. ‘When I joined as a consultant in Doncaster almost 20 years ago, on a Sunday we perhaps would do one emergency CT on the head of a patient who they thought

‘I love technology... but you still need a human arbitrator’

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might have a bleed,’ says Dr Dugar. ‘Today, over a Sunday, one of our quietest days, we would regularly do over 100 CTs. The volume of work has increased phenomenally compared to any other specialty.’ Her department now regularly does 1,000 examinations a day. Simultaneously, radiology is facing a staffing crisis of several years’ standing. The RCR warned last April that the ‘NHS radiologist workforce is now short-staffed by 33% and needs at least another 1,939 consultants to meet safe staffing levels and pre-coronavirus levels of demand for scans’. Mounting workloads have elicited some extra government funding in recent months, but for Dr Dugar’s trust, this has led to outsourcing. CT and MRI mobile vans have been drafted in, to help clear the backlog. These services are staffed by radiographers, the technical specialists who acquire the images for the scans – but the scans still need to be analysed and medically interpreted by radiologists. Radiology has been something of a technology pioneer, albeit sometimes of necessity – and the UK has led the charge internationally, Dr Dugar believes. The advent of teleradiology means that, for more than a decade now, night-time emergency imaging at Doncaster has been outsourced to Australia. Nationally, the RCR says that 14 per cent of the reporting of all medical scans in the NHS happens overseas. Outsourcing is here to stay, says Dr Dugar. ‘It’s work we won’t get back.’ bma.org.uk/thedoctor

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Artificial intelligence, in the sense of both ‘computer audition’ and ‘computer vision’, are already firmly embedded in Dr Dugar’s department. Voicerecognition dictation software has revolutionised reportwriting, for example. AI is also being used in brain imaging for stroke recognition: Dr Dugar admits that her AI machine sometimes outclasses her in recognising fine details such as lung nodules. ‘Computer vision does not tire,’ she adds. And AI will quickly improve, she believes, so that it may soon be entrusted with simple tasks such as identifying fractures, without the need for human verification. But predictions about technology’s potential are overblown, she says. Some believe they have exacerbated the workforce crisis, putting off potential recruits: Dr Dugar tends to blame Health Education England for not investing in enough training places.

The Bigger picture Technology’s limitations lie in the fact that it cannot ‘see’ the bigger picture that a radiologist’s experience and access to patient health records afford. Dr Dugar helped develop integration between existing healthcare IT systems in her trust, so patients’ information and images are accessible seamlessly. ‘As radiologists, we interpret the images in the light of all the other information that we have, information I can access with one click: whether that’s a blood test, a histopathology report, or notes that tell me the patient

has been feeling dizzy. I can also ring up the clinician and ask for more information, for clarification,’ she says. ‘In reporting on a chest X-ray, I’ll compare it with the previous one. If I see a shadow that existed five years ago, it’s probably benign. If I see a shadow that wasn’t there five years ago, it could be malignant. Teleradiologists often don’t have access to as much information as a local radiologist and AI may not either.’ Misunderstanding about the role of radiologists – even among medical colleagues – and the need for radiologists to vet scan requests to manage workloads can strain relationships with other departments. Human interaction, albeit sometimes mediated by technology such as Teams or Zoom, is important for strong teamwork – which in turn is vital to effective diagnosis and treatment, says Dr Dugar. ‘Our multidisciplinary oncology team meetings, for example, have been gamechangers for radiologists. They’ve brought the radiologists out of their offices and on to the front line of helping manage patients’ care, and mutual respect and a partnership approach have developed. ‘I don’t say no to the doctors requesting scans. What I tend to say is: “What is your question? How is the best way we answer it?” We might sometimes suggest a different test. ‘But the end goal is the same for everyone: we want to get a diagnosis for the patient and start the appropriate treatment.’

‘The volume of work has increased phenomenally’

‘The NHS radiologist workforce is now short-staffed by 33%’

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SIMON GRANT

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SEXISM AND SURGERY A recent paper in a medical journal about sexual assault generated a huge response which suggested the issue is a long way from being overcome. Jennifer Trueland reports

hen Becky Fisher and Simon Fleming co-authored a paper on sexual assault in surgery, they knew it would have an effect – but didn’t expect it to gain quite so much attention. Published in the Royal College of Surgeons of England’s Bulletin, Sexual Assault in Surgery: A Painful Truth detailed the specialty’s problem with sexual harassment, including rape. The response was immediate – doctors, most of them women, shared information about their own experiences. One described how she was left with PTSD after her educational supervisor repeatedly propositioned her – including grabbing her hand and putting it on him and asking her to come home with him as his family were away. She was a specialty trainee 3 at the time – and he repeatedly reminded her that he had the power to end her career. Another wrote a letter also published in the RCSE’s Bulletin detailing the continuum of sexism, including sexual harassment, she had experienced, predominantly during surgical training. This included alleged assault by a member of the theatre team, who would repeatedly seek physical contact with her, including rubbing his erection against her thigh. Her attempts to complain about the problem were unsuccessful – and at no point did anyone suggest she contact the police.

Gender imbalance Despite many initiatives over the decades, gender balance in surgical specialties is still a

long way off. The RCSE’s Women in Surgery network points out that the ratio of male to female consultant surgeons is approximately eight to one. While some specialties, such as paediatric surgery, have a higher proportion of female consultants, others – particularly trauma and orthopaedics and neurosurgery – are lower still. It was partly to try to change the culture that Laura Hamilton founded Women in Orthopaedics. A consultant orthopaedic surgeon in Sussex, she says that barriers remain for women who wish to take that path. ‘No one really encouraged me to be a surgeon, but I wouldn’t let anyone talk me out of it. The more that people were shocked or responded dramatically, the more that made me want to do it.’ As a woman, people made assumptions about her, she says, including that she would want to follow a career considered to be more geared to having a family. ‘I found that very annoying because people talked to me about kids all the time and I wasn’t really bothered about having kids when I was 20. Then there were other barriers. I was asked if I could handle the stress, could I make decisions, lots of comments like that – like women can’t make hard decisions. I’ve had lots of comments like that over the years.’ As it happens, Miss Hamilton does combine her 12-PA consultant job with being a mother of two, but being a consultant hasn’t stopped the sexist assumptions. Being called ‘Laura’

‘I was asked if I could handle the stress, could I make decisions... like women can’t make hard decisions’

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HAMILTON: Expected to follow a familyorientated career

FLEMING: Surgery has a problem with sexism

‘Some said they had spoken out before and it had done more harm than good’

‘On social media, we are seeing a movement of support and calling out of sexism’

at work when her male counterparts are called ‘Mr’, being asked (by a patient who was also a senior doctor) what she wanted to do when she finished training when she had literally introduced herself as the consultant orthopaedic surgeon, having colleagues on a trauma team decline to believe she was an orthopaedic surgeon – all of these have been a part of her life and career. ‘Doing a ward round, if I had a male registrar or senior house officer with me, the staff, patients and other medics would always talk to them, not to me – there’s very much the presumption that men are in charge in surgery, more so than in medicine.’ It starts with micro-aggressions, she says, which women in surgery face on a day-to-day basis, but, if unchecked, these can escalate into misogyny and even sexual assault. ‘There’s definitely a risk that if you accept the little cuts, the culture of misogyny will escalate, so I tend to put my foot down for seemingly trivial things.’ The other battle, she says, is that the ‘nice guys’ don’t recognise the extent of the problem. ‘So, every time we tell them a story, they are shocked and appalled, but they say it must be a one-off. They don’t see it every day like we do, so they think we’re being over-dramatic. It’s important to get men to be allies as women can’t get rid of misogyny without the help of men.’ This works two ways – Mr Fleming, a

co-author of the Bulletin paper, has received flak for speaking out on this topic because, as a man, some people have said it isn’t his place. Having been asked to write the paper because of his experience in tackling bullying and inequalities, he had contacted at least 20 women in surgery who had previously shared with him their experiences of sexual harassment, discrimination, assault and rape to ask them to co-author. Even when promised anonymity, they declined. ‘The common themes were fear of repercussions, of consequences to themselves personally and their careers,’ he says. ‘Some didn’t want to relive these experiences, and some said they had spoken out before and it had done more harm than good.’

A small community It’s long been an ‘open secret’ that surgery has a problem with sexism, ranging from ‘bad jokes’ to sexual assault and even rape, he says. That helps to explain the reaction to the paper and the subsequent revelations from other women in surgery who were prompted to share their experiences. ‘Everyone is dismayed, sorry and angry, but nobody is shocked,’ he says. Mr Fleming, a trauma and orthopaedic surgery registrar in London, says he is well aware of his privilege as a straight, white male. But he believes that makes it even more incumbent on him to amplify the voices of those who have less privilege.

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ED MOSS

PATEL: ‘Most of us – as women – have experienced it or witnessed it’

That includes calling out bad behaviour in surgery, mostly – but not exclusively – male to female, and usually with a power differential, affecting medical students and women earlier in their careers. Surgery is a relatively small community, he adds, so women can be afraid that it will harm their careers if they say no or speak out. ‘People say that consultants can’t affect your career,’ he says. ‘But that’s absolute tosh. Consultants talk to each other and you need sign-offs, and everyone knows that The Bulletin paper and aftermath prompted some to call this surgery’s ‘Me Too’ moment, in reference to the revelations about film mogul Harvey Weinstein. The story was covered in The Times and the RCSE, other surgical bodies and Health Education England issued condemnatory statements. Even the health secretary Sajid Javid tweeted that he had raised the issue with NHS leaders. But will it make any lasting difference? Miss Fisher, who is an SHO in general surgery in Gloucestershire, hopes so. ‘I don’t know where we go next – I want to say that we will keep on talking about it and that eventually it just permeates through.’ She hopes the publicity around the paper will embolden people in more toxic surgical departments to speak up against sexism – from so-called ‘banter’ to more serious incidents. ‘By making a big noise about it, then in the more difficult departments where these problematic behaviours are happening, it bma.org.uk/thedoctor

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makes a forum for saying: “Oh, didn’t you see that thing – we’re not supposed to do that any more”. And also, I hope it will make people feel less alone.’

FISHER: Hopes to embolden people to speak out against sexism

Action needed The BMA’s own research into sexism in medicine confirms there is a problem – and it’s something that representative body chair Latifa Patel is determined to tackle. ‘From a personal point of view, this is shocking and appalling but it’s not a surprise,’ she says. ‘I think most of us – as women – have experienced it or witnessed it, and some men may have benefited from it. It’s really saddening that we’re in 2022 and this is still happening.’ She would love this to be a ‘me too’ moment, and movement, but feels there’s a long way to go. ‘Certainly, on social media, we are seeing a movement of support and calling out of sexism, certainly from our allies who are men. But we also know from our survey results and from what our members have said that it’s still very difficult to speak out.’ The BMA sexism survey was followed by a roundtable event, and there are plans to continue this work, she adds. ‘The survey means we’ve got this really rich data which we can present to our stakeholders and our members and say this is a problem, we all need to sort it out, and here is the data. I don’t think any one can deny these results.’

‘We know from what our members have said that it’s very difficult to speak out’

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Doctors have successfully pushed for better PPE, and have demonstrated how it made them safer. They say the same protection should be available for all who need it. Tim Tonkin reports

A right to protection I

n the almost two years since the first UK-wide COVID lockdown, the growth in scientific understanding of the transmission, prevention and treatment of the SARS-CoV-2 virus has been vast. These advances in understanding have informed and refined strategies around preventing infection, with the use of PPE (personal protective equipment) a central part of combatting the spread of the pandemic. Yet there has been growing frustration among many doctors that the national guidelines being followed by many NHS trusts concerning the use of respirators in COVID infection control are still not robust enough, and not fulfilling the duties imposed by health and safety law. Until the start of this year the guidance published by the UKHSA (UK Health Security Agency) or its antecedent, continued to deem the use of fluid-resistant surgical masks appropriate when treating patients with suspected or

FERRIS: Conducted study in effects of FFP3 use

proven COVID infection. Last December, the BMA wrote to the chief executives of all NHS trusts highlighting their responsibility to ensure the safety and wellbeing of employees when at work, as per the Health and Safety at Work Act 1974. That same month saw the NHS publish new criteria for completing a local risk assessment in acute inpatient areas of hospitals, although no such guidance has been produced for doctors in primary care settings. The many months leading up to this change had seen staff at more than 30 UK trusts lobby their management to enable the use of FFP3 (filtering face piece 3) respirators when dealing with patients with confirmed or suspected cases of COVID. The trusts have been described as ‘pace setters’ and one of them is CUH (Cambridge University Hospitals) which, just before Christmas, ensured the fittesting and use of FFP3 or equivalent respirators for all

healthcare staff across COVID red wards.

Reducing infection CUH consultant geriatrician Matthew Butler was one of those who called on management at this trust to move to using respirators for COVID-19 patients, while occupational health consultant Mark Ferris subsequently helped conduct a study into the effect of their use. Both are now eager for this example to be replicated across the UK. Dr Ferris was one of the authors of a study at his trust on the effect of extending use of FFP3 respirators to red wards during the second wave of the pandemic, which subsequently found that doing so indicated significant protection from infection among staff on red wards. ‘We changed to FFP3 during the alpha variant peak but before we started vaccinating hospital staff. Analysing staff case rates subsequently

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BUTLER: ‘Ask to use a respirator if you are likely to be working with infected patients’

BLACK: Enabled members of his practice to switch to FFP3 masks

AGIUS: More work needs to be done

showed that while cases were increasing on green wards, as community prevalence increased, they were going down or staying the same on red wards,’ explains Dr Ferris. ‘Cases of COVID-19 in staff working on red wards was higher before the change [to FFP3] but similar afterwards.’ A month on from this change, Dr Butler was one of more than 1,700 clinicians whose signature was included on an open letter by the Fresh Air NHS campaign group calling for healthcare workers to have their PPE upgraded to protect against airborne transmission of COVID. Dr Butler strongly believes that doctors should not simply wait for permission to begin using respirators, but instead have the confidence to implement change directly. ‘I would just ask to use a respirator if you are working, or likely to be working, with infected patients. If they say bma.org.uk/thedoctor

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no, ask for it in writing that they’ve said no. I suspected that if you did that, they wouldn’t refuse you,’ he says. ‘It’s difficult to do that as an individual, but like we’ve seen with the number of trusts that have flipped, the momentum is building.’ BMA Northern Ireland council chair and GP Tom Black says his practice always maintained a supply of respirators right from the earliest days of the pandemic. ‘I give due credit to our local trust here who fit tested all the GPs, and nobody said no when we asked for a small amount of FFP3,’ he says. ‘We didn’t have very many, but we used them for what we felt were high-risk COVID patients.’ With the emergence of Omicron in November last year and despite the absence of official guidance instructing GPs to do so, Dr Black took the decision to ensure that all members of his practice switched to using FFP3s when seeing all patients.

Further to go BMA occupational medicine committee co-chair Raymond Agius says that, while progress has been made on shifting the guidance around use of respirators for hospital doctors, more action is needed if GPs are to be better supported. ‘Following the increasing numbers of trusts such as CUH using FFP3 respirators to protect all their staff dealing with potentially infected COVID patients it was welcome to see a significant change consistent with this approach in UKHSA guidance on 17 January. ‘However, [the] guidance still has shortcomings especially in respect of general practice. It is essential that the guidance be extended to take GPs and their staff into account and that they be provided with fit-testing facilities as well as respirators. There are signs that [the Department of Health and Social Care] is moving in the right direction and hopefully soon “pace setting general practices” will be followed by others in implementing better protection for their staff.’

‘I would just ask to use a respirator if you are working, or likely to be working, with infected patients’

‘It is essential GPs be provided with fittesting facilities as well as respirators’

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ED MOSS

Alcohol-related harm is increasing, but the provision of specialist services have been ravaged by years of austerity. Peter Blackburn visits one of the country’s few inpatient detox units, with doctors asking why such services are not available to all

THE LIFELINE

SAFE SPACE: Patient Jason McEvoy

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ED MOSS

‘Y

ou look much better already. You do.’ Philip Slater and Dominic Marshall are sitting in one of the group therapy rooms at The Level, an inpatient detox unit in Radford, Nottingham. Mr Marshall, who only arrived three days prior, is finding his feet at the centre where staff will look to help him with his addiction issues and related health problems. He describes arriving at the centre as a late ‘Christmas present’. Mr Slater, also a service user at The Level, is on hand with the reassuring words. Next to them is 35-year-old Jamie Stokes from Leicester, HELP AT HAND: who has had a 20-year addiction to alcohol and whose Dr Bicknell with health is ‘deteriorating rapidly’ with developing pancreatitis a patient and liver cirrhosis chief among his concerns. It is, he says, ‘time to change’. The centre was initially a 14-bed unit but owing to new Gary Bull, also from Leicester, has also been in the group Government money, resulting from Dame Carol Black’s session. He is nearing the end of his residential stay at the independent review into drugs, a further six-bed space unit, which takes patients for up to 21 days. The services wrapped around people such as Mr Bull include access to an above the existing unit has been opened. That funding – which appears to have breathed some optimism into the addiction psychiatrist, GP support, group therapy sessions, gym exercise, Alcoholics Anonymous sessions, acupuncture specialty – also allowed for the employment of a specialist GP, Marcus Bicknell. and the support and guidance of peers and staff with lived ‘It’s a fantastic experience,’ Dr Bicknell, who has worked experience. It is a process which has given the 52-year-old another change. He says he is, understandably, nervous but in the city for decades and also represented GPs and patients on CCG (clinical commissioning group) and council optimistic about returning to the outside world. committees, says. Mr Bull, who has been drinking for 40 years, found his ‘These are the most complex patients that you really ever problems spiralling owing to business difficulties and personal encounter in terms of the combination injury and realised things had gone too of mental health and physical health far when his 13-year-old son told teachers problems. his dad was drunk in the mornings. Mr ‘It’s a protective ‘There’s a different kind of impact in Bull says his mood had suffered and was bubble, we being with someone for two or three affecting those around him, that he had put them in a weeks – something so tailored and so ‘lost interest’ and was ‘resentful’. personalised and it is really quite special ‘I don’t know what I was expecting but safe, secure and moving.’ I came here prepared for the worst,’ he environment’ The Level is run by local housing says. ‘But everyone was so welcoming.’ charity Framework and works in partnership with Nottinghamshire ‘Most complex’ patients Healthcare NHS Trust and a number of other charities and The group of service users has just finished a group therapy local organisations. It was set up in 2018 after the NHS’s session. Lunch, gym time and reflections on the day lie substance misuse service, The Woodlands, at the Highbury ahead. It is a world away from the general adult mental Hospital in the north of the city, closed down to make health units or psychiatric hospitals – or the much less financial savings. supported community rehab schemes – that many of ‘The politics of this are very important,’ Dr Bicknell says, these service users have experienced before. describing the ‘massive harm’ of the 2012 Health and Social Things are very different here at The Level, which sits Care Act which took addiction services away from the NHS among the relics of what was once the industrial heartbeat and placed them in local authorities, vulnerable to budget of this city, near the former factories that made millions cuts. He says drug and alcohol services were decimated, of Raleigh bikes. At The Level, medical, psychological and causing harm to the most vulnerable patients. social care all come together with everything from sleep pattern support to therapy available. ‘It’s a protective bubble, we put them in a safe, Austerity’s impact secure environment where we can work with them,’ During The Doctor’s investigations into alcohol and the unit’s manager Adam Sutcliffe, a trained mental addiction services two doctors from different local authority health nurse, says. areas said their councils had removed around £1m from thedoctor | February 2022

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ED MOSS

RHINDS: ‘Highest amount of drug and alcohol-related harm we have ever seen’

ON THE MEND: Patient Gary Bull nears leaving the centre

funding in their areas. And one doctor said that in their area experience ward rounds at The Level, which is still able to when the contract was taken away from the NHS and put offer training due to a close partnership with the local out to tender, the local authority said it could only spend NHS trust. £110 per bed day – less than half of, or in some places even a On top of all of this, the country’s emergency third of the cost at most in patient units. It is a sorry scenario departments – already stretched beyond measure – also echoed across the country. bear the brunt of a lack of service provision and care in Andy Ball is a consultant addiction psychiatrist in Leicester the community. and refers patients to The Level as the local inpatient unit ‘Unfortunately, people who are very severely affected by closed when responsibility for services passed from the NHS alcohol and substance misuse can become very frequent to local authorities and money ran out. He says he is ‘very users of the emergency care service – some on a daily happy’ with The Level but wishes Leicester had its own local basis,’ London emergency medicine consultant Simon inpatient unit and describes service provision across the Walsh says. ‘That is very resource-consuming in managing country as ‘incredibly sparse’. those presentations but it’s also really The knock-on effects of austerity disheartening and demoralising seeing politics are serious for patients and the same people every day in their ‘People who are very professionals. Patients are ‘passed from various states of decline and often severely affected by pillar to post’ with services increasingly eventually resulting in their death.’ alcohol and substance inaccessible and barriers some staff misuse can become Alcohol-fuelled harm describe as ‘lacking compassion’ like not allowing smokers or veering away from Consultant psychiatrist David Rhinds, very frequent users difficult or complex patients. who looks after patients at The Level, of the emergency There are now only a handful – a says: ‘We were on this trajectory anyway care service’ count of five in 2020 – of inpatient units due to austerity, but lockdown and the in the country and the health service’s pandemic have not helped. We’re seeing addiction psychiatrist workforce has the highest amount of drug and alcohol been decimated. Many consultants being lost to other related harm and deaths we have ever seen.’ organisations and training posts no longer existing in many He says he is ‘deeply worried’ about the issues being regions in the country with no NHS services for junior stored up by huge increases in harmful drinking at home doctors to rotate through. with domestic violence, safeguarding issues, family mental health and early childhood trauma likely to be growing This has affected other parts of the health service. sharply behind closed doors. Numerous staff have told The Doctor there are now These concerns go far beyond anecdotal evidence psychiatrists who lack training in this area and have to call in one part of the country. The most recent NHS data GPs to ask for advice on treatment or prescribing, and for alcohol-related hospital admissions covers the preexpertise in the community is decreased too. pandemic period of 2018/19 and reveals a record high of Dr Ball says that, for example, in Leicester there is just 1.26 million admissions. one doctor training in the specialty – a specialty registrar. Yet it is clear the problem has worsened significantly And that doctor is only able to train because Dr Ball, who is employed by a third sector provider locally, is an established since then. In September 2020 – just six months into the pandemic – the Royal College of Psychiatrists found that trainer and the registrar can travel to Nottingham to 14

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ED MOSS

LEADING THE WAY: Therapeutic and structured activities co-ordinator Ryan Langley

Centre manager Adam Sutcliffe

ED MOSS

services had seen their budgets cut by up to 90 per cent in areas that experience high levels of harm, with less than 20 per cent of dependent drinkers accessing alcohol treatment and the number in treatment falling despite a significant increase in need. The report called for minimum standards in the provision of alcohol treatment services in England – as well as the restoration of funding. Senior NHS consultant psychiatrist and BMA board of science committee member JS Bamrah describes the reinstallation of comprehensive and universal NHS run or supported services in this area as ‘absolutely necessary’ for patients and the workforce. He says: ‘Public health doesn’t get the funding and the resources it needs. If clinicians were running services Funding slashed ‘Patients go from they would not run it this way. It’s all a In the face of so much need, the current pillar to post… reflection of the 2012 act… the result state of care across the country is They do not have was an obsession with tendering and indefensible. the fragmentation and breaking up of Here, in Nottingham, doctors and one place where all services.’ other professionals have come together their needs are met’ He adds: ‘Patients go from pillar to with a successful local charity to fill the post… They do not have one place where vast vacuum – and they are doing so with all their needs are met. When patients such success and in such a crippled care landscape that patients are referred from half of the country, come through our doors we don’t give them the best care we can – we can’t give them optimal care when it is so from miles north or south. fragmented. I think that if we don’t tackle this we are making But surely it cannot be the case that the provision of it a problem for our younger generations.’ crucial services is so reliant on personal relationships, third Back in the group therapy room at The Level, the sector organisations and the individual drive of particular comforting smell of a chilli con carne hanging in the air, staff? When it comes to addiction services, universal there are grimaces when the service users are asked about healthcare appears to be a myth. their experiences with health and care, prior to this apparent As Mr Sutcliffe says: ‘Too much rides on the individuals golden ticket of a place among the 20 beds of the unit. rather than the overall structure of provision.’ One of the group describes their experience in a The BMA is calling for the public health grant allocated psychiatric hospital. He says it was ‘impossible to sleep’, that annually to local authorities in England to be restored to there was no ‘after care’ and adds: ‘I was straight back out 2015/16 levels in order to begin to address this care crisis. to being alone.’ For this service user, and for so many other It is estimated that this would require £1.4bn additional desperately needy people across the country this is the reality funding by 2024/25, to give a total public health grant of – a society which creates the conditions for their struggles £4.7bn by 2024/25. and lacks the compassion to offer care in response. A 2018 BMA briefing found that alcohol treatment nearly 8.5 million adults were drinking at ‘high risk’ levels, up from 4.8 million in February of the same year. And the number of people addicted to opiates and seeking help had reached their highest number since 2015. ‘It’s remarkable really,’ Dr Bicknell says. ‘In the old days we would see someone with acute confusion as a result of alcohol-related problems probably about three or four times a year – we are now encountering acute confusion on a fortnightly basis due to the level of drinking, the lack of available treatment during COVID and the collapse of the whole care system really. ‘We are seeing a severity of pathology that is unprecedented.’

bma.org.uk/thedoctor

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thedoctor | February 2022

14/02/2022 11:47

EMMA BROWN

Professor Mala Rao is a globally recognised champion of public health and advocate of race equality, women’s health and sanitation. She speaks to Peter Blackburn about the lessons of the COVID-19 pandemic and why doctors should play a leading role in averting climate disaster

RAO: ‘Health services are substantial contributors to carbon emissions’

Step up for the planet

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‘H

and the NHS to play. istory will remember 2020 as the year ‘It is through action that we are most likely to ensure when the greatest public health disaster in this doesn’t overwhelm,’ Professor Rao says. ‘Health a century struck – and this pandemic laid services are substantial contributors to carbon emissions bare the health inequalities in our society through a and there is a huge amount the NHS can do to reduce disproportionate impact on the health of deprived and its footprint. I have been excited recently to see groups ethnic minority communities. of doctors demonstrating what can be done within the ‘But, the truth is that we are in a moment of NHS and the impacts this is already having on bringing history when even this event may be regarded as transient compared with the likely health inequalities down its carbon footprint and, perhaps most importantly, we are going to be facing if we do not rapidly avert the enthusing more people to join that campaign.’ climate catastrophe.’ Professor Rao adds: ‘We can put this at the heart of Professor Mala Rao’s grim warning demands attention everything we do. From the medicines we prescribe, and it is the relationship between health inequalities equipment we use, the supply chains we utilise, and the and climate change – and the role doctors and the buildings we occupy. Everything can be questioned and NHS can play in averting that – about which she speaks energy efficiency and cutting down carbon emissions is to The Doctor. possible in all the spheres in which we work.’ In a recent essay for a Fabian Society collection around health inequalities Professor Rao, who is a Influential role Some of Professor Rao’s arguments might seem like senior clinical fellow in the department of primary care issues for managers, system leaders and clinical directors and public health at Imperial College London, argues to address, but the pandemic response has shown the that the overshadowing of the ‘devastating’ effects of role all doctors can play. the pandemic by those of climate change means ‘now ‘When the pandemic began, the leadership of doctors is the time to act to ensure global warming does not became evident – they brought a systematic, scientific, exacerbate health inequalities’. evidence-based and pragmatic, experienced response. Her arguments that climate change will deepen I think this, in many ways, was a dress and exacerbate existing health rehearsal for climate change and inequalities are numerous, doctors and other healthcare workers convincing and in many cases ‘Now is the time to act can have the same role to play.’ indisputable: increased heat-related to ensure global warming The areas to tackle, according mortality is likely to affect those does not exacerbate to Professor Rao, are numerous. in densely-built urban areas with health inequalities’ They span from video technology limited access to green space most; showing travel to international warming increases the risk of foodconferences can be questioned to borne diseases which affect isolated doctors making their own choices about consumerism older people with low incomes; air pollution is highest and consumption – for example, in terms of their diet, car in crowded cities; and the brutal effects of flooding and use, air travel, financial investments and home energy other climate disasters are most severe for households bills – and using that education and experience to be lacking the resilience to mitigate them. role models for patients. Some of the areas may be even more significant, like managing carbon footprints and ‘Heat or eat’ wellbeing as part of the strategy for international medical In her essay, Professor Rao also illustrates the health recruitment in workforce planning when ‘in the future benefits of action on climate change. From the reduced climate catastrophe may impact on their abilities to air pollution which comes with decarbonising the maintain links with their countries of origin’. transport sector, to active forms of travel reducing the The vastness of the topic is remarkable and may risk of conditions like obesity and diabetes. And from reducing winter deaths and the ‘heat or eat’ choice faced leave many wanting to bury their heads in the sand but by low-income households by improving the energy Professor Rao is adamant this should not happen. efficiency of UK housing to reducing the incidence of ‘We only have a few years to work these things cardiovascular disease and cancer through reduction of through,’ she says. ‘Incrementalism won’t work any red meat consumption and, thus, the carbon footprint of more. We need to be looking at all aspects of our policies food choices. and procedures. We need to assess everything through If we accept these arguments – and that doctors a climate-impact lens. After all, what could be more are ultimately advocates for patients and a healthier important than addressing the worst health inequality society – there could be a significant role for doctors we face – gambling away the futures of our children?’

bma.org.uk/thedoctor

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thedoctor | February 2022

14/02/2022 11:23

CHARLOTTE MILLOY

Jeremy Lockwood swapped his patients for dinosaurs, when he retired from medicine to become a highly successful student palaeontologist. He tells Seren Boyd about his passion for the subject – and what it has in common with medicine

Bone structure F ‘I wanted to open a new chapter in my life, while I was still young enough’

CHARLOTTE MILLOY

FOSSIL FIND: Dr Lockwood with a cervical vertebra

or most doctors, retirement spells the end of 16-hour days and sleepless nights. But Jeremy Lockwood has never been busier than since he left general practice and reinvented himself. Today, he can be found scouring beaches on the Isle of Wight for fossils, sorting through boxes of bones at the Natural History Museum, or writing highly technical pieces about iguanodons. Because Dr Lockwood is a now a student palaeontologist, and a good one at that. Last year alone, he helped identify three new dinosaur species, rewriting dinosaur history on the island. It’s this passion and his PhD that keep him awake till the small hours now. ‘I don’t play golf and I don’t like gardening much,’ says Dr Lockwood, ‘and if I’m left to my research, I just keep going. It can get a bit obsessive’.

A childhood passion Dr Lockwood traces his interest in palaeontology back to childhood, when he spent days hunting for fossilised marine organisms such as trilobites and brachiopods in a local stream. Study and medicine supplanted that hobby for years: Dr Lockwood was a GP at a practice in Burton-on-Trent for 28 years. But the sight of dinosaur footprint casts on a beach in West Wight rekindled his excitement and the island became a regular destination for Lockwood family holidays. In 2015, at the age of 57, he decided to call it a day. ‘I loved my job but what made the decision for me was the Care Quality Commission coming in, another tier of scrutiny and stress. I wanted

LOCKWOOD: Collecting on the Isle of Wight beaches

to open a new chapter in my life, while I was still young enough.’ By the start of the pandemic, he and his wife Patricia had already moved down to the Isle of Wight and he had started his PhD at Portsmouth University, studying iguanodons on the island. He volunteered his services to the NHS, re-registering with the GMC – but was considered to have been out of medicine for too long.

Hunters and hell herons He was on the beach near Brighstone when a fellow fossil-hunter found a dinosaur snout, complete with teeth. ‘As we scouted around the beach, we both found other bits of bone, presumably the same animal. Then, the next week, he found a second snout. Normally these finds are incredibly rare, maybe one in 100 years.’ Dr Lockwood was part of the team that found, named and identified those two spinosaurid, fish-eating dinosaurs last year: Ceratosuchops inferodios which rejoices in the name ‘horned crocodile-faced hell heron’, and Riparovenator milnerae or ‘Milner’s riverbank hunter’. His other discovery came in a far less promising setting: basement storage units at the island’s Dinosaur Isle museum in Sandown and the Natural History Museum in London. ‘It was lockdown and I couldn’t travel so I thought I could document and measure all these bone fragments. It is rather tedious but I am quite meticulous and it helped me learn the anatomy in detail, so I could start to recognise variations.’ It was when he pieced together an iguanodon

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Spinosaurid skull model by Andrew Cocks

skull from fragments that he reconstructed a bulbous nose unlike any seen before. He concluded this nose belonged to a new animal; his supervisors, Professor Dave Martill from Portsmouth University and Dr Susannah Maidment from the Natural History Museum, agreed. A peer review of his paper conﬁrmed he had found a new species of iguanodontian and it was formally named Brighstoneus simmondsi in November, after Keith Simmonds who unearthed the skeleton in Brighstone in 1978.

New species, new insights The discovery debunked the prevailing wisdom that there had been only two iguanodon-like dinosaur species on the island in the Early Cretaceous period (125 million years ago): Iguanodon bernissartensis and Mantellisaurus atherfieldensis. It suggested in fact that there may be far more iguanodontian dinosaur species in the UK as a whole during the Early Cretaceous period than previously thought. His discoveries also raise the status of the Isle of Wight as an exceptional place for dinosaur discovery. In the Early Cretaceous period, the Isle of Wight was a floodplain where major flood events offered the unusual conditions necessary for animals to be buried immediately after their death. These days, coastal erosion eats into island cliffs at the rate of about two metres a year, revealing the fossils. Dr Lockwood is now coordinating a bid to redevelop Dinosaur Isle into a major museum and research centre, after the local council invited tenders. A charitable group he chairs and a German company are collaborating on a bid. bma.org.uk/thedoctor

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‘We’re every bit as much a World Heritage Site as the Jurassic Coast and, with these new discoveries, it’s now dawning on people that there’s something really exciting here.’ He predicts more excitement this year. At low tide, he ventures out in search of more pieces of his current puzzle: a sauropod. He has already found a three-foot-long limb bone and is hoping the cliﬀs will yield more treasures soon.

A medical eye Dr Lockwood recognises that his medical training – and his attention to detail – make him well suited to palaeontology. ‘Both medicine and palaeontology are about problem-solving. In medicine, you’ve got to elicit the history, get the facts, do other tests, and then try and work out what’s going on. Palaeontology on the Isle of Wight is like solving a jigsaw puzzle with bits missing and bits mixed together from diﬀerent puzzles.’ His experience in ﬁelds such as histology and pathology mean he has started giving tutorials to other students in Portsmouth’s palaeontology department. ‘I’ve found quite nasty fractures in some bones, and possibly tumours,’ says Dr Lockwood. ‘We’re currently studying a dinosaur that might have had osteomyelitis.’ Some of the encouragement he has treasured most has come from former colleagues and medics: several say they have enjoyed his window on ‘life after medicine’. ‘The museum’s always looking for volunteers,’ he says.

‘We’re studying a dinosaur that might have had osteomyelitis’

thedoctor | February 2022

14/02/2022 11:24

Pictures of doctors in white coats look antiquated or incongruous, given that they are no longer used in British hospitals. But was their ban justiﬁed?

GETTY

Bring back the white coat? In a previous issue, retired consultant Radhamanohar Macherla made a case for the return of the white coat. They were thrown out on the basis of ﬂimsy evidence, he said. Judging from your responses, a lot of doctors agree with him. Here is a selection

The article was correct. The white coat was abandoned to reduce the inﬂuence of doctors in the NHS, not to stop infections. There was never any evidence to show white coats caused the spread of infections in hospitals, but a cynical decision was made in Whitehall to strip doctors of their uniform. After 35 years working in the NHS, I have come to realise politicians consider doctors part of the problem, not part of the solution to challenges in the health service. The banning of white coats is just one visible example of this. Patients like to be able to identify doctors in hospitals. This is facilitated by a clearly identiﬁable uniform, the white coat. Nurses continue to wear their uniforms without causing an infection risk so why should doctors not return to wearing their white coats?

There is little if no evidence white coats pose an infection risk. Indeed, were the hospital laundry (remember them?) to launder them, one could at least be assured the outermost layer of a doctor’s attire was clean. Of course, there is no certainty as to how often ‘civilian’ clothes are cleaned – if ever! I have long since thought a strong motivation to be rid of the white coat was to undermine and deprofessionalise medicine. Gloucester consultant trauma and orthopaedic surgeon Matthew Henderson

Cambridge consultant surgeon Richard Hardwick

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I wholeheartedly agree with reintroducing white coats (I never agreed with the decision to scrap them in the first place, as it was a purely emotional decision not supported by any evidence at all). I would just add one element that is not clear from Dr Macherla’s article. There is absolutely no reason why white coats cannot be freshly laundered every day in the same way as ‘scrubs’ in which case there would be very little difference between them. The main difference of bare arms is of no consequence, unless clinicians scrub their arms between each patient contact, but any material difference of this practice has not been studied.

I was a psychiatrist in the Royal Navy and was a ‘brass-hat’. We wore full uniform when on duty in the naval hospital. I felt this would be intimidating to my patients and I was seen as dangerously progressive as I wore a white coat. I retired in 1976 and took up an appointment in the NHS as a community psychiatrist. I wore a white coat. We were in full enthusiasm for multidisciplinary working and I was told I was hiding behind a white coat. I did not take it oﬀ but then management ceased to supply white coats so I had to appear uncovered. I did notice that if things went wrong I seemed to be responsible. At the same time there was a move to close down doctors’ dining rooms for being elitist. It’s now water under the bridge as one might say but interesting psycho-dynamics that perhaps we should explore. We could have been seen to be arrogant. I do not know from personal experience what it is like now. Retired consultant psychiatrist David Marjot

Retired consultant cardiologist Michael James

This was such a good read. I totally agree with Dr Macherla that the white coat needs a comeback. Most doctors now are reliant on a phone for means of communication in the hospital and this guarantees somewhere to put your phone. More importantly the concept of the white coat being the sole vector for transmission of infection is clearly not the case as we continue with many infections in hospitals. The re-introduction could still ensure we are bare below the elbow by having half-sleeved coats. During the pandemic many doctors resorted to wearing scrubs irrespective of specialty (including GPs, dermatologists, paediatricians etc) so the concept of washing uniforms regularly, which may have hindered the clean white coat in the past, is dated. Please start a campaign to bring back the white coat. We could even follow the US system of a short coat for medical students and a long one for qualiﬁed doctors. At least we would know who is who. Birmingham consultant in emergency medicine Sa Narang

As a doctor who trained in Europe, this is the most memorable culture shock of my professional career. In European medical schools, soon-to-be doctors look forward to donning their white coats when attending clinical duties. It is a rite of passage. A sign that all that hard work has paid off. Following graduation at the start of your first ever post as a fully fledged doctor, you are given a pair of white uniforms, consisting of a white, smart button-up, short-sleeved top and white trousers. These get laundered on-site and never leave the hospital. There is no uniform-related transmission of pathogens to home environment while retaining the all-important bare-below-the-elbow mantra, as well as maintaining a professional look. Furthermore, the patients instantly know what the roles are when they come in contact with hospital staff. But here, in the UK, orthopaedic consultants look like bankers, geriatric consultants adopt the jumper look, general surgeons walk around in scrubs and some junior doctors seem to think a wrinkled shirt and worn-out shoes are the peak of fashion. Doctors then wear those same clothes to the pub, on trains and the Tube, and ultimately their homes, potentially spreading disease. We all know nobody has time to don a flimsy plastic apron for every patient on a marathon medical ward round. Personally, I have opted for a hospital scrub top and ‘work trousers’ – one of three pairs used exclusively for work, and nothing else, that stay at work for the week. Although I sometimes get disapproving looks, I feel this is a sensible balance of appearing professional while also protecting my family at home. I am in full support of bringing back a modern doctor’s uniform. Bristol radiology registrar Simon Rupret

bma.org.uk/thedoctor

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thedoctor | February 2022

14/02/2022 11:24

Your BMA The BMA annual representative meeting is evolving to include more members than ever before For more than 100 years, your BMA annual representative meeting has had the same core format. BMA members from across the UK meet in one town or city, and spend several intense days discussing and debating the issues facing the profession. Votes are cast and policy is made on behalf of every member. Members from different backgrounds and specialties, at different stages in their careers and representing each corner of the UK, meet in one place. This offers attendees new insights and opportunities to network and collaborate. Attendance, however, has always come with some sacrifice. Be it our clinical jobs, annual leave, time with our families and friends or our caring responsibilities. Travelling and staying away from home as well as engaging in debate for the best part of a week is a considerable sacrifice. And from talking to our members, we also know that for some medical students and doctors it was simply impossible to countenance such a commitment. These are the voices that our association couldn’t benefit from. And as we all know, our BMA’s greatest asset is the collective voice of our membership. This has always meant that your ARM could never be fully representative of the medical students and doctors it serves. And over the years we had many debates about colleagues with caring responsibilities and those working less than full-time in the full knowledge that many of these colleagues weren’t enabled to give their voices in person at the event. The pandemic, as in so many other areas of medicine, has brought opportunities as well as challenges. Your last two ARMs have taken place virtually. This has removed at a stroke many physical barriers to participation, but it’s also fair to say many of our members have missed the experience of meeting and discussing policy with hundreds of other medical students and doctors, with their divergent views and experiences. With the above in mind, i am incredibly excited to tell you that, for the first time in more than a century, your BMA is changing the way we make policy, to be more 22

@drlatifapatel accessible, to be more inclusive, and to listen more. This year, we hope to have come up with the ‘Goldilocks’ solution – an ARM that combines the convenience of online with the immediacy of faceto-face contact. A representative meeting that is truly representative and gives all our members the opportunity to engage. Our meeting will be held in Brighton, and virtually, from 27 to 29 June. We hope that a hybrid ARM will make the event more accessible and inclusive to all members than ever before. Whilst your ARM has been webcast live for quite some years, we now offer the opportunity for those at home to participate in debate! Those familiar with our meeting will also notice that we have shortened it. Historically, it spanned from registration on a Sunday to three full-day meetings spread across four days, concluding on a Thursday afternoon. We know this time commitment was a barrier to many. Your ARM is now more compact and requires less time from its attendees, again, with a view to enabling more of you to join us. There has never been a better or more important time to engage in the work of your BMA. We will be making policy to support and protect doctors dealing with COVID and its aftermath, so that they can continue to care for their patients. The agenda is in the hands of you – our members. You submit motions. You tell us, what’s important to you. This is just one way in which we are trying to make the BMA more accessible and inclusive to its members. The BMA is not a building in London, Edinburgh, Cardiff or Belfast, but the sum total of its members’ energies, experience and interests. The more we as an association can harness our members’ immense talents and commitment, the better. As always, do get in touch if you would like to know more and I welcome any feedback you may have on how we can better serve you. My door is always open. Email me at RBChair@bma.org.uk Dr Latifa Patel is interim chair of the BMA representative body

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on the ground thedoctor

Highlighting practical help given to BMA members in diﬃculty

A doctor who was absent due to long COVID faced increasing pressure to return to work despite debilitating symptoms Long COVID can have a terrible effect on a doctor’s health. At the very least, those who suffer from it should expect the support of the health service for which they have toiled during the pandemic. A GP trainee was debilitated by the condition. Having treated a patient while immunosuppressed, long COVID affected his heart, caused significant respiratory symptoms, ‘brain fog’, and led to him using a wheelchair for a time because multiple joints were inflamed. Absent from work for 18 months, the employer and Health Education England managed his absence informally, with regular contact, and with support from his associate dean. But it seemed a change in lead employer caused the onset of a much less sympathetic approach. The doctor was informed that his absence was to be reviewed at a formal stage of the absence management policy. This meant the matter could escalate, via – horrible phrase – ‘absence management triggers’, up until the point of dismissal. This put him under considerable additional stress during what was already a very difficult time. He had struggled with his physical recovery for months, and recovery from long COVID is rarely linear. The prospect of having to either return to work or face dismissal only served to heap on psychological pressure. Many would find this approach callous, and pointless too, given the doctor was in no position to return to work at that time. But it was also against NHS Employers guidance, which could hardly be clearer on the subject: ‘Any sickness absence related to COVID-19 for [Agenda for Change] and medical staff should not be counted for the purposes of any sickness absence triggers or sickness management policies.’ With guidance such as that, resolving the case should have been straightforward, but the BMA senior employment adviser supporting the doctor still needed

to be persistent and persuasive. The adviser raised concerns during the first formal meeting, stage one of the process, with the employer. The employer said that it planned to use the absence management triggers and if the member had not returned to work within eight weeks, another meeting would be convened under stage two of the policy. The adviser told them that not only was it contrary to national guidance, but out of step with the approach being taken by neighbouring trusts. The adviser then contacted the BMA industrial relations officer who covers the trust, and established that another adviser had also raised concerns, that the policy most definitely had not been agreed with staff, and that the issue had been raised with HR. An HR representative then contacted the BMA adviser and asked for more information about the neighbouring trusts, all of them major employers, who were following the national guidelines. Following this exchange, the trust finally did the right thing. The outcome form from the stage-one meeting was retracted. The meeting itself would be regarded not as a formal step in the absence process but a sicknessreview meeting. There was a commitment that, in holding such meetings, the purpose was to follow the occupational health report and recommendations, and not make decisions which affected pay or absence triggers. The trust apologised – the result of misunderstanding and miscommunication, they said. The doctor said of the BMA’s intervention: ‘It means more than I can probably express.’ This should never have happened. Employment policies can sometimes be obscure or ambiguous, but this was neither. Other doctors in a similar position with the same employer should also benefit. Some details have been changed to protect confidentiality

The Doctor

Editor: Neil Hallows (020) 7383 6321

BMA House, Tavistock Square, London, WC1H 9JP. Tel: (020) 7387 4499

Chief sub-editor: Chris Patterson

Email thedoctor@bma.org.uk Call a BMA adviser 0300 123 1233

Senior staﬀ writer: Peter Blackburn (020) 7874 7398

@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. The Doctor is a supplement of The BMJ. Vol: 376 issue no: 8326 ISSN 2631-6412

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Staﬀ writer: Tim Tonkin (020) 7383 6753 Scotland correspondent: Jennifer Trueland Feature writer: Seren Boyd Senior production editor: Lisa Bott-Hansson Design: BMA creative services Cover photograph: Simon Grant Read more from The Doctor online at bma.org.uk/thedoctor

14/02/2022 11:25

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St Brides Castle, Pembrokeshire

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Stigliano, Tuscany

It’s never been easier to experience the Holiday Property Bond for yourself, free and without obligation. Please read “Exclusive holidays for life” (on the right) to understand the risks as well as the benefits of an investment, and then request your free Information Pack today. We’ll send you all you need to decide whether the Bond is right for you. You’ll find details of our Bond holiday locations together with information about how you can book a private tour of one of our UK sites or arrange a meeting with a representative – either in person or virtually via an online video call. To request your Information Pack:

Call FREE on 0800 66 54 90 Visit our website hpb.co.uk/BMA Scan the QR code

Javea, Costa Blanca

An initial payment from £5,000 and a quarterly fee of just over £30 (that is around £130 a year), linked to RPI, gives you access to all HPB’s holiday homes. For each HPB holiday, you will pay a no-profit user charge covering only property running and maintenance costs and use of on-site facilities. The charge is level throughout the year – there are no high season premiums. For a studio for two the charge averages about £300 a week, for a 2-bedroom property sleeping up to six around £460 a week. Larger properties are also available. After an initial charge of 25% your money is invested in a fund of holiday properties and securities. The fund itself meets annual charges of 2.5%. Your investment return is purely in the form of holidays and, as with most investments, your capital is at risk. You can surrender your investment to the company after two years or more (subject to deferral in exceptional circumstances) but you will get back less than you invested because of the charges referred to above, as well as other overheads and changes in the value of the fund’s properties and securities. This advertisement is issued by HPB Management Limited (HPBM) registered at HPB House, Newmarket, Suffolk, CB8 8EH. HPBM is authorised and regulated by the Financial Conduct Authority and is the main UK agent and the property manager for HPB, issued by HPB Assurance Limited (HPBA) registered in the Isle of Man and authorised by the Financial Services Authority there. The Trustee of HPB is Equiom (Isle of Man) Limited, registered at Jubilee Buildings, Victoria Street, Douglas, Isle of Man, IM1 2SH. The Securities Manager is Stanhope Capital LLP of 35 Portman Square, London, W1H 6LR. No medical examination required. HPB is available exclusively through HPBM. HPBM promotes only HPB and is not independent of HPBA. Holders of policies issued by HPBA will not be protected by the Financial Services Compensation Scheme if the company becomes unable to meet its liabilities to them but Isle of Man compensation arrangements apply to new policies.

14/02/2022 11:25