The Doctor, March 2022, issue 41 by The BMA

The magazine for BMA members

thedoctor

Issue 41

March 2022

GP workload

Intense pressure forcing doctors out of the profession

Tackling the backlog

A clinic in an unlikely setting

An impossible choice Forced to choose between a job and caring for family

On the side of humanity

The doctors giving care, supplies, and hope to Ukraine

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MATT SAYWELL

In this issue 3 At a glance Election time for BMA council

4-7 Retail therapy The NHS clinic tackling the backlog in an unlikely setting

8-13 On the edge GPs facing unbearable pressure consider their futures

14-15 Unacceptable Sexism in surgery, and the urgent case for change

16-19 For humanity Rushing supplies to doctors in Ukraine under Russian attack

20-21 A crime to seek refuge How government plans would criminalise some people seeking sanctuary in the UK

22 Your BMA The BMA needs to be open about its own discriminatory behaviour in the past

23 On the ground A doctor was left choosing between his career and caring for his parents

Welcome Chaand Nagpaul, BMA council chair Like so much of the world, we here in the UK continue to watch the unfolding humanitarian crisis in Ukraine with a sense of abhorrence and disbelief. The loss of life and the displacement of thousands of people following the Russian invasion is an unimaginable tragedy, and the BMA has made clear that it stands in firm solidarity with people of Ukraine. In this month’s edition of The Doctor, we hear from two Ukrainian doctors, Dennis Ougrin and Iryna Nayshtetik, who remain determined to use their skills to help their patients and country during the nation’s darkest hour. We also feature the escalating crisis facing the UK’s general practice workforce, which has seen hundreds of GPs quit or retire in recent years. Behind these damning figures, however, there are countless heartbreaking personal stories as to why so many doctors feel no choice but to leave their posts. In an in-depth and hardhitting analysis by senior staff writer Pete Blackburn, we hear from some of the many GPs who have left or who are considering exiting general practice, about the pressures they faced and what must be done to support their specialty. New solutions and innovative ideas are also in high demand when it comes to dealing with the enormous backlog of patient need generated during the past two years of the pandemic. Demonstrating that necessity is truly the mother of invention, this month’s edition examines how one trust in Dorset

has utilised a local department store to provide diagnostic services and care to patients. This experimental approach has not only allowed for more care to be given and freed up capacity in other parts of the trust health system but has also had the added benefit of boosting the local economy. Acknowledging and addressing the culture of sexism that exists in the NHS is a long-standing challenge all of us must face. With a recent paper in the Royal College of Surgeons of England’s Bulletin highlighting the extent and severity of sexism within surgery, BMA interim representative body chair Latifa Patel has responded by calling for a commitment to wholesale reform across every health organisation in the UK. Afghanistan and the war in Ukraine are perhaps the most recent humanitarian crises. Those fleeing conflict zones and seeking safety abroad has been growing globally for the best part of a decade. While many see the UK as a source of potential refuge, the Nationality and Borders Bill has caused many, including the BMA, to express concern with what effect many of its provisions will have on those trying to seek asylum here. Read the latest news and features online at bma.org.uk/thedoctor Keep in touch with the BMA online at instagram.com/thebma twitter.com/TheBMA

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AT A GLANCE GETTY

ELECTION TIME: Stronger regional representation pledged

Vote, and shape your future M

embers are the lifeblood of trade unions and professional associations such as the BMA – and a robust and diverse membership requires equally broad and effective representation. It is for this reason that, as the 2022 BMA council elections approach, it is important to reflect on changes to the association’s electoral processes and democratic structures. These changes, which were called for and approved at last year’s BMA annual representative meeting, aim to help the association better serve those it represents. This year’s elections, voting for which opened on Wednesday 16 March, will see a record number of candidates standing for office. Five seats on council will be designated for members from minority ethnic backgrounds. This year’s election will also see stronger representation at regional level, with UK-wide seats replaced with positions across all devolved nations and English regions. BMA council chair Chaand Nagpaul said he believed that changes and improvements to the association’s elections would help to ensure a stronger and more reflective council body. bma.org.uk/thedoctor

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He added, however, that there was as much onus on those voting as standing in the upcoming elections and encouraged members to use their votes. ‘As an association, we strive to constantly listen to and learn from our many members, all of whom represent every branch of practice and part of the health service. ‘At a time when doctors are battling unprecedented pressures and the NHS facing ever graver perils, it is vital that the BMA remains as strong as ever as the voice of doctors everywhere. ‘By using your vote, you can play a critical role in helping to shape our union going forward and the role it will play in fighting for you and for our health service.’ With a total of 69 voting seats in the running, this year’s election will use the single transferable vote method for all contested seats. Ballot papers, which were sent out on 16 March, have been streamlined into a single grid format, with voting open to all BMA members until 5pm on 19 April. For more information, visit bma.org.uk/councilelections thedoctor | March 2022

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BRAND NEW: The outpatient assessment clinic

Retail therapy Downstairs for menswear, upstairs for orthopaedics (and much more)... a new NHS clinic in the unlikely setting of a department store is tackling the backlog and boosting staff morale. Seren Boyd reports ALL PICTURES: UNIVERSITY HOSPITALS DORSET NHS FOUNDATION TRUST

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he top floor of a Dorset department store is unlikely proof that crisis can breed innovation in healthcare. The new outpatient assessment clinic sits above menswear in the Poole branch of Beales and it shows positive change is possible when time and head space are given to thinking outside the box. By designing clinics from scratch, rather than revisiting old formulae, University Hospitals Dorset NHS Foundation Trust is now tackling its diagnostic backlog – and, it believes, offering better patient care. It’s been a great opportunity to build partnership with others across the county, including Dorset County Hospital and Dorset CCG (clinical commissioning group). And there have been some unforeseen side effects too: as well as being a shot in the arm for the local retail sector, the new clinic is boosting staff morale. ‘These are the most innovative changes I have seen in orthopaedic clinics in more than 30 years of working in the NHS,’ says orthopaedic surgeon Professor Robert Middleton. ‘Clinics can be physically and mentally draining; you can feel hopeless as you can never quite keep up with demand and expectations. But, with these new clinics, I have a feeling of liberation and satisfaction after a good day’s work.’ It was a conference hall redeployed as a mass vaccination site that provided the blank canvas the trust needed to kickstart creative conversations about tackling waiting lists. As chief operating officer Mark Mould threw down the gauntlet to the different specialties to ‘think big’, new ‘assessment pathways’ were literally mapped out on the floor with tape. bma.org.uk/thedoctor

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An appointment takes place at the outpatient assessment clinic

Consultations followed with everyone from patient groups to commissioners to researchers at Bournemouth University and Arts University Bournemouth, to ensure every patient’s needs were catered for.

ON THE UP: The health secretary ascends the escalator to the clinic from Beales department store

Freeing up hospitals Just nine months later, in mid-December, the new clinic opened – 2,600 square metres of partitioned space devoted to ophthalmology, dermatology, orthopaedics and breast- and abdominal aortic aneurysm-screening – in the prime location of Poole’s Dolphin Shopping Centre. Shifting diagnostic testing into the community and freeing up hospitals to focus on emergency care was a recommendation of Professor Sir Mike Richards’ review in 2020. The Government is investing £350m in 40 community diagnostic centres across England, all additional capacity. The £5m funding for the lifetime of this clinic came through grants and funding sources in Dorset. Some of the materials used in the new outpatient assessment clinic in Beales were recycled from the decommissioned Nightingale Hospitals, including wash-stations, doors, and light fittings. And volunteers from the COVID

‘A great opportunity to do things differently and design our clinics from the ground up’

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‘What has been five separate NHS appointments can be covered in one’

vaccination clinics are now being redeployed to ensure the smooth through-flow of patients – and to redirect strays in search of haberdashery.

Designed for efficiency

New efficiencies take different forms in the new clinic. For a start, the time patients spend there is much shorter than at a traditional clinic – because gaps between diagnostic tests and consultations have been designed out. ‘Optimal flow’ means there is little waiting around. At the ophthalmology clinic, for example, cataract patients have a series of tests before seeing a doctor who decides with them whether they need an operation. The doctor moves between rooms where patients are ready to be seen, maximising the time they have to focus on the condition. Patients suspected of having conditions ‘We need to such as glaucoma and macular degeneration incorporate flow through a different, technician-led this new way stream, undergoing a series of diagnostic tests at different stations. Clinical management of working decisions happen later, remotely. The number into the of patients passing through these diagnostics training of our doctors’ has almost doubled, from about 24 a day to 40. ‘It is an efficient way to see patients and a very positive experience for people,’ says consultant ophthalmologist Mahesh Ramchandani. ‘It’s been a great opportunity to do things differently and design our clinics from the ground up, how you might want to Breast-screening room design them.’

Professor Middleton says he too is able to see twice as many patients as before in the orthopaedics clinic, which focuses on hip replacement. But the benefits go far beyond efficiencies of time. An orthopaedics patient now sees five different specialists in one visit: a surgeon, an anaesthetist, a physiotherapist, a pain specialist, and a LiveWell Dorset health adviser for guidance on lifestyle issues. So, as well as being assessed for surgery, the patient is given support and advice to help them get fit before their hip replacement. This reduces the need for intermediate appointments with their GP, and the likelihood of surgery cancellations, as Professor Middleton explains. ‘One of the problems we have with waiting lists is that when finally the patient is called in for surgery, they have been waiting for months or even years, with nothing being done to get them fit for surgery. If they’re not fit, the operation is delayed or cancelled. Now, what has been five separate NHS appointments can be covered in one.’ The clinic’s location in a shopping centre appears to be having a positive effect on attendance at routine breast-screening clinics too. This is especially true among women at the lower end of the target 50 to 70 age band, says Lisa Bisset, clinical director of the Dorset Breast Screening Unit. ‘Historically, it’s the younger age group who are less likely to turn up because they are generally the busiest. The early feedback we’ve had is that having it in a shopping centre, somewhere they need to go anyway, makes it much more convenient for them.’ It’s hoped that more immediate access to screening will mean fewer symptomatic referrals, which take up GPs’ and surgeons’ time.

Stepping up An element of these efficiency savings is job planning: tasks being assigned more strictly to those with the relevant skills. Previously, in orthopaedics, for example, a considerable amount of a surgeon’s allotted slot with a patient might be spent accessing records and then writing up notes. Now, for a surgeon such as Professor Middleton, ‘99 per cent of the consultation is spent with the patient, not looking at the computer’. Likewise, in the cataract clinics, technicians 06

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MIDDLETON: ‘Innovative changes’

do all the measurements and tests: the ophthalmologist’s time is focused on the patient, not the paperwork. The effect has been to free up capacity in other parts of the health system. Routine breast-screening at Poole Hospital has been reduced, allowing for larger clinics there for women who need a follow-up assessment after an initial screening. ‘We have radiographers who do biopsies and ultrasounds, who report X-rays, so I need them doing what they are qualified to do,’ says Lisa Bisset. There is an opportunity – and an imperative – to go further in reassigning tasks, says Mr Ramchandani. The particular need in his specialty is to increase the system’s capacity to assess test results, to keep pace with increased diagnostic testing. ‘We need to incorporate this new way of working into the training of our doctors,’ he says. He firmly believes the accuracy of modern technology means a wider pool of healthcare partners, including opticians, can be involved in interpreting scan results, with the right supervision and training. ‘There’s a definite need for the hospital to be helped,’ says Mr Ramchandani. ‘We can’t cope with everything ourselves: we need to use the skills in the community.’

Momentum for change The scale of the backlog is huge and it’s a serious concern. ‘Among these are patients who, if they’re not seen, will lose vision permanently,’ says Mr Ramchandani. ‘During lockdown we did risk-rate those patients who were more likely to run into bma.org.uk/thedoctor

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problems. But who knows which others might have issues that are running out of control?’ Workforce pressures also remain high. But one unexpected outcome of the new clinic is that in the breast-screening service, for example, staff are choosing to extend their hours. Lisa Bisset believes the momentum for change is an important motivator. ‘Everyone has got the same goal at the minute: we all want to get to that point where we can say we have recovered from COVID,’ she says. ‘When we share the charts about the progress we’re making, people can see their efforts are making a difference and it drives them on. ‘I’ve worked for the NHS for 30 years too and I know that the size of the organisation means it has to run the way it does. But actually COVID has given us a bit of a shakeup, and this project is having a ripple effect outwards. Now even the junior radiographers feel they can come up with ideas for how we might work differently.’

Professor Middleton has set himself the goal of reducing the period between GP referral and full assessment and listing for surgery to two to four weeks. Although tackling the backlog and efficiency savings are important, the overriding aim is improving quality of care. For him, this is inextricable from team morale. ‘COVID has brought us together and we are determined to recover and offer our patients the best possible care. It’s a great feeling when you know you really are making a difference at work. There is light at the end of the tunnel – and we will come out of COVID better.’

‘Everyone has the same goal... we all want to get to that point where we can say we have recovered from COVID’

Treatment rooms at the outpatient assessment clinic

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NEIL HODGE

THORNTON: ‘Pressure of work unbelievable’

On the edge

10 08

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The demands GPs face have outweighed the satisfaction they extract from their jobs, some say. Peter Blackburn talks to doctors overworked, under-appreciated and ready to turn their backs on the profession – and to those who have already left

‘D

‘In my practice, I’ve had three salaried GPs who handed in their notice, within a six-month time period, to me handing in my notice,’ Dr Jha, who now works as a locum, says. For Dr Jha the workload felt ‘completely unsafe’ and began to impact her physically and emotionally. ‘The safe limit is 25 patients per doctor per day [but] on some days I’d have 70 patient contacts,’ she says. ‘I was going home worrying about it, worrying about if I’ve missed something. I didn’t realise how much it

‘I can’t make 100 clinical decisions from 8am in the morning to 6.30pm at night day after day and not make mistakes’

JHA: Workload is unsafe

SARAH TURTON

o you think anything is ever going to change at work?’ Lincolnshire GP Mark Thornton knew his therapist had got straight to the crux of the matter. Nothing was going to change. And he was ‘completely burned out’. For Dr Thornton, who started working as a GP in 1997 and has been a partner in his practice since 2014, working in general practice has become a daily struggle to manage ‘unbelievable pressure’ amid soaring demand and ‘incredible’ bureaucracy. The two years of the COVID-19 pandemic have taken an unsustainable working life and made it utterly unbearable. In 2020 Dr Thornton’s father passed away after contracting the virus and ‘just keeping the building open’ in the fog of uncertain funding streams, rocketing demand and workforce pressures became too much. And that is without mentioning the £25,000 ‘super tax’ on earnings Dr Thornton ‘did not want’ but arose owing to covering the work of practitioners the practice cannot recruit. The impact – friends coming to stay and asking if he is ill, looming financial stress and genuine burnout – means drastic action is required. For Dr Thornton that means a month of unpaid leave, returning to work on a three-day-a-week basis and planning to step down from partnership as soon as financially viable. Beyond that even his future in general practice as a salaried GP, rather than a partner, is in question. ‘I’ve just had enough,’ Dr Thornton says. ‘I can’t make 100 clinical decisions from 8am in the morning to 6.30pm at night day after day and not make mistakes.’ He adds: ‘The pressure of work is unbelievable. I am constantly struggling to try and get suitable staff to come and work with us, we have permanent vacancies and agency rates are extortionate. And we are one of the most uber-regulated businesses in the entire world… It is just absolutely out of control.’

Unsafe workload Dr Thornton’s story is far from out of the ordinary. Hertfordshirebased Neena Jha has worked as a salaried GP at the same practice for seven years. In August last year Dr Jha gave her notice because she could no longer tolerate the ever-more intense demands in her workload. bma.org.uk/thedoctor

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unrealistic and she now works as a part-time retainer while focusing largely on leadership roles for the Cambridgeshire and Peterborough local medical committee and as chair of conference of the LMCs of the UK, among other positions. For Dr BramallStainer, general practice was supposed to be a career ‘for the next 30 years’, working with patients in an ‘immensely privileged position’. But that was not realistic. BRAMALLSTAINER: Lost ability to communicate

‘There’s always going to be another crisis. It’s not fair on my family’

was affecting me – it was actually my practice manager who noticed it. I was just completely burnt out, I just started losing weight without realising it … I was late, replying to emails, forgetting things at work, and I think I was developing compassion fatigue as well.’ Katie Bramall-Stainer, who was diagnosed with MS in 2010, also says the pressures of working in general practice made her unwell. ‘For me the cracks began to show with regular partnership days of 12, sometimes 14, hours or longer… I look back now, through the retrospectoscope and see that this was the early aggressive phases of a chronic illness that became a perfect storm for me. ‘I remember having a relapse that was characterised by an expressive dysphasia in July 2011. I’m known for being a bit of a motor-mouth. I was unable to hold a consultation – I couldn’t speak – it was immensely traumatising. The practice response was to put me on telephone consults as if that made anything better; in fact it only made it worse.’ In Dr Bramall-Stainer’s case continuing as a GP partner was

Sudden resignation A north-east GP, who asked not to be named so they could speak freely, told The Doctor they had stepped down from partnership after a recurring bout of exhaustion and burnout lasted more than their ‘normal’ two-week period of personal difficulty and ‘bouncing back’ felt impossible. ‘I’ve always said I’ll just get through this year but I’ve realised there’s always going to be another crisis. It’s not fair on my family. I had to make a sudden decision to resign.’ They added: ‘I love my job, I love my patients and I love my colleagues. But as a partner I’m not sure, if I kept going, that I would have been able to do this for the next 10 years. I don’t think I would have the resilience. It’s not sustainable, I don’t think, to be able to have any quality of life.’ It says much about the situation the NHS finds itself in when GPs refer to needing two weeks to recover from particularly stressful moments in their working lives as ‘normal’. Numerous doctors told The Doctor their working lives felt like ‘fighting to survive’.

In February 2020, in a bid to reverse the stasis in GP workforce numbers the Government announced a drive to recruit an additional 6,000 GPs in England by 2024. Yet despite these promises, as of December 2021, there are the equivalent of 1,516 fewer fully qualified full-time GPs compared to 2015. And in the year between December 2020 and December 2021, the NHS lost 454 GP partners. Michael Mrozinski is one of the doctors who left general practice in that time period. Born in Glasgow, Dr Mrozinski qualified back in 2009 and began the process of specialising as a GP, working in general practice roles in both Scotland and London. During his final year of GP training, he realised that the physical and mental demands posed by general practice in the UK were simply an unsustainable working environment, and in 2016 he took the difficult decision to relocate to Australia. ‘In the circles of doctors, when they talk about careers, being a GP is probably [considered] one of the worst careers you could do as a doctor just now,’ he says. ‘People thought they would have a better lifestyle with general practice but from my experience, certainly during my registrar year, the partners in the practice were staying on until 8pm, 9pm or 10pm literally every single night. ‘I used to leave at maybe just after 7 o’clock, a couple hours after we’re supposed to finish, and they were kind of joking about how I was “going home early today”. It’s all jokes, but I couldn’t do that for the rest of my life.’

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Stepping away

The Doctor can also reveal the findings of a landmark BMA survey responded to by 2,357 GPs which highlights the profound strain pressures in general practice are placing on the wellbeing of doctors and the care of patients. Just one in 20 respondents said their workload was manageable. And nearly nine out of 10 reported that their workload was excessive and either prevents or significantly prevents the provision of quality and safe care. The survey also revealed that, using mean average figures, GPs are working more than 130 per cent of their contracted hours in their primary roles. It is a situation which has a huge effect on the wellbeing of doctors and patients. South-west GP Harry Minas, who now works two days a week clinically, says: ‘You get the moral injury. Your gut tells you things are going to go wrong but you can’t put them right because the system prevents you from doing so.’

Dr Minas adds: ‘My passion for seeing patients is undiminished but I have to ask myself as an older GP who doesn’t have the mental stamina of a 20-year-old any more whether the system allows us to continue to work in it. I’m not going to recover as fast if I do consecutive days of 10-and-a-half hours. It would be like me coming to work having drunk five pints. I cannot function as well. And the biggest risk is that this cognitive fatigue builds up. If you try to work harder and harder and faster and faster you are actually

VAN MELLAERTS: GPs leaving the profession are a huge loss to society

‘Your gut tells you things are going to go wrong but you can’t put them right’

SARAH TURTON

These worrying figures are only likely to rise, with 16 per cent of respondents to a recent BMA survey saying they intend to leave the NHS altogether after the COVID-19 pandemic. Alongside these stark statistics the number of GPs choosing to work part-time has been increasing, with doctors moving toward working patterns that may help protect them from stress, ill-health and burnout. And, to cap it all, on average GP surgeries in England now have 2,222 more patients each than in 2015, with appointment bookings reaching record highs over the winter of 2021 – some 4.9 million more appointments in December 2021 compared with December 2019, a sharp rise of 20 per cent. BMA GPs committee executive officer Richard Van Mellaerts says doctors would ask patients whether they should make changes in their working lives if they were experiencing the conditions many GPs are working in. He adds: ‘I think it is profoundly sad. Doctors study for many years and give up an awful lot to get to the point where they qualify as GPs and they go into the profession with huge hope and huge goodwill. ‘For things to get so bad that people have to even think about stepping away because of the pressures that they are experiencing is tremendously sad. It is a huge loss for them and a huge loss for society and patients as well if the systems and working environment are such that they cannot continue to work in the same way.’

MINAS: Not confident he can physically recover from demands

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ED MOSS

action would have in terms of access and provision.

Abuse at work

AMUTHALINGHAM: Working towards leaving the NHS

‘GPs on the ground need to feel supported by those people organising the system around them’

putting yourself at grave risk of harming someone and then you will also have all the scrutiny and the trauma of that.’ Some of the effects of the COVID-19 pandemic are clear in the data regarding demand for services, but there are also significant looming concerns which are less easy to measure. Doctors working in general practice fear a growing mountain of unmet need in their communities and are also managing the huge risk of patients who are waiting to be seen by secondary care of other health services but will face lengthy, and evergrowing, delays in care. Dr Van Mellaerts says: ‘My worry is that COVID is going to have a very long tail not just through repeated infection going forward but from people who didn’t come and see us at the time, people who have illnesses which developed during COVID but they have not been to see us yet or from existing chronic illnesses which have deteriorated.’

The Doctor spoke to a number of GPs as part of this investigation and one of the unifying themes was a deep sadness and anger about the way the media and Government have portrayed primary care and the effect this has had on patient relationships with staff. After everything GPs contributed and sacrificed during the pandemic – literally transforming services and patients in the space of days and hours to keep patients and staff safe and to protect continuity of care and, often, putting themselves at risk due to chronic failings in personal protective equipment supply – ministers and journalists demanded GPs provide more face-to-face appointments and government even suggested those who failed to cooperate could be ‘named and shamed’ with league tables published. All this despite those failed government promises regarding the training of GPs and the obvious effect such

The BMA’s survey of GPs highlights the problem. Nearly 85 per cent of respondents reported having witnessed verbal abuse directed at other staff in their workplace and more than 65 per cent reported they had themselves experienced verbal abuse at work. And just over 8 per cent said they had witnessed physical abuse directed at other staff in their workplace. Dr Van Mellaerts says: ‘There’s a sense of disbelief because it is so far disconnected from what we have been doing, how hard GPs have been working and the sacrifices they have made. It’s not just about not being recognised – people aren’t GPs for recognition – it’s being told that you are doing a bad job, that you aren’t caring for people. That is the opposite of what has happened and that is deeply, deeply distressing.’ For many doctors this working environment is the result of a gradual decline in resource and workforce, increase in demand and the more recent effects of the COVID-19 pandemic. For trainee or newly qualified doctors this overwhelming environment is the one to which they are welcomed to learn their trade. And for some it quickly becomes clear that is not possible for them. Thuva Amuthalingham finished his training in August 2020 during the early waves of the pandemic. He started in a full-time role working four days a week in general practice but has already moved to two days

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of clinical general practice and is now ‘working toward’ stepping down to one day and then, ultimately, leaving the NHS. ‘The hope is not to do clinical work at all because of how impossible it feels,’ he says. ‘That’s the unfortunate truth.’ Dr Amuthalingham, who runs the ‘first five network’ for the Black Country and West Birmingham – a networking and support group for doctors in their first five years – adds: ‘I would go as far as to say this is the standard feeling among new GPs.’ The lack of support for the profession pervades every part of the system. One GP told The Doctor that among the final straws leading to them stepping down from partnership was being promised funding for the expansion of premises when asked to take over the running of a neighbouring practice previously run by a private company which had then handed its contract back. No money was forthcoming and staff worked extra sessions in side-rooms with no windows. In the end a small amount of funding was made available to install windows.

Urgent need to invest The need for action could hardly be more urgent. In countries facing similar demographic issues to the UK, plus dealing with the eﬀects of the pandemic, primary care is much more heavily resourced and there is often a more prevalent recognition that a strong health system needs strong general practice to work with patients in the community and protect

secondary care. The latest efforts in this area from NHS England and the Government – alongside the litany of failed promises and inflammatory rhetoric – is to impose a contract on GPs which doctors leaders say will ‘fail to help patients and support practices’. So, what can be done to turn this deeply concerning situation around? The BMA is calling for long-term investment in increasing the NHS workforce accompanied by a workforce strategy to ensure that the appropriate number of future staff are being recruited and trained. It is also urging the Government to invest in general practice staff, services and premises and to remove unnecessary targets and bureaucracy. Dr Van Mellaerts says: ‘We already provide the vast majority of patient care for a fraction of the NHS budget and we are one of the most cost-effective general practice systems in the world. Ultimately, if general practice fails then the NHS fails.’ And GPs The Doctor has spoken to are also united in calling for the Government and NHS England to provide consistent public statements of support for GPs and deliver on its commitment to work with health bodies and representative organisations on a national campaign to stop abuse of NHS staff. Dr Van Mellaerts says: ‘We need to have overt support. GPs on the ground need to feel supported by those people organising the system around them. That is crucial.’ On 17 March, the BMA and GPDF jointly launched the ‘Rebuild General

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GP workforce decline

6,000 extra GPs by 2024 promised

But in reality:

-1,516

by December 2021 compared with 2015

Practice’ campaign. Delivered in partnership with communications agency, BB Partners, it aims to highlight pressures aﬀecting general practice, and calls for the resources needed to ensure GPs are supported, patients receive the best care, and to ease the backlog. Dr Thornton’s response to his therapist’s knowing question: ‘Can you see anything changing at work?’ was: ‘I can’t see anything other than it getting harder’. It was a telling, immediate and instinctive response. Unless urgent action is taken there will be many more GPs feeling their only choice in the face of so much pressure is to make similar decisions to cut their hours, step back from partnership, move to locum work or leave general practice altogether. The impacts for patients, the NHS and communities across the country would be unthinkable.

‘We already provide the vast majority of patient care for a fraction of the NHS budget’

Additional reporting by Tim Tonkin thedoctor | March 2022

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ED MOSS

FISHER: Research encouraged other doctors to come forward

Sexism seems to be embedded in NHS culture; the means of tackling it is not. Following last month’s piece on a highly significant paper, doctors set out the urgent case for change. Jennifer Trueland reports

UNACCEPTABLE T

he NHS pays more attention to how doctors make toast than to stamping out sexism – and this has to change. That’s the view of BMA representative body chair Latifa Patel, who wants to see a commitment to reform at every level in every health organisation across the UK. ‘You go into the NHS and you’re taught not to leave a toaster on or you’ll set off a fire alarm, but you’re not taught the policy on sexism,’ she says. ‘And we know there’s more sexism in the NHS than there are toaster fires. But we’ve just had 50,000 junior doctors rotating and they’ve all been told about fire safety as it’s compulsory in induction, but no doctor is being told that sexism isn’t right.’ Last month The Doctor reported on what some have called surgery’s ‘me too’ moment. This followed a paper published in the Royal College of Surgeons of England’s Bulletin, outlining the specialty’s problem with sexism ranging from ‘jokes’ and ‘banter’ to serious sexual assault, 14

including rape. The paper, by surgeons Becky Fisher and Simon Fleming, prompted many other doctors to describe their own – often harrowing – experiences. Many organisations and individuals, including England’s health secretary Sajid Javid, expressed concern about what the doctors, mostly women, shared.

Sexist remarks For Dr Patel, expressing concern isn’t enough. ‘We need a commitment at every level of every organisation, from the leaders at the top right to the bottom,’ she says, adding that individuals have responsibilities too. ‘The poorest behaviours you walk by and accept is probably the behaviour that’s going to flourish in that environment. We’re saying you have to call it out, you have to have clear policies, you have to make sure people know about them, and you have to implement them.’ Although The Bulletin paper – and some of the experiences subsequently revealed, mostly through

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social media – focused on serious sexual assault, it was PATEL: An issue that needs much also clear that so-called lower-level sexism, such as jokes, more discussion was also a major issue. Again, Dr Patel says that this should not be deemed as an acceptable part of an organisation’s culture – and just because the perpetrator didn’t mean any harm, doesn’t mean it isn’t harmful. ‘At the end of the day, it’s not just how it’s seen or perceived by the person who’s doing it, it’s how it’s perceived. To the person who’s doing it, it might just be one joke they’ve done and moved on, but to the person receiving, it might be the tenth.’ This rings true for Professor Claire Hopkins. An ENT consultant at Guy’s and St Thomas’ NHS Foundation Trust and professor of rhinology at King’s College, London, she describes how, as a trainee in surgery, she felt she had to ‘laugh along’ with sexist jokes if she wanted to fit in and somehow laugh it off, it turned women against surgery.’ progress in her career. She began a group called WENTS (Women in ENT ‘I was the only female and most junior doctor in the Surgery) which aims to inspire, support and empower department – it was a typically male environment,’ she women at all stages of their careers – and she makes says. ‘There was constant sexist the point that things are banter; it was very light-hearted getting better in some surgical ‘You have to call it out, you have but it was the norm. Some specialties, including ENT. of the experiences talked ‘One of the reasons I chose to have clear policies’ about now were everyday to go into ENT was that I occurrences, and it didn’t occur think generally that [sexist to me at the time that the behaviour was inappropriate.’ behaviour] is less prevalent than it is in a specialty such as She recalls the behaviour of one senior male orthopaedics, for example.’ colleague. ‘At the end of operating, the consultant Even with her level of seniority, however, she is still surgeon I was working for would slap me on the bottom subjected to microaggressions – such as being called and say, “now I’ve serviced my patient, I’m going home by her first name when male colleagues are called Mr or to service my wife”.’ Professor. ‘It’s still hard to be a woman in surgery, and we need that support to help encourage women to come through it.’ Inappropriate questions There was another occasion when Prof Hopkins – who Male support initially intended to specialise in orthopaedics – was It’s also important to raise awareness, she adds. ‘I think attending a Friday meeting of trauma surgeons. ‘I was our male colleagues in general are supportive and are shown an X-ray of a pelvic fracture displayed on a screen allies – they just don’t realise that it happens on a regular and asked in front of the entire room to talk through what basis. I don’t think anything is going to change overnight, sexual position I’d used to cause that fracture. but it’s important to try and ‘It’s only now when I look make people more mindful. back on it that I think, “Oh my ‘We just thought it was part of the life Even if just a few people notice god, that was actually terrible”. when these things happen, But it was the norm of where I of being a surgeon’ and correct it themselves, or was working and if you didn’t stand up for the junior who is get on with it, you didn’t fit in.’ being treated unfairly, then over time, things will change.’ She knows of female doctors who decided against Dr Patel is also determined this issue will not be swept a career in surgery because of the way women were under the carpet. ‘My dream would be for it to be talked treated – including one who said she had left because about all the time,’ she says. ‘It should be talked about she couldn’t stand the toxic sexist environment in a whenever a member of staff goes to a new department, department that Prof Hopkins had actually found quite at every induction. Because we know it’s so prevalent, supportive at the time. ‘I just saw it as normal behaviour,’ so rife, and it’s only when it becomes part of routine she says. ‘At the time we just thought it was part of the induction and discussion that people feel they can life of being a surgeon. I’m not saying that’s a good thing, call it out.’ because although I was able to grow a thicker skin and bma.org.uk/thedoctor

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GETTY /ARIS MESSINIS

SHELTER FROM THE STORM: Children treated at a paediatric hospital in Kyiv lie in their beds in a basement being used as a bomb shelter

Doctors have responded to Russia’s invasion of Ukraine with fundraising, courage, and ingenuity. Tim Tonkin reports 16

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EMMA BROWN

GETTY /ARIS MESSINIS

OUGRIN: Overwhelmed by support in the UK

FOR HUMANITY

ike some lesser-known law of physics, it’s often the case that for every appalling and unprovoked action, there is a corresponding positive and humanitarian reaction. And so it is with the doctors in and outside of Ukraine who are providing urgent humanitarian support in the face of the Russian invasion. Consultant child and adolescent psychiatrist Dennis Ougrin is one of many Ukrainian doctors living and working in the UK who have sprung into action. He set up a JustGiving page for medical equipment, which raised almost £60,000 in its first few days. After procuring a mobile ultrasound and other basic medical supplies such as gloves and bandages, Dr Ougrin and his wife set off on 26 February, travelling by car from the UK to the Polish border to hand over the lifesaving provisions. ‘We were hoping that the Ukrainian community in the UK could maybe raise £10,000, but we were overwhelmed by the bma.org.uk/thedoctor

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‘There is so much support for Ukraine in the UK and other countries’

support we received,’ says Dr Ougrin who is also a member of the Ukrainian Medical Association of the UK. ‘We probably will do this [journey] on Thursday, again. We are hoping, because there is so much support for Ukraine in the UK and other countries, that perhaps we could move from driving our little car to something a lot more substantial. ‘First-aid kits are particularly important. I speak with the deputy health secretary of Ukraine every day, so I know what the needs are on the ground. He told me yesterday that the Army has a good supply of first-aid kits, but it’s the Territorial Army which is called the Territorial Defence in Ukraine that doesn’t have enough, nowhere near enough in fact.’

Desperately needed supplies Dr Ougrin says much of the medical supplies provided by him and his wife were likely destined for a hospital in Dnipro in the east of Ukraine where much of the heaviest fighting has so far occurred. thedoctor | March 2022

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EMMA BROWN

GETTY/ARIS MESSINIS

A doctor in the newly located paediatrics centre in Kyiv

He acknowledges, however, that medical supplies were likely to soon be in high demand all over Ukraine. ‘I’m in touch every day with a colleague of mine,’ says Dr Ougrin. ‘He went to the same medical school as me and is based in the city of Rivne and I know exactly what equipment needs he has got. The logistics are tricky, but I hope we can organise something for him as well.’ When handing over their medical supplies, Dr Ougrin and his wife were also able to rescue her sister-in-law and two children from Ukraine and drive them to safety in Rzeszów, Poland. The rest of Dr Ougrin’s family remain in Lviv in the west of Ukraine. ‘It [Lviv] has not been terribly affected by the war just yet, but I think Putin is crazy and sadistic enough to keep going and target every single city in Ukraine,’ he says. ‘It’s only a matter of time before Lviv is affected too, which is why I think it’s important for people, especially children, to leave.’ Despite the desperate situation in his home country, Dr Ougrin says he believes the invasion has led to a tremendous unity and resolve among the people of Ukraine. He also adds that, while he feels it was a mistake by western countries to rule out intervening militarily, he and other Ukrainians are immensely grateful for the solidarity and support that has been shown by the international community. ‘I think there’s a remarkable unity and 18

OUGRIN: Leaving his home with medical supplies

‘There will be a strong fight for as long as is required’

‘There’s a remarkable unity’

support that people offer each other, I’ve never come across anybody who has got a defeatist view and there’ll be a strong fight for as long as is required,’ he says. ‘I have to say that the source of support that we are getting from western countries is also unparalleled. We are getting a lot of assistance, something that I am personally grateful for and something that I think has stiffened our resistance substantially and increased our resolve.’

Ingenuity and mental strength Dwindling medical supplies and equipment within Ukraine is a source of growing concern, with the World Health Organization recently highlighting that the country’s health service was dangerously close to running out of oxygen. Of further concern is the threat being posed to health professionals, with organisations such as the BMA and the WHO condemning Russia’s invasion and warning that the medical neutrality of doctors and their colleagues must be respected. Rheumatologist Iryna Nayshtetik is one of thousands of healthcare professionals attempting to use her skills amid the ever-growing danger and uncertainty in her home country. She, along with other doctors and nurses, is in the process of establishing an emergency medical centre in their village located on the outskirts of Kyiv, although she admits they have limited access to medical equipment. ‘In the case of invasion by the Russian

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Army, we are trying to prepare; we are making different medications or preparations and trying to communicate with other healthcare professionals and other doctors who are near here,’ explains Dr Nayshtetik. ‘In our emergency place, which we are making right now, we only have access to an ECG, but we have our hands, we have our minds, and we have a willingness to defend our Ukrainian nation and we will do our best.’ While her community remains unoccupied, Dr Nayshtetik along with those around her has already had to seek shelter in the village’s bunker. With Russian forces thought to be just 50km away from her location at the time of speaking to The Doctor in early March, Dr Nayshtetik explains how her husband had already been mobilised as part of a Territorial Defence unit in readiness for any possible attack. ‘We are very close to each other, closer than in 2014. The whole world is Ukraine right now,’ says Dr Nayshtetik. ‘I think we are very strong right now, psychologically very strong, and we are willing to defend our Ukraine and we believe in our victory.’ In light of the unfolding humanitarian crisis in Ukraine, the BMA has committed £25,000 through its BMA Giving appeal, with funds to support the work of the British Red Cross and Ukraine Crisis Appeal. The association has also pledged to provide free and confidential support to anyone

GETTY /SERGEY BOBOK

GETTY /YURIY DYACHYSHYN

A member of the Ukrainian Territorial Defence Forces searches a destroyed Russian military vehicle in a forest outside Kharkiv

People wait for a train to Poland in a railway station in Lviv

‘We have a willingness to defend our Ukrainian nation and we will do our best’

WRIGLEY: Medical neutrality must be respected

affected by the events in Ukraine through its 24/7 counselling and peer support services.

Pledge of solidarity BMA deputy council chair David Wrigley says the association stands in solidarity with the Ukrainian medical profession and people. ‘It is heart-breaking and difficult to comprehend the harrowing situation unfolding in Ukraine, with reports of Russian Government hostility towards both Ukrainian military and civilians. ‘The principle of medical neutrality is fundamental to international humanitarian law and must be respected. The BMA is calling on the Russian Government to acknowledge the role that doctors and the wider health service plays within Ukraine, and to stand by the moral obligation to ensure that the medical workforce can freely continue to care for patients, and save lives, without threat of violence or interruption. ‘We express explicit solidarity with the people of Ukraine and appeal for an end to the invasion and attacks. As we closely monitor the situation, we would also urge the UK Government to offer necessary humanitarian aid and support to those fleeing the conflict.’ thedoctor | March 2022

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Dr Arian when he was a child

A crime to seek refuge The Government’s immigration bill includes a plan which could criminalise those seeking sanctuary. A doctor who arrived as a refugee says it would cause serious harm. Tim Tonkin reports

‘It would create a two-tier system for asylum seekers based on their mode of travel to the UK’

he belief the UK has historically been a tolerant and welcoming nation, one that has opened its doors and provided refuge to those ﬂeeing persecution, is a popular if debatable one. Less ambiguous, however, are the recent policies on asylum and immigration that have been enacted by successive governments in the past two decades. Ushered in under the then home secretary Theresa May in 2012, the so-called ‘hostile environment’ saw access to public services, such as education, housing and healthcare, restricted to those unable to demonstrate their legal immigration status. It was this policy that between 2014 and 2017 saw the introduction of legal requirements compelling doctors and other healthcare professionals to identify ‘overseas visitors’ and to charge them upfront for non-urgent medical care services. The detrimental health eﬀects of the hostile environment on patients and the NHS are the subject of a recent paper published in the Journal of the Royal Society of Medicine, which labels the regime as one that has frequently ‘deterred people from seeking treatment’ and seen thousands ‘wrongly turned away from services’.

‘Dehumanising’ A decade on from the introduction of the hostile environment, the Government is seeking to introduce a new raft of laws around asylum and immigration through the Nationality and Borders Bill. Under review in the Lords, the bill has already attracted criticism from organisations such as the BMA, which has warned that many of the measures the bill seeks to introduce are likely to undermine health and wellbeing further for those seeking refugee status. These include the bill’s potential for ionising radiation to be used for assessing the age of those arriving in the UK, a process the BMA says is unethical as it would result in ‘direct harm without any medical beneﬁt to the individual’ – something parliamentarians have raised with the Government repeatedly throughout the legislation’s scrutiny. The bill would also enhance powers allowing those seeking asylum to be housed in locations such as military facilities or even to remove asylum applicants to oﬀshore locations while their applications are being considered,

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GREAVES: ‘This bill will have a negative impact on healthcare access for migrants’

thereby potentially limiting their access to adequate healthcare. Perhaps most concerning are plans to create a two-tier asylum system, one that would see those arriving in the UK by means other than an official resettlement programme designated temporary asylum status, have their claim for asylum dismissed or even face criminal charges. Emergency medicine doctor Waheed Arian knows only too well the pain and hardship of being displaced, and the challenges faced by refugees. Having fled war in Afghanistan for Pakistan in 1980s as a young boy, he then, at just 15-years-old, escaped the Afghanistan civil war to the UK in 1999, both for his own safety and to realise his ambition of becoming a doctor. His journey to the UK, which was arranged after his parents sold virtually everything they owned to pay an ‘agent’ to arrange travel, is one of those that the proposed bill would seek to criminalise. ‘When you’re living in a conflict zone, you can’t wait for months or years for a [resettlement] scheme,’ explains Dr Arian. ‘The reason why we took that journey to the agent was because the normal routes, the legal routes, didn’t exist and they still don’t exist. The alternative is death, either physical death or emotional death, because you don’t actually have any future [where you are].’ Arriving unaccompanied in the UK in 1999, Dr Arian was initially arrested and detained at Feltham Young Offenders Institution for two weeks for being in the UK illegally. A court, however, ultimately dismissed the case against him allowing him to remain in England. During the next four years he was able to work multiple jobs, take classes and ultimately be accepted to study medicine at Cambridge and Imperial College, before joining the NHS where he remains to this day. Dr Arian warned that by criminalising certain forms of asylum seeking and by further restricting access to suitable accommodation and care, bma.org.uk/thedoctor

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the bill, if passed, threatened to dehumanise and cause harm to vulnerable people who have already risked everything. ‘The judge decided that [my] case had to be dropped because according to the UN Convention refugees shouldn’t be penalised because of the route they take, so hence, my actions were not illegal,’ Dr Arian explains. ‘[Through this bill] you’ll be criminalising people, sending them to a prison and then just deporting them back. Simply put, they aim to criminalise, dehumanise and turn away refugees who are coming here to seek safety, which is their human right. These are people who are not just numbers. They are human beings with families, but they also come here with their potential that they would love to realise and to contribute to their host country and the world at large.’

‘When you’re living in a conflict zone, you can’t wait for years for a resettlement scheme’

Barriers to care BMA medical ethics committee chair Zoe Greaves warns that many aspects of the wording of the legislation are deeply troubling and would likely have a hugely detrimental effect on the lives of vulnerable people attempting to seek sanctuary in the UK. She says: ‘We believe citizenship is a right not a privilege, and this bill will have a significant negative impact on healthcare access for migrants, particularly asylum seekers, who already face insurmountable barriers to attaining their human right to health. ‘It would create a two-tier system for asylum seekers based on their mode of travel to the UK as well as unnecessary barriers to refugees, including healthcare professionals, seeking to contribute to British society. ‘The expanded use of Ministry of Defence sites, including military buildings, to accommodate asylum seekers, is something the BMA has consistently opposed, due to the notoriously poor facilities at such sites. ‘Meanwhile, clauses of the bill enabling the offshoring of people seeking asylum, the removal of citizenship from individuals by the health secretary without notice, and the use of ionising radiation to assess the age of asylum seekers, are all profoundly concerning and deeply unethical. ‘The BMA is not standing idly by in the face of these unethical and immoral plans, and we are regularly briefing, informing and lobbying lawmakers of our profound reservations regarding this bill.’

ARIAN: ‘They aim to criminalise, dehumanise and turn away refugees’

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Your BMA

An open discussion about diversity is needed if we are to move forward At the BMA, we firmly believe we are here to represent all doctors. That doesn’t – and shouldn’t – mean treating everyone in exactly the same way. But it does mean looking at people’s needs and ensuring the medical profession is inclusive, and values different experiences and insights that people can bring. Sometimes as a profession we’ve not been very good at that. If you look at the history of medicine, there is little doubt that in the past we have been guilty of discrimination – of using words and taking actions that have been the opposite of valuing diversity. It’s not always a question of being overtly discriminatory – although there are examples of that too. It’s also been about not being proactive, not calling out patient injustices, not being allies to those who don’t fit the still-enduring medical stereotype of the straight, white, cisgendered male. This has clearly been the situation when it comes to our members who are LGBTQ+. We know that in the NHS and in wider society, the LGBTQ+ community is disenfranchised, and are negatively affected in many ways: accessing services, being unable to speak out, facing bullying and harassment, often working in environments that make it detrimental to be open about their lives, loves and family. At the BMA, we’re looking inwards as well as outwards, to see how we can proactively support members who are LGBTQ+. What can we, as a trade union, and a professional association do that we aren’t already doing? We also need to be honest about our own history on this. We’ve been looking at our archives and we’ve found the BMA made homophobic statements, for example in the 1950s, when submitting evidence to Parliament. There were things said that are simply not true and statements we do not believe. They do not represent the values of our association today. I don’t believe we should sweep our own history under the carpet. We may have been operating in the context of an unfair society, but we still should have been doing more. We should have been proactive, we should have been calling it out. So what are we doing now? On behalf of today’s BMA leadership I apologise for those failures of the past. I apologise to the people and communities affected. We recognise that homophobia 22

@drlatifapatel didn’t just affect LGBT+ doctors and medical students, but our patients too. Because we know that what the BMA says – or doesn’t say – has a ripple effect in the NHS and in wider society too. We need to hold ourselves to a higher standard, apologise, and commit to doing better. In association with GLADD, we have launched a survey on sexual orientation and gender identity. We hope all doctors and medical students will complete it to help us understand how we can create an inclusive environment. It shouldn’t just be up to members of the LGBTQ+ community to fix this – we all have a part to play – and I would urge you to make your views known. This month has also seen International Women’s Day, give us the opportunity to reflect on inequalities. Again, the BMA’s history on sexism doesn’t bear much scrutiny, and again, I apologise to the women who have not been represented in the way they should have been. But I do believe as an organisation we have made, and continue to make, significant strides. As I have said before, I am only the fourth woman at my level in the BMA in two centuries. That’s extraordinary in what it says about the BMA of the past, and what is says about the way the BMA has changed, but it’s not my achievement , rather, it’s about the members of the representative body who decided they would put their faith in a woman, in a junior doctor, in a minority ethnic doctor. We now have more women in senior elected positions than ever before and we need this to continue. At the BMA, we have a programme of work looking at eradicating sexism in medicine, but we also want to celebrate the brilliant things women are doing. Our Voices of Women campaign wants to hear from as many of you as possible, so that we can amplify and showcase what BMA women are doing, and can achieve. You never know who you might inspire, you don’t know who you are being a role model for. So please, share your stories. Dr Latifa Patel is interim chair of the BMA representative body RBChair@bma.org.uk

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on the ground thedoctor

Highlighting practical help given to BMA members in diﬃculty

A consultant was left having to decide between his career and the care of his elderly parents Contrary to popular belief, doctors do have lives outside medicine. And for Irfan Ahmed, an important part of his was ensuring the care of his parents. They are in Pakistan, and Professor Ahmed, a consultant surgeon, was using up a large proportion of annual leave to visit them, and he needed more time. The pandemic has made travel significantly more difficult and stressful. Planning for, and undertaking, the journeys was having a significant effect on his wellbeing. Feeling a strong obligation to care for his parents, Professor Ahmed applied for a 12-month career break. His employer, like most – if not all – in the NHS, had a policy for considering such applications. The NHS often speaks of its family friendly credentials. However, Professor Ahmed’s application was rejected, without what he felt were clear reasons. This left him in an invidious position, and he appeared to have no option left but to give up his job. This would have been a terrible own goal for the health service, given its need to retain doctors and its frequent statements about the need to support them. He called in the BMA, which supported him at the appeal panel set up by his health board. BMA assistant secretary Niall Hermiston, who helped prepare the appeal, focused on the need for the employer to recognise the cultural and religious obligations which Professor Ahmed felt towards his family, and the stated requirement in the employer’s policy to take note of the risk of resignation – which in this case was very real.

The Doctor

The appeal panel consisted of a deputy medical director and an HR manager. Fortunately, the appeal panel found in Professor Ahmed’s favour, to his delight and relief. After some further negotiations on the details, the career break has now begun. It is of course the case that doctors of all ethnic backgrounds have caring responsibilities and obligations, but it would seem fair to observe from recent cases that a high proportion of those with issues regarding older parents are from a south-Asian background. A doctor relocated to Australia, because the British Government would not allow him to move his mother from India to the UK. There have also been examples of doctors unable to take longer periods of annual leave, even though some of that leave may have been used up in COVID quarantine. It’s hardly unexpected or unpredictable that, in a caring profession, there will be members who wish to, or feel they need to, care for their parents. It’s a fundamental human instinct, and the health service needs to ﬁnd ways of accommodating it. This reiterates the importance of the BMA’s call for a softening of the adult dependant relative rules to enable doctors and their colleagues in the NHS to care for older parents in the UK should they need to. To talk to a BMA adviser about work-related issue, call 0300 123 1233 or email support@bma.org.uk

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 July 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 July be obtained from the publishers on written request. The Doctor is a supplement of The BMJ. Vol: 376 issue no: 8330 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: GETTY/Chris McGrath Read more from The Doctor online at bma.org.uk/thedoctor

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