The Doctor, May 2022, issue 43 by The BMA

The magazine for BMA members

thedoctor

Issue 43

May 2022

For Alastair’s sake Learning lessons from a tragedy

Unprotected PPE shortages highlighted by BMA inquiry

Penalty charges Parking fees make an unwelcome return

It never went away

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Why are politicians saying the pandemic is over?

16/05/2022 11:38

MATT SAYWELL

In this issue 3 At a glance Passionate debate after two ‘extraordinary’ years at the local medical committees conference

4-7 Penalty notice The return of parking charges to many hospitals

8-11 For Alastair’s sake Why the NHS must learn from a tragic case of a consultant who took his own life

12-15 Let down A woeful lack of PPE revealed by the BMA’s inquiry into how COVID was handled

16-20 It never went away The former health secretary may say the pandemic is over but the reality could hardly be more diﬀerent

21 Viewpoint When a doctor’s exam took an unexpected turn

22 Your BMA Setting the agenda for the BMA annual representative meeting

23 On the ground How the BMA helped a consultant whose experience was undervalued 02

Welcome Chaand Nagpaul, BMA council chair With the Government dragging its feet on its own official inquiry into COVID-19, this month sees the BMA publishing two reports of its own into the pandemic. They cover several issues affecting the medical profession, with truly shocking findings highlighting the gross inadequacies in protecting frontline workers from a lack of personal protective equipment provision, through to inadequate risk assessments and next to no support given to staff during the greatest public health crisis of the past 100 years. The reports also lay bare the effect the pandemic has had on doctors’ mental and physical health following what can only be described as the most gruelling period of their professional lives. While harrowing in nature, it is our hope that this series of reports will force ministers to engage in a meaningful conversation about the political failings of the pandemic and to bring about the changes needed to save and protect our health service now and into the future. This is especially critical right now as we face having to tackle the highest backlog of care the NHS has ever faced. Some politicians have declared the pandemic to be over but, in a sobering piece, frontline doctors warn growing complacency in wider society and the resulting pressure on the NHS is threatening to derail efforts to tackle the vast backlog of electivecare needs. One aspect of the pandemic that has

come to an end for many is access to free staff parking at hospitals. Suspended during the height of COVID, charges are now returning to many trusts with some doctors reportedly having to pay up to £2,000 a year just to park at their workplaces. The article highlights the huge variation in how trusts in England, which collectively made more than £90m in staff parking charges in the 2019/20 financial year, often apply fees, while hearing from doctors who want to see England follow the rest of the UK in abolishing what is an unfair tax upon their work. Also, in this issue of the magazine, we speak to Ruth Watt, the widow of ‘diligent’ diabetes and endocrinology consultant Alastair Watt who tragically took his own life following a traumatic brain injury and work-related stress. Since his death in 2017, Dr Watt has pursued answers about her husband’s treatment by his employer, the former Northern Devon Healthcare NHS Trust, and has now brought a successful legal challenge against the trust with the BMA’s support. Dr Watt, who is a GP, wants society to understand that those in caring professions must be cared for, too. 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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SARAH TURTON

AT A GLANCE Workload, technology and the media: GPs share their experiences ‘It has been an extraordinary two years for our profession.’ Opening the UK conference of local medical committees earlier this month, BMA UK GPs committee chair Phil White poignantly summed up the feeling within a packed hall in York. ‘For each and every one of us,’ he said. ‘All of our lives have changed.’ Dr White continued: ‘I can honestly say I have never felt so proud to address a group of people – to share a room with a group of people – as I do today… I am proud because when our patients needed us most, we changed our ways of working almost overnight. We embraced technology to give patients the best access possible and we put ourselves in harm’s way for those who could only see us face-to-face.’ And, turning his focus to national media and politicians, Dr White added: ‘General practice has maintained services, working harder than ever for our communities, despite what the press and the Westminster Government think.’ After such a tumultuous two years during the pandemic – an unprecedented health crisis which arrived at a time when general practice was already in crisis – it is little surprise that GP leaders had a huge amount to discuss, and debate was as passionate as it was important. Among the motions passed by LMC representatives were demands to celebrate and value the contribution of international medical graduates. The calls included support for tier 2 sponsorship, a mandated five-year minimum visa award and support for the relocation of close family of NHS workers to the UK. Shropshire GP trainee Adewale Saka said he was unsure if he would get his tier 2 visa and felt ‘pressured’ because he needs his job to look after his family. Northern Irish GP Ciaran Mullan described any barrier to bma.org.uk/thedoctor

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doctors helping solve workforce and workload problems as ‘nonsensical’. GP representatives also called on the UK government to investigate the effect of recent digital innovations on health inequalities amid fears that technology has isolated the most vulnerable in society. Anu Rao, BMA GPs committee IT lead, said: ‘The BMA is committed to reducing health inequalities that arise or are exacerbated by things like access to technology, and has already begun work calling on the UK Government to assess the impact that recent digital innovations have on health inequalities.’ Elsewhere GP leaders demanded a new GP contract which rewards continuity of care and called for the BMA to negotiate safe working limits for general practice. Rachel McMahon, of Cleveland LMC, said GPs felt the pressure to ‘do more from everyone around us’. She added: ‘Our workload is impacting our health and wellbeing and the safety of our patients.’ By Peter Blackburn For more information, visit bma.org.uk/what-we-do/ local-medical-committees

VOICES HEARD: (top) Dr White, (left) Dr McMahon and Dr Rao

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SIMON GRANT

COVID hasn’t gone away, but free staff parking has, in many parts of the country. Ben Ireland talks to doctors angry at the withdrawal of a rare pandemic perk

PENALTY CHARGE 04

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SIMON GRANT

oliticians may speak of ‘exiting’ the pandemic; the reality is anything but. There is, however, one aspect that is well and truly over for many doctors. What they’re exiting from in many parts of England is one of the few small perks gained during the pandemic – free staff parking at hospitals. Charges often running to hundreds of pounds a year returned to many sites last month after a two-year pause. Doctors say it amounts to a tax on their work – a tax they have no choice but to pay, given their working hours and a lack of public transport alternatives. ‘Charging staff to come to work is wrong on every level and trusts shouldn’t be able to get away with it,’ says Mike Henley, a consultant urologist and chair of the BMA’s East Midlands regional consultants committee. ‘The pandemic brought it into sharp focus: when push comes to shove, the world doesn’t fall apart when staff parking is free. ‘I’ve always thought hospital car parking charges are iniquitous. Really, they are a direct subsidy to the running costs of the NHS. There are places that charge £2,000 a year for car parking. That’s some levy on your salary.’ Dr Henley says doctors often finish work at unpredictable times. ‘Quite often there’s no public transport, and doctors will be on their own. It’s quite different to many ordinary workplaces.’

Lower earners hit Junior doctors, on lower salaries and working on rotations at hospitals that can involve lengthy travel, often feel the pinch the most. Cristina Costache, a paediatric specialty trainee 3 in Yorkshire, says parking charges add to the realterms ‘pay erosion’ of recent years. ‘We don’t earn that much as junior doctors and parking costs will probably continue to go up with inflation,’ she says, noting how many hospital staff look for nearby on-street parking to get round fees. ‘We don’t choose where we work as trainees – I can’t choose a trust that has no parking costs or good public transport.’ In a previous part-time rotation at Bradford, Dr Costache was charged £35 a month to park, the full-time rate, ‘and it didn’t even have lights’. Safety concerns meant ‘we would never allow each other to walk out alone’, she recalls. Dr Costache, a member of the BMA junior doctors committee, believes parking should be free for all NHS staff, and asks: ‘If you make some people pay and some people don’t pay then where bma.org.uk/thedoctor

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do you draw the line?’ There is a disparity across trusts. While fees are being reintroduced in England, Northern Ireland is removing hospital parking fees. A bill was approved in March and received Royal Assent this month. Wales chose to abolish hospital parking charges in 2008, although this only came to fruition in 2018. Scotland made the move in 2009. However, three PFI sites in Scotland – Ninewells Hospital in Dundee, Glasgow Royal Infirmary and the Royal Infirmary of Edinburgh – continued to charge staff to park until the pandemic. To even things up, the Scottish Government spent £35m to buy car parks in Dundee and Glasgow from private providers in August 2021. Staff at Edinburgh, meanwhile, are petitioning NHS Lothian over being asked to use a park-andride site they say adds up to two hours a day on to commutes and puts agency staff off taking roles, ‘making the hospitals unsafe with staffing levels’.

COSTACHE: Parking charges add to pay erosion

‘Charging staff to come to work is wrong on every level’

Postcode lottery Alan Robertson, a consultant cardiologist at Ninewells and deputy co-chair of the BMA Scottish consultants committee, says the removal of the £35-a-month charge in Dundee was a de facto pay rise – and would make even more difference for staff at Edinburgh, who are charged £7.20 a day. ‘In Scotland we were given a £500 COVID thank you payment, but that was taxed so free parking was more financially beneficial,’ he says, as he spells out the challenges doctors face with using public transport – such as working overtime late into the night, working across multiple NHS sites, childcare commitments, and commuting from suburbs to cities. ‘People were really pleased.’ Referring to England, he says: ‘After a couple of years of not paying, I can see how it would annoy people – certainly if there’s a postcodelottery element.’ And there is, as it stands. The BMA has been told at least seven trusts extended free parking until 1 May, two did so indefinitely, two more deferred charges for three months and one has told staff it has delayed its decision on the issue. Two stressed they never charged staff to park. Leeds Teaching Hospitals NHS Trust

‘There are places that charge £2,000 a year for car parking’

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DATTA: Charges a tax on work

reintroduced staff parking fees at £30 a month on 1 April; Sheffield Teaching Hospitals NHS Trust plans to reintroduce fees at 2020 levels, but not for a month, while Lancashire and South Cumbria NHS Foundation Trust postponed the reintroduction of fees for three months.

Misleading signs ‘The removal of free parking was the tipping point for the morale of the NHS staff’

Shanu Datta, a consultant psychiatrist in Lancashire and South Cumbria, and deputy chair of the BMA consultants committee, says: ‘Staff have long felt car parking charges are a tax on work. ‘Charges are very much subject to the whims of individual trusts and their boards. It’s really opaque for staff. It’s a de facto tax. If the devolved nations can afford [to make staff parking free], why can’t trusts in England?’ Trusts in England raked in £90,098,213 in staff parking fees in the 2019/20 financial year, according to NHS England’s Estates Returns Information Collection data. This came from charges at 159 of 214 non-ambulance trusts. In 2020/21 – the year fees were removed – £5,272,594 was earned from 71 trusts. When he was working weekly clinics at Rochdale Royal Infirmary at the peak of COVID, Dr Datta noticed ‘they didn’t change the signage’ meaning ‘all the costs and penalty notices were still there’. Rochdale Infirmary, part of the Northern Care Alliance NHS Foundation Trust, is recorded in the NHS Digital data under the Pennine Acute Hospitals NHS Trust, which made £175,626 from staff parking fees in 2020/21, and £317,455 from patients. Dr Datta says: ‘Members of the public, and I dare say some staff, were still paying. Some didn’t believe me when I said it was free, and others didn’t

want to fight the hospital over a fine.’ He reported the same issue at Stockport NHS Foundation Trust – which took £9,503 in staff parking fees in 2020/21, and £180,533 from patients – when he went there for his first vaccine. UHCW (University Hospitals Coventry and Warwickshire NHS Trust) went from zero income in 2019/20 to earning the most of all trusts, £904,434, in 2020/21. A car park with an additional 1,600 spaces was opened in March 2022 in response to a lack of spaces. But the deal, with property developer Prime Plc, came at a cost to staff. Monthly parking costs at Coventry, and St Cross Rugby, rose from £43 to £50 per month as of 1 April. UHCW local negotiating committee chair Prakash Satodia says the extra spaces were a ‘welcome development’ but ended up a ‘trade off’ for higher prices. ‘It’s an above-inflation rise when the cost of living is going up,’ he says. ‘The trust will argue we had it free for the last year or so, but that doesn’t stand because that was paid by Government.’ Dr Satodia points out no profits from staff, or patient, parking go to the trust because it is part of a PFI (private finance initiative) contract. ‘When they cut my PAs and increase parking charges, they are taking from Peter to pay Paul,’ he adds. ‘Health can’t be a business.’ Dr Datta believes parking fees are ‘particularly galling’ for staff who pay through salary sacrifice as it reduces their pension contributions ‘for the privilege of parking your car at work’. He says that, while the issue has ‘long been a bone of contention’, the current cost of living crisis is a good time to lobby for universal free parking for NHS staff.

Petitions Meenal Viz, a junior doctor who made it on to the cover of British Vogue for her campaigning for the protection of healthcare workers in the first wave of COVID, has used her following to help gather more than 13,000 signatures on a Parliament petition calling for staff parking to be free permanently. ‘The removal of free parking was the tipping point for the morale of the NHS staff,’ she says. ‘As doctors we run through walls for our patients and show up whatever the circumstances. What we’re not happy with is how the Government keeps telling us how they’re on our side then does things, like this, that clearly show otherwise.’ Dr Viz, who pays about £40 a month to park

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Hospitals raked in far less from from parking during the pandemic – but charges are now coming back

EMMA BROWN

at work, believes the strength of feeling exists to overturn the health secretary’s decision and make hospital car parking free for staff again. ‘You can see it on the ground level,’ she says. ‘We’re still dealing with the pandemic, and there’s the backlog. The Government has shown the money is there, we just need the political will. And there’s enough support that we can challenge this decision.’ Buckinghamshire GP Anthony Gallagher was behind a 2020 petition which amassed huge support and is credited with prompting the Government’s decision to offer free parking. His change.org page now has more than 1.1 million signatories. Dr Gallagher questions how significant income gained from staff parking is to trusts compared with wasted costs, such as the £8.7bn the Department of Health and Social Care wrote off in overspend on PPE (personal protective equipment) purchased in the same financial year. While he accepts trusts ‘are not given the funding necessary to do the job they are asked to do’ he believes charging staff to park at work is ‘unreasonable’, pandemic or not. ‘It’s a form of income tax exclusive to NHS workers,’ he says, pointing to a knock-on effect on morale: ‘Once you have a policy to charge you have to have a policy to fine those that can’t afford to pay the charge and that leads to recruitment and retainment problems and staff shortages as well as stress and suffering.’ Dr Henley calculates that, over more than

25 years, he has spent upwards of six months of his time purely walking between his parking space and the area of the hospitals he has worked at. ‘What a waste of time,’ he says. But he has a bigger issue: ‘It’s respect for what doctors do as a profession, the stresses and unpredictability of the job. There’s a risk that, because car parking charges are coming back, it’s going to make people question their relationship with their employer. ‘Charging staff for car parking is, quite simply, either a money-making scheme for cash-strapped trusts or a cash cow for private companies.’ Dr Gallagher draws the same conclusion: ‘If a few pounds here or there is really operation critical, [trusts] need better management. Charging staff to park at work is surely the laziest and least effective solution to the NHS funding problem.’

A BRIEF RESPITE ... 2019/20

Income from staff parking from all trusts in 2019/20 (159 trusts charged): £90,098,213

£90m

Average across 214 trusts: £421,020 Three highest earning trusts from staff parking: Manchester University Hospitals Trust: £3,181,202 University Hospitals Birmingham Trust: £2,198,437 Leeds Teaching Hospitals NHS Trust: £2,076,244 Income from patient parking fees in 2019/20 (157 trusts): £199,228,466

VIZ: ‘We can challenge this decision’

‘It’s a form of income tax exclusive to NHS workers’

Source: NHS Digital

2020/21

£5m

Income from staff parking from all trusts in 2020/21 (71 trusts charged): £5,272,594 Average across 206 trusts: £25,597 Three highest earning trusts from staff parking:

University Hospitals Coventry and Warwickshire NHS Trust: £904,434 North Tees and Hartlepool NHS Foundation Trust: £705,293 Epsom and St Helier University Hospitals NHS Trust: £419,276 Income from patient parking fees in 2020/21 (129 trusts): £47,876,208

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CHARLIE BIRCHMORE

For Alastair’s sake

Consultant Alastair Watt took his own life after experiencing terrible stress at work. His widow Ruth, whom the BMA supported in taking legal action, says employers and the Government need to realise that doctors are human too. Seren Boyd reports 08

RUTH: Lessons need to be learnt

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about his symptoms and recovery showed ‘Alastair’s espite everything, Ruth Watt remembers her clinical knowledge and reasoning remained excellent’, husband as the man he always was. Ruth says. The Alastair who put trousers in the wash He was much more talkative, more emotional: he with bananas and nails in the pocket, who raged over the Brexit vote, Donald Trump’s election. melted new cycling shoes in the oven by misreading ‘But he was still the same person.’ the heat-mould instructions. The sportsman and Five months after his accident, occupational proud dad, the diligent ‘clever doctor’. What happened to Alastair in his last 20 months has health cleared him to return to work. He was excited to be back. not tainted her memories of him. But it’s hard to forget the man Alastair became towards the end, the sleepless, tormented ‘lost soul’ Struggle to be heard who believed he had failed. The man who walked Alastair raised concerns over his pre-existing workload out of the house into the darkness in December in the ‘return to work plan’ he was encouraged to write 2017 and was found in a field the next day, after a that September. Yet, it would be eight months before it fatal overdose of insulin and was even discussed. anti-depressants. His phased return to full‘He had an excellent team of nurses In the years since, Ruth has time work saw him mostly who supported him but he had no wanted answers. in clinic: his role covered registrar, no colleague’ Some of those answers she everything from obstetrics has now, through a successful and gynaecology to obesity to legal action she brought against Alastair’s employer, transition. He was also heavily involved in developing an the then Northern Devon Healthcare NHS Trust, with integrated diabetes plan across primary and secondary BMA Law’s support. care for North Devon on his own initiative. She has needed to understand, for herself and her ‘He had an excellent team of nurses who supported teenage twins, why he did it. And she wants others to him but he had no registrar, no colleague,’ says Ruth. understand too, to sound a warning that those in the For the first month, before he regained the driving caring professions need good care too. licence withdrawn due to injury, he would often cycle the 52-mile round-trip to work. Tipping point By January 2017 there were calls for him to resume Alastair Watt was already finding his workload on-call work in the MAU (medical assessment unmanageable before his accident in April 2016. He unit): neither Alastair nor his occupational health was a diabetes and endocrinology consultant at a busy consultant felt he was ready for the role’s fast pace and district general and had been working single-handed multitasking. But pressure was mounting: that spring, since his colleague and fellow endocrinologist had the trust announced its intention to offer 7/7 (sevenretired in 2012. days-a-week) services, at the Government’s prompting. Alastair was ‘exhausted and stressed’, says Ruth, There had also been a referral to occupational health and a cycling trip in Wales with his brother and friends by management, which Alastair felt was unwarranted would be a good tonic. Sport was important to him: and unfair. before cycling, he had played rugby to a high level while In the months that followed, discussions focused on at medical school in London. Alastair’s resuming on-call He and Ruth met at Barts: she duties, rather than addressing ‘He couldn’t make them is a GP. his workload more generally, understand how much work he But on that trip to the as the inquest heard and as was doing’ Brecon Beacons, his bike The Doctor has previously wheel clipped another’s tyre, reported. Alastair continued catapulting him over his handlebars and resulting in a to request a review of his workload. The consultant serious head injury. He spent three-and-a-half weeks who led his first job planning meeting, in April 2017, in hospital, being treated for a contrecoup subdural had no idea Alastair used to have a colleague. Still haematoma, then a rare form of hyponatraemia, nothing changed. cerebral salt wasting. Finally, at a meeting in September, it was agreed He spent five restless months at home. Initial speech Alastair would not do on-call, his workload would be difficulties and facial palsy resolved within weeks. slightly reduced – and he would take a pay cut. ‘He Regaining the processing skills required for reading, was so stressed before the meeting because he felt writing, organisation, took longer. Yet, their discussions he couldn’t make them understand how much work thedoctor | May 2022

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CHARLIE BIRCHMORE

(Left) Alastair and Ruth

RUTH: ‘Alastair looked OK so it was assumed he was OK’

But of this she is convinced: Alastair’s isolation and repeated calls for a colleague were not heeded. Much of what he did was ‘unrecognised and unvalued’, Last days especially his work on the integrated diabetes plan Immediately after the meeting, he went off on sick which was mostly in his own time. leave for a fortnight, returned to work briefly, then went ‘They never sat down with him and acknowledged on sick leave again in mid-October. all his roles and what work that entailed. His specialist His mental health deteriorated sharply. Soon, he work alone was more than full time, without the was too anxious to walk his beloved spaniel, Oscar, or additional work and pressure of on-call.’ collect the children from the bus-stop. By November, She has used FoI (Freedom of Information) requests he was having suicidal thoughts. ‘He just shrank, to access Alastair’s work emails to managers on the went off his food, stopped sleeping, couldn’t make a subject of his job plan – and to look back through decision. He believed he had lost his job and felt that vacancies advertised on NHS Jobs. The trust said at his he’d failed.’ inquest they had not been able to recruit for the role The day he went of endocrinology colleague missing, 12 December, he for Alastair. ‘It’s important that we allow was incoherent, ‘probably ‘I found no evidence of any doctors to be ill and allow them the psychotic’, and had convinced job adverts after October 2014 space to get better’ himself he had mismanaged either through my FoIs or legal some of his patients. proceedings,’ says Ruth. Alastair slipped out at nightfall, sparking a man hunt Ruth has also pushed to see the findings of an NHS that spanned the 26 miles between their home and the Improvement investigation into the trust’s former hospital. Ruth joined the search, with friends. He was management, which she finally achieved through court found in a field in their village. The coroner concluded disclosure. The medical director had faced a vote of that Alastair took his life following a traumatic brain no-confidence by senior clinicians early in 2017, amid injury and work-related stress. accusations of bullying: he left the following year. Ruth ‘This is a small community and Alastair had a public believes this report should be made public. death,’ says Ruth. ‘There were police everywhere. ‘We have to start talking openly about what happens There were even rumours that he did drugs because when things go wrong, so lessons can be learnt. At the police told locals they were looking for the syringe he’d moment, it seems there’s a culture of fear in the NHS used. I want people to know what happened.’ that shuts the conversation down.’ She is adamant she has no complaint against Searching for answers Alastair’s clinical colleagues. And she’s clear that her Ruth has wanted to make sense of what happened in complaint is against the former management of the the months immediately before Alastair’s death. trust, not its current executive. ‘He turned in on himself and didn’t give me loads ‘I know that the trust’s changed, and there have of detail.’ Her dealings with the trust management been masses of improvements. But openness and have been difficult and distressing. She has had ‘no the acknowledgement that things didn’t go right for acknowledgement, no apology, no gesture’, she says. whatever reason would mean so much to me.’ he was doing,’ says Ruth. ‘Then he felt discriminated against because he wasn’t able to do the MAU work.’

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Space to recover

Protecting memories

Ruth insists that a lack of in-depth knowledge about brain injury, including among medical professionals, meant that Alastair’s struggles with complex processing were not recognised. She acknowledges that he hid them too, for fear of looking unprofessional and, later, for fear of losing his job. His processing ability was assessed before his hospital discharge in May 2016 – and never formally revisited in relation to his work. ‘Alastair looked okay so he was assumed to be OK,’ says Ruth. But there’s a more general, more pressing point: ‘It’s important that we allow doctors to be ill and allow them the space to get better. “The workload was the workload”, we heard at his inquest. Alastair had to suffer a pay cut because he was not able to do the work in MAU. This wasn’t fair because he was doing the work of two consultants already.’ Ruth was given compassionate leave after Alastair’s death and was supported fully in her own return to work. Her colleagues shielded her from more stressful roles. She dropped a session, even changed her day off to help establish new routines in bereavement. ‘My colleagues said, “Anything you don’t feel you can manage, you hand over”. And I knew that was true. I felt huge guilt about being off work: you feel you’re dumping colleagues in it. Alastair felt hugely guilty about being off sick. Even on his last day, he was worried about his patients: he was the only consultant.’

Ruth believes Alastair would not have approved of her personal injury claim against his employer – or of the settlement she’s received. ‘Alastair didn’t approve of people suing the NHS and I did agree with him, but I wanted answers and truths and taking legal action was the only way to get them. We’d never seen the need to be in a trade union like the BMA before but thank God we were because that’s how I got my answers. This was never about the money.’ Ruth and her twins keep Alastair in the conversation: they still go to the rugby, still discuss what he’d have thought. He definitely wouldn’t have approved of the trampoline. ‘We’re moving on with our life but I continue to be so outraged at what happened to him. This comes with me: this is part of my future and my past. ‘The Alastair after the head injury was still Alastair, with the same principles and values. He still loved his sport, still loved his family. I want him to be remembered as the person he was, so full of life and energy.’

‘We’re human too’ Ruth wants a wider conversation about workloads for frontline workers in the NHS. In her own practice, where she is a partner, she says, ‘We sometimes feel we’re not practising medicine as we would like to because of the pressure of time and the lack of human resource. ‘It’s dressed up as resilience and professionalism to fill in the gaps, to always do more, but you can only do so much. At some point, people will buckle and some things can make them more vulnerable, in Alastair’s case a traumatic brain injury … Management were too focused on what they needed Alastair to do rather than what he could realistically cope with. ‘If you’re very stressed, you can’t do good medicine. It’s how you make an intelligent, hardworking, ethical person like Alastair fail. He just burnt out: Alastair didn’t have a history of mental health problems. This Government’s not listening. But it must because we are human too.’ Ruth says she’s banned her children from going into medicine. bma.org.uk/thedoctor

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Help at hand BMA Law’s personal injury scheme offers BMA members and their families free advice and representation* if they are injured through the fault or negligence of a third party. This includes accidents at work, on the road or in a public place, and disease claims. Key benefits: – Most other lawyers acting for personal injury claimants take a ‘success fee’ of up to 25 per cent of damages for past losses and pain or suffering. BMA Law takes no such fee – If you are employed under a standard NHS contract or GP partnership, BMA Law can often recover for the trust or practice the costs of sick pay advanced (and on occasion locum cover) – If you received hospital treatment after a road accident, a successful claim ensures recovery of appropriate costs for the NHS trust providing treatment. For a free consultation, contact 0300 123 2014 or email info@bmalaw.co.uk * Subject to reasonable prospect of success

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LET DOWN It will be years before the Government’s public inquiry into COVID gives its findings, but lessons need to be learned now. So the BMA is publishing its own reports into the pandemic, the first two revealing the woeful lack of protective equipment in the early days of the epidemic, and the profound physical and mental strain it has placed on doctors. By Tim Tonkin

ince it was founded in 1948, nothing has tested the Deficiencies in PPE (personal protective equipment) abilities and durability of the NHS as COVID-19 has. either through shortages, being of incorrect type or The selfless and courageous response poorly fitting, was a phenomenon commonly reported from health professionals over many months of the by doctors across the board during the first weeks of pandemic contrasts sharply with criticism of the the pandemic. Government’s handling of the initial stages of the Respondents to the call for evidence from doctors crisis, labelled by the Parliamentary health and social working in AGP (aerosol-generating procedure) settings care and science and technology committees as ‘one revealed across-the-board shortages or a complete of the most important public health failures the UK absence in a range of PPE. This included 71 per cent of has ever experienced’. respondents citing shortages in full-face visors, 65 per While there are two ongoing inquiries into the cent citing disposable goggles and 54 per cent reporting pandemic, one led by the UK government and one by deficiencies in FFP3 (filtering facepiece 3) masks. the Scottish parliament, the former is yet to even agree One GP based in Northern Ireland told the BMA they a final terms of reference for its remit – let alone begin were ‘amazed at how paltry it was’. to examine the facts. ‘[It was] like going over Recognising the urgency the top in WW1 with a bow ‘The PPE guidance was based not on safety, and arrow.’ of finding answers, the BMA undertook a detailed study of ‘At the start, despite but ratherthe lack of preparedness’ doctors’ views and experiences knowing of the virus spread, through an online call for no PPE was provided,’ says a evidence conducted between November and December consultant based in Wales. last year. Drawing on doctors’ submissions, as well as data ‘Not even masks let alone thinking of level 2 PPE for compiled through multiple COVID tracker and viewpoint aerosol-generating procedures. This was when many of surveys, the results of these investigations now form the my colleagues and I became ill.’ basis of five reports on the pandemic. PPE failings The first and second of these reports, which focus In its first report, the BMA determines that initial respectively on the protection of the medical profession shortages in PPE were exacerbated by a failure to enact from COVID-19 and the effect of the pandemic on the pandemic-preparedness measures in the years prior to medical profession, have been published. COVID and inadequate or poorly communicated safety Their findings paint a harrowing image of what guidance once the pandemic began. thousands of doctors had to endure, and how failures in The latter included some doctors being instructed by government policy before and following the onset of the pandemic, had a dramatic effect on staff’s physical safety their employers not to use PPE during the early weeks of the pandemic, with Government guidance failing to keep and mental wellbeing. pace with the rapidly changing situation on the ground. One of the most damning findings from the BMA’s ‘I was not allowed to use the PPE that I had personally first report is that 81 per cent of the nearly 2,500 paid for,’ one medical academic consultant from doctors participating in the call for evidence state they England told the BMA. did not feel fully protected during the first wave of the ‘They [the trust] said it will be unfair to the rest of pandemic in 2020. 12

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NEIL HALL – POOL/GETTY IMAGES

INTENSE PRESSURE: Doctors continue to face high COVID infection rates while battling a vast backlog

the staff if I used my own. When I said that I would be assumption that aerosol transmission only occurred happy to share with people that I work with, they said, during aerosol-generating procedures’. It was already unless I could provide [for] everyone in the trust, it becoming clear COVID could be spread by talking or wouldn’t be “fair”.’ coughing, but the guidance – on which employers The report says the tended to rely – did situation was further not change. compounded by the IPC cell, ‘False platitudes of staff safety ‘The PPE guidance was the pan-UK body tasked with based not on safety, but rather were peddled out’ reviewing and developing the lack of preparedness,’ one infection prevention and staff, associate specialist and control guidance, downgrading the requirement in specialty doctor based in Scotland reported. March 2020 for those interacting with COVID patients. ‘False platitudes of staff safety were peddled out, Staff were required only to have a fluid-resistant when in fact staff were left at higher risk.’ There were also worrying disparities in the surgical mask, ‘ostensibly driven by the unfounded bma.org.uk/thedoctor

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GETTY

Demand for BMA counselling services Lack of PPE

71%

A 173 per cent increase, comparing the period February 2019 to January 2020, to February 2021 to January 2022

reported shortages in full-face visors

DEMAND UP

173%

source: BMA

65%

in disposable goggles

54% in FFP3 masks source: BMA

damage to my spinal cord,’ they explain. ‘I now walk with crutches and cannot walk more than about 200m without them. I also have bladder and bowel problems and have to intermittently catheterise. There is not a day that goes by where I don’t have some form of pain.’ ‘I caught COVID in March 2020 from a colleague at work,’ a junior doctor from Scotland told the BMA. ‘I have been mostly bedbound since. My life as I knew it had ended. These are supposed to be the best years of my life but I’m spending them alone, in bed, feeling like I’m dying almost all the time.’ The mental and emotional toll of the pandemic upon the medical profession has also been enormous. Demand for BMA counselling services between February 2021 and January this year saw a 173 per cent COVID’s legacy increase compared with the period of February 2019 At least 50 doctors are to date known to have died of and January 2020. contracting COVID-19, while many more are thought to Responses given to the BMA highlight the huge have suffered prolonged and debilitating symptoms of psychological effect the the virus through long COVID. pandemic had on many ‘These are supposed In its second report on the doctors’ professional and pandemic, the BMA cites a to be the best years personal lives. survey conducted in February of my life but I’m spending ‘I was worried for my own this year which found that them alone, in bed’ mortality [and] more so among doctors who had for my family’s,’ explains a locally employed doctor developed long COVID, 11 per cent said that they had from England. been forced to reduce their working hours. ‘I didn’t physically go inside their house for at least A further 51 per cent said that, while they were six months. One day I arrived to [see] my father crying still able to work, their condition had affected their in the window waving at me. He opened the front door quality of life. One medical academic trainee from and asked me to quit my job, he was worried I would England said that, after contracting COVID from their also die as a result of COVID exposure at work.’ workplace on two separate occasions, they were left One SAS doctor based in England told the call to permanently disabled. evidence that the pandemic had been ‘one of the ‘My second COVID infection has left me with experiences around COVID risk assessments, with staff from ethnic minorities reporting higher levels of dissatisfaction with the risk-assessment process and ethnic minority staff and women experiencing more issues with fit testing in their workplace. Forty-eight per cent of ethnic minority doctors told the call for evidence their individual risk assessments had been either mostly or completely ineffective at protecting them during the pandemic, compared with 35 per cent of white doctors. Shortages in PPE and having to care for seriously ill patients, often while not feeling properly protected personally, had a huge mental and physical effect on thousands of doctors during the pandemic.

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NEIL HALL / POOL / AFP /GETTY IMAGES

worst periods of my life’ adding that they had had to seek private therapy having at times felt suicidal because of their experiences. A Scottish GP meanwhile confessed to still having flashbacks of wheeling former patients to an ‘overfull morgue’ and having to deny visitation access to families whose loved ones were dying. ‘There is no escape from it,’ another SAS doctor told the BMA. ‘I see dead colleagues in the trust news emails, local and national press. I dream about it at night. I’m intermittently consumed by the ocean of sadness it has caused.’ Yet, at a time of unprecedented mental and physical stress, many doctors responding to the call for evidence spoke of how, far from receiving much-needed support, they were often left feeling abandoned or even attacked by the Government. Doctors working in general practice in particular found themselves being targeted by the UK Government and national press and, as a result, some patients, after being falsely portrayed as ‘not working’ and failing to provide the public with access to care. In its second report, the BMA states that the UK Government’s failure to publicly back and defend doctors in the face of this growing hostility undoubtedly damaged the morale of the medical profession as a whole.

‘Derided in the press and by politicians as lazy and told to get our act together’

‘Extremely demoralising as a GP to have worked very hard for the last two years adapting to a new world/technology and ways of seeing patients to help keep everybody safe and meet demand, to then be derided in the press and by politicians as lazy and told to get our act together and see patients face to face,’ said a GP from Scotland. ‘This attitude in press and by politicians is doing possibly irreparable damage to the morale of GPs and the respect/attitude patients have for us.’ ‘I am now finding demand from patients has risen exponentially and with long delays in referrals to secondary care, we are receiving a lot of verbal abuse from angry and frustrated patients,’ said a salaried GP from England. ‘This has not been helped by the negative impression of primary care perpetuated in the media and by the comments of some politicians. It has made me question if I want to continue in primary care once the pandemic is over.’

Responding to the publication of the first two of the association’s reports into the pandemic, BMA council chair Chaand Nagpaul (pictured) says the studies represent a landmark in research about COVID-19, how it affected doctors and how Government failures and mishandling frequently exacerbated the situation. He says: ‘These reports are probably the most significant body of evidence about the pandemic ever prepared, containing the lived experiences of doctors during one of the most traumatic times in NHS history. [They] also reveal, unequivocally, that the Government failed in its duty of care to the medical profession and point to critical lessons that must be learned for the future. ‘Some of the decisions made by the UK Government during the pandemic had tragic consequences. At least 50 doctors have died as a direct result of contracting COVID-19 whilst many thousands more have suffered or continue to suffer anxiety, burnout and moral injury. Doctors have had to care for dying colleagues, hold smart phones in front of dying patients so loved ones could say good-bye, and go to work sometimes daily with inadequate personal protective equipment, poor risk assessments and little or no respite.’ He adds: ‘We are determined that doctors’ voices are heard and so by bringing together for the first time their experiences and their evidence, we can present our findings to the public inquiries with total clarity.’

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SIMON GRANT

PAUL HERRMANN

WALL: ‘We feel like we are about to lose all our staff again’

The former health secretary has said the COVID pandemic is over. The reality could hardly be more different, with high case numbers, staff absences, and a terrible legacy of stress and overwork. Ben Ireland reports ‘We have been overworked, colleagues are psychologically stressed’

GOYAL: Facing exceptional demands

‘W

e’re hanging on by our fingernails.’ Dan Goyal, a consultant in internal medicine in NHS Highland, has been pushed to the limit and left reconsidering his career choices. ‘The demands on the service, both COVID and non-COVID, are exceptional. In the past we’ve had time to gather our thoughts, but we haven’t had that for a year or so. It’s worse than it’s ever been.’ A new Omicron variant – labelled BA.2 – drove a fresh surge in cases and gave frontline staff like Dr Goyal no respite, even after two years. Despite vaccination success, ONS DOUGLAS ROBERTSON

data shows a significant recent spike. And the effect on doctors and other healthcare workers is severe. In Scotland, according to estimates from the Office for National Statistics, 5.35 per cent of the population had COVID in the week ending 16 April, falling to 3.01 per cent in the week ending 7 May. In England, the comparable figures were 5.90 and 2.21 per cent. The percentages may be falling but the overall number of cases are still higher than at many points when tight public health restrictions applied. The hidden wave quietly ripping through the country has led to fewer deaths than previous spikes, but healthcare services remain on their knees as they battle through 94 per cent bed occupancy levels and ambulance wait times of up to 22 hours amid unprecedented staff absences driven by COVID and stress. ‘In terms of COVID itself, we are much better at dealing with it, and we can handle it, but in terms of accumulated stress, it’s much worse,’ Dr Goyal says. He explains: ‘Each wave has seen the virus get progressively less severe. Now, we expect patients to recover, even the more vulnerable. Prior to this we have been putting in the effort to get them to recover but knowing the odds are against them. That’s a relief, but we have been overworked, colleagues are psychologically stressed – and now we’re getting pressure from Government to clear waiting lists.’ South-west England has been one of the

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SIMON GRANT

It never went away bma.org.uk/thedoctor

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PAUL HERRMANN

positive we are getting them in within 48 hours and giving them pre-treatment. That didn’t exist in the first and second waves. We have effectively kept one entire ward’s worth of people out of hospital. ‘A lot more patients are presenting with symptoms that are not specific. For older adults, delirium is the most common but lots of patients are coming in with chest pains, or abdominal pain. It fits with the new symptoms of COVID. We’ve become incredibly cautious with anybody coming in.’

Staff absences

WALL: ‘People say we are living with COVID but it doesn’t feel like it’

‘We are doing amazing things to keep the vulnerable out of hospital’

‘People are very much at the limit of what they are able to do’

worst affected areas in the country by this latest wave. The Northern Devon Healthcare NHS Trust had, at the time of writing, six full-time COVID wards in operation, including one at a community hospital. In January 2021 there were four wards, but the trust had the option to send patients to the 116-bed Exeter NHS Nightingale. ‘COVID numbers are almost at the same as the January 2021 peak,’ said David Strain, when he was interviewed by The Doctor on 6 April. He is the regional NHS lead on COVID who has also played a major role in the BMA’s response. ‘The rhetoric is that COVID is all over. But the numbers I have seen suggest we would have the same number of people in hospital with COVID as the previous peaks.’ Patients in UK hospitals with confirmed COVID were at slightly higher numbers on seven days in early April – around 20,000 – than they had been at the year’s previous peak on 10 January, the figure for 6 May being 10,270. Deaths where COVID was listed as one of the causes were also at similar levels in early April as they were in January. The level of deaths is ‘still more than heart attacks, strokes, pneumonia’, Dr Strain adds. ‘We always have to put the caveat in that the patients we see in hospital are at the narrow end of the wedge. We are seeing that same narrow end of the wedge but not as many people are going to ICU. In the last wave, there were five or six times as many patients in ICU support. ‘We are doing amazing things to keep the vulnerable out of hospital. As soon as they test

Yorkshire-based consultant in pain medicine and anaesthesia, Ian Wilson, says his hospital is encountering many triple vaccinated COVID patients. ‘So many people are coming into emergency departments that we have trolleys in waiting areas.’ Helen Wall is a GP partner and clinical director at Bolton Clinical Commissioning Group. She says: ‘It doesn’t really matter whether patients go in with COVID or not. As soon as they test positive they have to be isolated in a COVID ward. It has an impact on patient flow. Then no one can get through the front door in [emergency departments], and people are on trolleys for lengthy periods of time.’ The level of staff absence has made things exponentially worse. There were 74,082 staff off in England on 31 March. You’d have to go back to 20 January for a higher daily total. Dr Goyal’s 15-strong medical team, which includes five consultants, has trudged through with three to five doctors off at any given time. It is a vicious cycle with COVID causing stress, stress causing absence and absence piling on the pressure. Often even doctors signed off by their GP don’t want to take time off ‘because of the impact it has on their team’. ‘People are very much at the limit of what they are able to do,’ adds Dr Wilson. ‘It’s still a challenge to absorb that clinical workload and find the right places for people to be safely cared for.’ And with NHS waiting lists at record levels – 6.4 million in England alone – Dr Wilson makes the point that Government does not seem to have grasped – more staff off with COVID equals ‘fewer people to do the catch-up work we need doing’.

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WILSON: Staff absences affecting catchup work

Dr Strain says staff tend to be off for longer in the current wave. ‘Before, people had minor symptoms and were champing at the bit for that negative test to come through after five or six days,’ he adds. ‘Now, more staff are unwell for longer, 10 or 11 days – or they have long COVID so can only come back for half days.’ As well as COVID absences, he notes: ‘A fair number of people are facing burnout. The recovery that was supposed to begin at the start of this year has been set back.’ For many staff it is simply too much to go back to work.

PTSD and guilt Erica Favero was clinical nurse manager on a COVID ward in a south-west community hospital for the first and second waves and has since been diagnosed with PTSD. ‘When I tried to go into COVID [wards] again [in the current wave] it hit me completely,’ she says. ‘I couldn’t walk into the ward, and I had palpitations. About a week before being asked to go back into COVID, I started a shift trying to overcome this feeling, but it got worse. I was talking to a patient but wasn’t really concentrating on what they were saying. I burst into tears.’ Ms Favero says she now has to live with the guilt that she is not able to care for COVID patients and support her colleagues. Staff absence also remains ‘an ongoing nightmare’ in primary care, says Dr Wall. ‘In December and January, every single practice in the area had most staff off. We scraped by and got through that – now, months down the line, we feel like we’re about to lose all our staff again – and I know hospitals are struggling too. People say we are living with COVID, but it doesn’t feel like it.’ bma.org.uk/thedoctor

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Having to self-isolate with COVID himself recently, conducting clinics online, Dr Wilson believes staff are more likely to pick up the virus outside of hospital than in it due to public apathy, the end of free tests and Government messaging. Dr Strain agrees. He says: ‘People have decided it’s gone. While I appreciate why, wanting it to be gone and it going are two different things. It hasn’t gone.’ ONS data shows just 40 per cent of adults said they had taken a lateral flow test between 16 and 27 March, down from 61 per cent between 6 and 16 January. And only 68 per cent of adults reported wearing a face covering outside their home, dropping from 95 per cent between 19 and 30 January. The BMA has lobbied for the Government to reconsider its move to scrap free COVID testing for the public, which it says ‘risks creating a two-tier society between those who can afford to pay for tests and those who can’t’. Dr Strain adds: ‘The big demoraliser is when staff wear their FFP3 masks and goggles, and shower before leaving the building, then go to the park and ride or get on the bus and are surrounded by people who are oblivious to it. The rhetoric that COVID is all over makes the work they have been doing every day seem pointless.’

STRAIN: Staff off sick with COVID for longer

‘Wanting COVID to be gone and it going are two different things. It hasn’t gone’

Unmet need Among those driving that rhetoric is former health secretary Matt Hancock, who recently declared ‘the pandemic is over’. The prime minister’s office said in April that COVID should be ‘managed like any other respiratory illness’ – although this was rebuffed by the BMA, which said the Government was ‘burying its head in the sand to the immediate threat of the virus to our healthcare services’. The effects of COVID-19 are being keenly felt in primary care. Dr Wall says cases of long COVID where patients didn’t know they were infected are a common occurrence and the mountain of unmet need which built during the pandemic is now showing, too. Dr Wall estimates 40 per cent of her patients are presenting with issues the patients ignored or thedoctor | May 2022

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DOUGLAS ROBERTSON

GOYAL: ‘It’s not sustainable’

‘COVID is crippling us, then I go into the normal world, and it feels like COVID doesn’t exist any more’

are related to secondary care delays. That unmet need – that mounting backlog – is the elephant in the room. And the biggest question is whether there will be enough staff left to deal with the backlog if pressures continue as they are? ‘Resignations are high,’ says Dr Goyal. ‘Every third person I speak to is looking for the exit – to New Zealand, Australia, to go and work on a cruise ship. Everybody is on edge. I’m questioning my career choice, to be honest. ‘We are passing the work around because we don’t have the capacity. That brings on a spiral. We don’t have enough capacity to treat people well enough to prevent them from becoming more severely unwell – and we end up having to put NHS resources into recovering them. And that continues.’ These issues threaten to become existential for an underfunded NHS with too few staff and appearing to lack the full support it needs from ministers. ‘The big question is how many post-COVID issues we’re dealing with,’ Dr Goyal adds. ‘We know if someone gets discharged with COVID they will have a very significant healthcare usage for at least two years. And we have had a lot of COVID patients.’

A service crippled NHS leaders and the Government will have to find the will to address some of these very significant questions – and the answers to those questions must include addressing pay 20

and terms and conditions, wellbeing of staff and, perhaps most fundamentally, the future shape of the workforce. Dr Goyal says: ‘Everybody does more hours than they should, and they’re not being paid overtime. If the organisation was like that for the first or second wave of a pandemic, fine, but we are two years down the line now and have ended up with an inefficient service and more resignations. It’s not sustainable.’ Dr Wall agrees ‘morale is shocking’. ‘In any crisis people go through that stage of ‘we’re all in this together’, or ‘we are going to beat this’ when you have that adrenaline,’ she says. ‘Then people get fed up. ‘Throughout the pandemic we’ve seen patients get really disgruntled, then we’ve had another wave. Some patients are actively choosing to be abusive to us because they perceive we are using COVID as an excuse not to see people when really we are working harder than we ever have. We are busier than we have ever been, dealing with more patients day by day.’ Dr Wall adds: ‘Because of the amount of demand versus the capacity, versus having staff off with COVID or stress or anxiety we are in a really difficult position – and it’s been worsened because nobody [in politics] is coming out and saying it. ‘COVID is crippling us, then I go into the normal world and it feels like COVID doesn’t exist anymore. This wave that we all know is really happening, and is bad, is hidden from the public. ‘There are more challenging times ahead.’

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viewpoint

The right signals The training session was dull, barely relevant and compulsory – but then it took an unexpected turn ‘Five minutes left !’ the invigilator said. I still had a question in front of me on the screen, but my spirits had drained away long before. Doctors are no strangers to taking exams, indeed they are the portals through which we have to pass at every stage of our careers. I remember moments of panic and moments of triumph, of inspiration and disappointment, going all the way back to my late teens. But this particular one was stirring no such emotions. It did not help that it was compulsory, and that it could only be taken on site as opposed to online. And it did not help that the topic, while important – child protection – had been set without any consideration that I, as a geriatrician, might ﬁnd it of limited relevance. There had been many other ‘mandatory modules’ in the months leading up to it, each with the inevitable test at the end. If only ‘mandatory’ equated to ‘useful’. But no, I had had to answer hundreds of questions, including such gems as, ‘Employers have a legal responsibility if they employ more than how many workers?’ and ‘What is the name of the Act passed in 1985 relating to hazards in the workplace?’ Please don’t send in the answers. I understand that one should know not to discriminate, to conduct interviews in a particular way, and yes, we should know the ﬁre drill. Some of these are a matter of common sense while others are important to be made clear. New employees could be briefed on relevant regulations during induction by a couple of sessions. But formal tests, repeated at varying intervals on details of the employment laws and health and safety regulations are, I think, completely pointless. Surely our lives as doctors in the NHS are gruellingly time-intensive already, and every moment spent wasting our time on some module or other is a moment away from patient care.

‘Two minutes left.’ In this test, I hadn’t known the answers to most of the questions, and the ones I did answer were mere guesswork. The other candidates, either clever enough to sail through it or even less motivated than I was, had already slunk off. The invigilator caught my eye, smiled, and then did an extraordinary thing. She appeared to purse her lips and blow me a kiss. I was completely flustered. As a whitehaired man in his 60s I didn’t tend to attract much attention of that kind, but, far more importantly, this was a workplace, and hadn’t there been at least one mandatory module dedicated to this very topic? I stared hard at the screen, unable to process it. ‘One minute.’ And then she whistled. Not, admittedly, like a building-site wolf whistle, but a whistle nonetheless. And clearly directed at me as I was the only other person in the room. This was too much. I’m a happily married man. I gave up on the final question, pressed ‘submit’ on the test and made for the door. But she reached my desk before I could even haul myself up. ‘Whistleblowing,’ she said, with a sympathetic grin. ‘That was the answer to the question you’ve been staring at for the last few minutes. I know I shouldn’t, but I was trying to give you a hint.’ There was so much of the health service in that moment. A daft directive from management, in which we were all trapped. A bending of inflexible rules with a compassionate intent, which we all do at times. And a great dollop of misunderstanding between colleagues – there’s plenty of that too – which in this case turned the blandest afternoon for just a few moments into a scene from a Carry On film. Radhamanohar Macherla, now retired, was for more than 20 years a consultant physician with Barts Health NHS Trust thedoctor | May 2022

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Your BMA

The annual representative meeting agenda will reflect your concerns

27 to 29 June sees the most crucial event in the BMA’s policy-making calendar, your annual representative meeting, which this year takes place in the city of Brighton while also being publicly streamed live online. Ahead of this important event, your ARM agenda committee, and myself as chair, have started our analysis and prioritisation of the motions you submitted for debate. For many, the process by which your agenda is drawn up appears at face value to be a rarefied exercise shrouded in secrecy. I must confess that way back when I was a grassroots member, I too thought the same. Please be assured that it shouldn’t be, we don’t intend it to be and it is not. My primary role as chair is to allow the representative body, those attending ARM, to make a fully informed choice when voting, following a fair, honest and open debate. My challenge is that we can only prioritise less than 10 per cent of the motions submitted. While we would love to debate every motion submitted to us, time constraints make this impossible, leaving us with the enormously difficult job of prioritising the motions we receive. With this in mind, I would like to take this opportunity to provide a greater insight into the work of myself and your eight elected ARM agenda committee members, and the expert staff members. Let me explain how we as a team prioritise the motions that inform the future policy of your BMA. Among the considerations when determining a prospective motion is whether it is well-written, or more specifically whether its wording will allow it to stand the test of time if endorsed at ARM. This is imperative as it is this wording, and not the proposer’s speech, that sits in our policy book and shapes our work. Is the motion topical and relevant? Is it in response to a dominating event or issue of the past 12 months? Most importantly – does the issue the motion concerns require action to be taken within the next 12 months? Why debate it this year? In reviewing a motion the committee and I ask to what extent its enaction as policy would see benefit in particular for our association’s membership, for our profession, as well as for patients and wider society. Motions must be factually accurate, must not contain wording that could be considered defamatory or oppose 22

@drlatifapatel or conflict with human rights and ideally be seeking to remedy an existing deficiency in BMA policy. Ultimately, the aims of a motion must be realistic and something that is within the BMA’s remit to achieve. For instance, debating the contract of another profession, isn’t something we have power over. While not every motion submitted to the committee is approved, each one is meticulously considered and evaluated by myself and my colleagues, and we thank all of you for your submissions. Our work is made possible thanks to the support and insights of dozens of experts working in the BMA’s policy, research, ethics, communications, legal departments and the association’s equality, inclusion and culture team. In one sense, my job as agenda committee chair is a simple one in that my chief priority is to ensure every motion put before conference is accurate, interpretable so they can be openly and effectively debated. I can also honestly say that in my seven years as an elected agenda committee member, we have always aimed to produce an agenda that is fair and representative of all our members. Critically, even after an annual agenda has been finalised additional motions can still be prioritised either as emergency motions for new issues, or the five chosen motions voted directly by the representative body. The single most important thing your agenda committee does is to listen to all of you. It is only through the feedback we receive each year that we are able to refine and improve everything we do. We read every piece in detail. I look forward to the many debates to come at this year’s ARM, and welcome and urge you to make your voices heard. In the run up to your first hybrid ARM do continue to tell me what I can do to represent you better. I am listening. Dr Latifa Patel is interim chair of the BMA representative body

thedoctor | May 2022

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on the ground thedoctor

Highlighting practical help given to BMA members in diﬃculty

Experience counts for a lot... except for the consultant whose previous years of service were seriously undervalued. The BMA took up his case You might think that when your employer makes a decision about your pay, there would be some kind of record or reasoning written down about it. It is, after all, one of the more important decisions an employer makes. But when a consultant thought – rightly – that he had been paid too little on appointment to a new post, it was impossible to discover exactly what was going through his employer’s mind at the time. He had seven years’ experience as a consultant in the armed forces, but a few years after being appointed to an NHS post, realised that he had been initially placed too low on the pay scale. His employer had treated him as if he had only three years’ consultant experience. He raised it verbally, and through emails, but without success. So, he called in the BMA. The employment adviser ﬁrst wrote to the chief executive, who conﬁrmed the doctor’s pay was worked out on three years’ experience but did not say why. The chief executive said it was discretionary whether non-NHS prior experience was taken into account. This is true, but would an employer really want to imply armed forces experience – much of which was spent working in NHS hospitals in any case – was less valid than if he had been directly employed by the NHS? Or was there another reason? We don’t really know, because the employer kept no records as to why it made the decision. But there was a clue at the grievance hearing when the panel asked for details of the member’s armed forces experience, and found

The Doctor

that some of it was spent in a NCAS (National Clinical Assessment Service) remediation programme. The panel upheld the employer’s original decision because it said he was not working as a fully independent consultant for all of the previous seven years. The employer might have taken the original decision on the same grounds. However, the BMA found this reasoning to be ﬂawed because, had the doctor been employed directly by the NHS but gone through an NCAS programme, his years of service would still have counted for the purposes of seniority. It made this point at the appeal, and also put forward the doctor’s strongly held view that he was being penalised for having served his country. This seemed to chime with the appeal panel, which also seemed to share the member’s frustration about the lack of documentation regarding the original pay decision. It found in his favour. Given the process had taken two years of patient work, and that the consultant had by then been at the trust for nine years, it meant he was owed tens of thousands of pounds in back pay. Plus, the panel said the process for how seniority and reckonable pay were calculated needed to be reviewed, with full documentation remaining in an individual’s personal ﬁle, and for the employment contract to be changed to make clear the years of seniority awarded at the outset. The doctor said he was indebted to the BMA adviser, and that his success would not have been possible without her expert guidance.

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 William Gibbons. A copy may be obtained from the publishers on written request. The Doctor is a supplement of The BMJ. Vol: 377 issue no: 8338 ISSN 2631-6412

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Staﬀ writers: Tim Tonkin (020) 7383 6753 and Ben Ireland 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

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