The Doctor – issue 49, November 2022

doctor

ENOUGH IS ENOUGH

Why junior doctors feel compelled to consider industrial action

Going strong The GP couple in their 80s

Prison doctors Unique challenges, growing pressures

GMC

A doctor’s widow battles to hold regulator to account

In this issue

BMA warns against further budget cuts Letter to new PM also calls for action on pensions and juniors’ pay 4-7

Enough is enough Indebted and exhausted junior doctors explain why they are considering industrial action 8-11

From bad to worse Why Northern Ireland’s healthcare pressures are the worst of all 12-15 The bars to good care Prison doctors tell of their struggle to provide effective healthcare to inmates 16-19 Going strong What drives those who want to stay in the profession, even into their 80s? 20-21 The fight goes on A widow’s struggle to get better support for doctors under GMC investigation 22 Your BMA Doctors’ training needs a rethink if staff shortages are to be tackled 23

On the ground A specialty doctor takes action when work is dumped on her

Welcome

Phil Banfield, BMA council chair

At the time of writing, I’m on my third prime minister, chancellor and health secretary after just four months as chair of the BMA. Hopefully there isn’t another Conservative party merry-go-round between now and this magazine landing on your doorstep because we desperately need to get on with the business of fixing our broken NHS.

The list of required fixes is long: pay, pensions and workforce shortages should all be at the top of ministerial in-trays. We await the Government’s solutions in the upcoming fiscal statement with great interest.

‘Learned helplessness’ is how Alan Stout, the chair of the BMA Northern Ireland GPs committee, describes the state of patients and communities in the country where he works – as health services fall apart amid a stagnant political system.

In the November issue of The Doctor we report from Northern Ireland, speaking to the doctors trying to provide care and compassion in a health service which is performing worse than anywhere else in the UK on almost every measure.

Also in this issue of the magazine we speak to Viji Suresh, the widow of Sridharan Suresh, a consultant anaesthetist from the North East who took his life after receiving a letter from the GMC informing him that he would have to appear before an interim orders tribunal. The notification came after Dr Suresh had been assured he would not be the subject of a GMC referral. The BMA has been supporting Ms Suresh’s legal cases against Dr Suresh’s trust and the GMC to drive system change in how doctors are treated when under investigation. We must not wait for more tragedies to take place before the wellbeing of doctors is taken seriously.

Last month, it was announced junior doctors in England would be balloted in the New Year over taking industrial action. In this issue of The Doctor we speak to four junior doctors about their support for strike action – with pay erosion, student debt and the ever-increasing pressures of unsafe working environments all taking their toll.

The November issue of the magazine also includes features looking at health and wellbeing in prisons and we speak to doctors who are still working well after retirement age, plus those who have returned to the NHS after retirement, about their experiences.

Keep in touch with the BMA online at instagram.com/thebma twitter.com/TheBMA

AT A GLANCE

BMA warns against further budget cuts

The BMA has written to Rishi Sunak warning his Government must act immediately to address workforce shortages, pensions and workload pressures ‘before it is too late’.

In a letter to prime minister Rishi Sunak, association council chair Phil Banfield outlines in no uncertain terms the challenges threatening the stability of the NHS and the medical profession.

In his 31 October correspondence with Mr Sunak, Prof Banfield warns punitive pensions taxation and real-terms pay cuts for doctors coupled with ever-rising workloads are exacerbating the NHS’s staffing crisis.

While insisting the BMA is eager to work with ministers to find solutions to these challenges, Prof Banfield further warns any proposals to implement future cuts to the health service’s budget would only make matters worse.

‘I must warn against making direct cuts to NHS budgets or to allow spiralling inflation to do its own erosive damage. It would be a false economy not to prioritise the NHS at a time when it is most needed by its patients and indeed to contribute to a healthier population on which the economy can rebuild.

‘NHS England has already warned that inflation will, without positive action and investment from Government, lead to cuts to services. The lower standards of care currently commonplace across the NHS, the record waiting times and waiting lists, the personal anguish behind each one of these statistics, should not be acceptable.

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‘Staff morale has been left in tatters by the unceasing workload they were experiencing prior to and during the pandemic. This has continued unabated. The staffing crises across all professions and real-terms pay cuts have left doctors feeling completely taken for granted.’

With junior doctors set to be balloted about potential industrial action next year, Prof Banfield says he hopes returning secretary of state for health Steve Barclay will seek to ‘fully engage’ with the BMA junior doctors committee on its call for pay restoration to 2008/09 levels.

He also warns tackling the pensions crisis is critical if the haemorrhaging of experienced, senior doctors from the NHS

is to stop and the pressures on understaffing begin to be addressed.

Prof Banfield says: ‘From your previous role as chancellor, you will be aware of the impact that punitive pension taxation is having on the retention of senior NHS doctors. The number of doctors taking early retirement has more than tripled over the last 13 years, with the average retirement age already falling to 59.

‘We simply cannot afford to lose the expertise and resource these doctors represent. Replacing them will be impossible, and even filling some of their vacancies will take significant time and be more expensive than keeping them in post.’

RAY MCCRUDDEN

UNDER PRESSURE: Workload strain cannot be exacerbated further

Enough is enough

Talk to any junior doctor, and it’s obvious why they are considering industrial action. Indebted, exhausted, and working at greater intensity than ever before, they want their pay restored to previous levels. Interviews by Ben Ireland

There is a fable which says that if you put a frog in boiling water it will jump out, but if you put it in cold water and slowly increase the temperature, it won’t notice and will slowly boil to its death.

‘Junior doctors feel like that frog in the cold water,’ says Priyesh Parekh, a specialty trainee 2 in paediatrics working as a senior house officer at University Hospitals Coventry and Warwickshire NHS Trust and training to be a GP. ‘We cannot continue like this after more than a decade of below-inflation pay awards leading to poor retention and junior doctors doing more for less.’

Dr Parekh feels this goodwill, this desire to work in a profession that is intrinsically caring, the years of hard work it takes to get there, and the willingness to take on massive debt to fund study, have been taken advantage of by the Government.

Dr Parekh has seen colleagues move into careers such as management consulting and firms targeting highly skilled medical professionals. He joined one webinar and was ‘amazed’ to find 200 other doctors had also logged in.

He says: ‘I’ve definitely had moments where I question if continuing in medicine is the right choice.’ And when he looks around and sees overworked consultants being taxed excessively on their pensions, or GPs slogging through five days of 12-hour shifts, the exit door looks appealing.

‘A lot of doctors are realising we are being taken for a ride and we shouldn’t accept it,’ he says.

Junior doctors have also had their progression affected by the COVID pandemic. During the second wave, Dr Parekh was pulled into the ‘chaos’ of ICU from the ENT rotation

he was enjoying and considering specialising in – working up to 76-hour weeks – and missed a respiratory rotation.

He says things have not calmed down much since then and rotas are still ‘very packed’, and people ‘put up with’ working beyond their hours – often not even taking breaks.

The success of industrial action in other professions such as the Criminal Bar Association, which negotiated a 15 per cent uplift, has caused some ‘optimism’, he says.

‘It’s always playing on my mind whether staying in medicine is the right thing,’ he says. ‘Pay restoration would show we are valued.’

‘Doctors are realising we are being taken for a ride and we shouldn’t accept it’

PAREKH: Questions

whether medicine is the right choice

ALEX CAUVI

very job comes with its hardships, but people don’t realise that one doctor might be covering six, eight or even 10 wards overnight. We’re being run ragged between wards and foundation year 1s are getting £14 an hour for the privilege.’

Ellen Newberry, a medical registrar at Barnsley Hospital NHS Foundation Trust, may be classed as a ‘junior’ doctor – but feels anything but when she is looking after two to three hundred patients out of hours.

‘I’m in my seventh year of medical work now and there are people 15 years into their careers still called “junior” doctors. Overnight someone at my stage is often the most senior doctor in the hospital, so when people dismiss us as “junior” it’s quite galling.’

Dr Newberry, who worked at Sheffield Teaching Hospitals NHS Foundation Trust for her three-year internal medicine training programme, believes all NHS staff are underpaid, not just doctors.

She worked as an HCA (healthcare assistant) between 2007 and 2011, before embarking on five years of medical school and taking on £45,000 in student debt. As an HCA, she earnt a little less than today’s F1 doctors do, and that’s without taking inflation into account.

And since her own F1 year in 2016, she says: ‘My job has got significantly harder, from the sheer volume of patients. And I know my pay package has gone down significantly [in real terms] in that period.’

Dr Newberry says a typical shift starts with 20 to 30 patients waiting to be seen, having been admitted by the

emergency department.

‘They could be waiting for hours and hours,’ she says.

‘The difference from when I started is that now it’s relentless, not just a terrible few weeks or months over winter.’ And she says it’s ‘not uncommon’ for F1s to be looking after more patients than the Royal College of Physicians deems

appropriate for their level of experience, ‘before you factor in medical outliers’.

All this for pay which by the BMA’s calculations has been eroded in real terms by 26 per cent since 2008.

‘If we don’t do anything – it’s not going to stop here,’ Dr Newberry says. ‘If you don’t draw a line now, where do you draw it?’

NEWBERRY: Job intensity has increased

‘The difference from when I started is that now it’s relentless, not just a terrible few weeks over winter’

‘E

NEIL HODGE

In his F1 year, while being paid £14 an hour, Alistair Ludley accumulated £1,044 of interest on his near £90,000 studentloan debts – more than his annual repayment of £903.

‘I’m not sure I’ll ever pay this off,’ he says.

Now an F2 at University Hospitals Sussex NHS Foundation Trust, Dr Ludley was the first in his family to go to university and chose medicine for a ‘stable, engaging, complex, fun career which was fairly remunerated’.

The reality, however, is that he has had to rely on a landlord giving him an NHS discount to live in Brighton, where rents are ‘similar to London, without adjusted London salary weighting’. This, after studying in London, paying ‘sky-high rent’ with maintenance grants that ‘barely scratch the surface’.

Now earning a base rate of £16 an hour, he’s due to embark on a role with a 48-hour average week, including some 70-hour oncall weeks, at the very boundary of the legal maximum. Owing to contract terms, he points out that, ‘on bank holidays, sometimes the lowest-paid person in the hospital could be the F1’.

In one job, he was one of two doctors looking after all the medical adult patients in the hospital overnight. ‘You could be talking 100 to 150 patients per doctor per night,’ he recalls.

‘When I was on my surgical rotation, we could have up to 120 inpatients at any moment. There was one F1 doctor looking after those patients overnight.’

Dr Ludley volunteered at Charing Cross during the first wave of COVID, unpaid, as a final-year medical student, along with many others. Given that, the 2 per cent pay offer from the pay review body felt like ‘a kick in the teeth’.

‘I have devoted my life to pursuing medicine. I diligently

worked through secondary school, stressed through multiple competitive application processes, took multiple exams and interviews, studied for at least five years, and took on £90,000 of debt.

‘All to work for an exhausted, under-staffed and under-appreciated monopoly employer, at £14 an hour.’

Dr Ludley reports a vicious interplay

between poor remuneration, insufficient staffing and burnout for those doctors who do remain – with the NHS in England now short of around 46,000 full-time doctors.

He says: ‘You work three or four 12.5-hour shifts in a row, without time for a break, and you’re burnt out by the last shift. If you ever need to take a sick day, this leaves your already short-staffed colleagues even more short. The cycle viciously repeats itself.

‘It will never end until you properly staff things. And proper staffing doesn’t begin until you entice people into the profession with fair pay.’

‘All to work for an exhausted, under-staffed and under-appreciated monopoly employer’

LUDLEY: Huge responsibilities and poor pay for foundation doctors

‘F amily and friends were questioning why my knees were bruised. It was because I knelt in front of a computer all day to work.’

Vanya Gurr, now an F2 in emergency medicine at Barking, Havering and Redbridge University Hospitals NHS Trust, recalls the first four months of her career as a doctor at a different trust.

‘The next four months I regularly sat on a bin lid because there wasn’t space for enough chairs,’ she adds. ‘The last four months I often sat on a step ladder because it had a little back support.’

Hospitals’ inadequate working conditions are known, but most people might expect junior doctors working life-saving shifts for £14 per hour to have a chair.

Dr Gurr was troubled recently when a social media video circulated showing facilities such as curved screens, wellness rooms and touchscreen coffee machines for NHS managers in a trust she had worked in, while doctors and nurses were left with inadequate facilities on the front line.

‘I can’t explain how frustrated and upset we were,’ she says. ‘I’ve had days where I’ve been on the ward looking after 25 people with one other F1, doing four people’s work, not taking a break, staying late. I’m a hard worker, but you need recognition for what you’re doing.’

She questions the logic in employing ‘wellness leads’ when basics are not provided to frontline staff. ‘Our wellbeing is having a chair, an office, a computer,’ she says. ‘Wellness is adequate staffing so I’m not leaving two hours late every evening and can take a half-hour lunch break. Not putting on a ballet show we don’t have time to attend.’ While junior doctors are set to ballot on industrial action in a dispute about pay this January, Dr Gurr speaks for many when she says poor working conditions are the main concern. She says: ‘The issue is the sacrifice we put in and how rubbish our lives are comparative to the pay.’

Dr Gurr notes how F1 and F2 are ‘the years you are meant to be supported’. Her reality? ‘I found myself doing my rounds with little to no supervision. The responsibility and amount of work doesn’t seem fair compared to the pay.’

She notes how some friends rely on locum shifts ‘to get by’ and in some cases haven’t been paid for months. Dr Gurr considers what her life might have been in a different

career ‘basically every day’. Her partner is an accountant and has had an 18% pay progression in the last year alone while her junior doctor salary has eroded by more than a quarter since 2008. She recalls ‘reservations’ as a first-year medical student but after briefly switching to aerospace engineering she returned to medicine for ‘a rewarding and well-respected career, which I thought was decently paid’. And, crucially, because, ‘I wanted to help people’.

Dr Gurr hopes to specialise in public health as her career progresses but before that she hopes – like many – to take time out of the NHS to work overseas, with her eyes set on New Zealand.

A longer version is available online at bma.org.uk/thedoctor

the doctor | November 2022 07 bma.org.uk/thedoctor

‘I’m a hard worker but you need recognition for what you are doing’

GURR: Forced to use bin lid as office seat

‘Our wellbeing is having a chair, an office and a computer’

From bad to worse

On almost every measure, Northern Ireland’s health and care system performs worse than anywhere else in the UK. Waiting lists are proportionately much higher and rising – with more than half waiting more than a year even to get an outpatient appointment.

Waits of five years or more for an initial outpatient appointment are not uncommon, doctors say, with patients then languishing for the same time again on a waiting list for treatment. Many die before they reach the top of the list.

General practice is also in crisis with growing numbers of practices either closing or at risk of closure – official figures show there were 319 active practices at 31 March 2022, compared with 350 in 2014. The situation is even more acute in the west of the country, which has seen a drop of 16 per cent.

There is also a shortage of doctors, in primary and secondary care – putting more pressure on those who remain in post, many of whom are retiring early, or considering it.

So why is the situation so bad in Northern Ireland? ‘The simple answer is capacity,’ says Alan Stout, chair of the BMA Northern Ireland GPs committee. ‘We just have not planned capacity and workforce well enough. We’re short of GPs, we’re desperately short of nurses, we’re short of most hospital specialties.’

Waiting lists are, to an extent, a symbol of a system that isn’t working properly. But they also have a real effect on the lives of people, whether they are waiting for treatment themselves, or working in Northern Ireland’s HSC (health and social care).

Faced with the prospect of lengthy waits, for even life-saving treatment, some are choosing to pay even where they can’t really afford it, while others simply don’t have that choice.

Even in areas such as cancer, patients are having to wait. Latest figures published in September show almost two thirds of patients requiring treatment for cancer had not started treatment two months after urgent referral.

It’s a scandal, says Dr Stout, but patients have come to expect this is the way things are. ‘You can refer to many things in medicine as learned helplessness. That’s what our population has at the moment – they just have an expectation and a helplessness that they’ll be on a waiting list and that they’re going to be on it for years and years, because it’s been going on for so long.

‘It’s amazing – if it were anywhere else, people would be on the streets campaigning, whereas here we just seem to accept it, literally.’

Political stasis

Emergency departments are also under huge pressure, says Siobhan Quinn, an associate specialist in emergency medicine in Belfast. She describes overcrowding – with eight trolleys in a bay intended for three patients being a typical situation.

‘We have around 50 clinical spaces and this morning we had 68 patients waiting for a bed –you can imagine what our department looks like. Ambulances queue outside because there is no trolley to put patients on. There is a lack of dignity for patients and it is demoralising for staff.’

The rest of the UK also has capacity problems and tight resources, and, as with Northern Ireland, has been grappling with a pandemic for the last two and a half years. So, what makes the situation particularly bad?

David Farren, chair of the BMA Northern Ireland consultants committee, blames several factors, not least the political situation. Devolution was suspended again in February

‘We’re short of GPs, we’re desperately short of nurses, we’re short of most hospital specialties’

STOUT: Patients feel helpless about waiting times

If ‘crisis’ sums up the health service in England, Wales and Scotland, then perhaps we need to invent a whole new word for Northern Ireland, where patients can wait five years for an appointment. Jennifer Trueland asks why the challenges faced there are so particularly acute

because the main parties could not agree to power-sharing, largely owing to disagreements on Brexit and the Northern Ireland protocol.

‘Our Assembly hasn’t sat for [a significant part] of the time it’s been there – so political decisions haven’t been made,’ he says. ‘We’ve not been able to form a budget for more than a year.’

This is something that also frustrates Dr Stout. ‘It’s had a massive, massive impact, the current one [suspension of devolution] in particular, because we had a tantalising glimpse of a multiyear budget, which is absolutely fundamental to doing things differently. And not only did a multiyear budget get taken away from us, but an actual proper in-year budget has been taken away from us. So, what happens is that as a system, you just revert to fire fighting and dealing with crises and problems as opposed to actual, proper planning.’

Successive attempts at rationalising hospitals and services across Northern Ireland have failed, partly due to the lack of a functioning Northern Ireland Assembly, but also because of political nervousness. ‘There are very few things that will lose votes like closing down a hospital or a service,’ says Dr Farren.

‘We’ve been calling for years for the politicians in Northern Ireland to have a big conversation with the public to explain that, for example, you might wish to have your baby in the local hospital, but it doesn’t have all the services that you and your baby might need. And that you’re better travelling a bit further and having all those services near you.’

The Doctor requested interviews with health minister Robin Swann and chief medical officer Michael McBride. The Department of Health said neither was available.

But, as well as doctors and members of the public, we also spoke to Ruth Barry, senior policy impact and influence manager at the PCC (Patient and Client Council). This arms-length organisation represents the interests of the public, both by individual advocacy (supporting individuals in their interactions with health and social care services), and also in engagement and campaigning to promote the patient voice.

Unsurprisingly, the PCC reports growing demand for its services, with its small team handling 6,195 calls via its free-phone service between April 2020 and March 2021.

One of the top areas of concern is access to general practice, says Ms Barry. ‘We want to work in partnership with both the BMA and Royal College of GPs and other organisations

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to try to find solutions to the issues. What’s absolutely key for us is that the patient’s voice must be at the centre and in our work, we’re relaying the patient experience.’

Chaotic planning

Perhaps backing Dr Stout’s point about population acceptance, relatively small numbers of patients have contacted the PCC about lengthy waits, Ms Barry says – around 15 to 20 in the last six months. ‘In a handful of cases we were able to make a difference in terms of expediting the waiting, but that’s not to say that’s something you can do in every case. And if they want to make a formal complaint or raise a concern, we support them to do that.’

Whether or not patients are making formal complaints about it, lengthy and chaotic waiting lists mean extra work for health services, including general practice, says Dr Stout. He describes the situation of one patient who needs surgery to remove the gall bladder. While on the waiting list, she has had at least 27 contacts with health services, including five trips to emergency departments and duplicate tests and scans. ‘We all knew she had gallstones and needed the surgery… it’s crazy,’ he says.

Meanwhile, workforce shortages across all branches of practice are only likely to worsen, as more GPs, staff, associate and specialty doctors and consultants retire – many early – driven away by relentless pressure and other challenges such as punitive pension taxes.

Dr Farren doesn’t sound optimistic that things will get better any time soon. ‘Every time we have an election, every candidate will say that health is too important to be a political football, and we need to prioritise health for everyone in the nation. And then after the election, health will be the last ministry to be appointed because nobody wants the “poisoned chalice”.’

He believes caretaker minister Robin Swann has done an ‘amazing’ job throughout COVID, but warns: ‘If we ever form another government again in Northern Ireland we’ll have a different minister. And we’re concerned that it will go back to the same old, same old, trying to eke out the same service, with the same level of activity, while spread too thin, with exhausted staff.’

QUINN: Lack of dignity for patients is demoralising staff

‘[Patients] have an expectation that they’ll be on a waiting list and that they’re going to be on it for years and years’

BLACK: Runs a successful practice which had been on the brink of closure

When Tom Black arrived at his practice in Derry’s Bogside area on a Friday morning, there was already a patient waiting in the car park. A young mum was worried about her child, who was having a bad asthma attack. She didn’t want to go to hospital – so she relied on her local GP.

Like most in the UK, the Abbey Medical Practice runs a telephone triage system, and on this morning in particular, was running telephone clinics that were supposed to be for emergencies only, as it was just ahead of a bank holiday weekend.

But what are you supposed to do when you have a clearly ill child – and desperately concerned parent – in front of you? Even when you know that treating the patient will put you behind before the day has even begun.

Dr Black, chair of the BMA in Northern Ireland, is senior partner at the practice and clearly loves it and the community it serves. ‘These are all my people,’ he says, gesturing at rows of houses and flats as we drive through the historic city, the second largest in Northern Ireland. ‘I know them, and their families, and they all know me.’

This intimate knowledge of the patient population is evident as the morning clinic proceeds. Dr Black barely seems to need to refer to the patient’s notes in front of him as he enquires about people’s families, asks for updates on previous conditions – and really listens to what patients say.

Some of the calls seem to stretch the definition of ‘emergency’ to the point of [my] incredulity, but he is unfailingly courteous and the patients on the other side of the phone audibly relax as he dispenses wisdom – and usually a prescription.

Patients in his practice tend to be at least 10 years older, biologically speaking, than their actual years, he explains, so experience all the multiple morbidities of older age when they are much younger than in the general population – even for Northern Ireland, which has the lowest life expectancy in the UK. This is owing to the high levels of deprivation in the area with Foyle the second most deprived area in Northern Ireland after west Belfast. Sometimes patients get quite indignant with him when he tells them his age, and they realise that he’s as old or older than them – and certainly he carries his 63 years lightly. ‘They say “you’re very fresh” – that’s the word,’ he laughs. ‘I tell them it’s because I gave up smoking at the age of 25.’

Today the Abbey Medical Practice is thriving and busy with six GP partners (four whole-time equivalent), experienced managers and receptionists, nursing staff and access to an

extended multidisciplinary team, including pharmacists, a mental health practitioner, physiotherapy and social workers. Yet within the last five years, it was on the brink of closure. A spate of retirements meant they were down to three doctors and were, Dr Black says, in crisis. They got through it, with help from the Northern Ireland GP rescue team. A key factor in that survival was paying locums and salaried staff ‘a fortune’ until they could recruit sufficient partners.

On this particular Friday, there were two partners officially working, including Dr Black. But it was notable that another partner had popped in to check up on some scans, and that even when the two GPs on duty grabbed a short coffee break, they each carried with them a sheaf of prescriptions to be signed.

After morning surgery, each GP set out on a home visit before an afternoon of more calls and in-person consultations in the surgery. Clearly it irritates Dr Black that there remains a perception that GPs aren’t seeing people faceto-face, and the common belief home visits are a thing of the past.

‘Home visits are easy,’ he snorts. ‘You get in the car, get the radio on, drive to see one patient, then get in the car, radio on, same again, and you can only see a few patients.’ That’s easier than a morning chock-full of telephone consultations – some of them requiring significant follow-up action.

Spending a few hours in a practice obviously only gives a snapshot – a moment in time – and can’t tell the whole story. But the overwhelming impression at Abbey Medical Centre is of a team that is working hard, really hard. It’s also a practice which is very much part of its community. And, presumably like every other practice in the UK, its doctors have to sign a hell of a lot of prescriptions.

Interview by Jennifer Trueland. There is a fuller version of this feature at bma.org.uk/thedoctor

Healthcare in Northern Ireland is under extraordinary pressure. How does it even survive? Through thousands of dedicated doctors and other NHS workers. Derry GP Tom Black is one of them

THE BARS TO GOOD CARE

Health and wellbeing are probably not the first things that would come to most people’s minds when considering prisons and their role in society.

With a prison population of 81,000, England, Wales and Scotland have the highest incarceration rates of inmates per 100,000 of population in western Europe, while the total number of inmates in UK prisons is predicted to rise to 97,000 by 2025.

Despite its large and growing population, those imprisoned in the UK should receive equivalent standards in healthcare to those in society.

This ambition is further complicated by the fact that those in the prison population often tend to be in poorer health than those in society.

A report published by the Nuffield Trust in

October last year examining the challenges around healthcare access in prison, found many people entering prison have complex health issues concerning mental health and addiction.

GP Mark Pickering has spent the past 13 years of his career working in prisons and secure psychiatric hospitals. He is one of a relatively small number of doctors responsible for assessing, referring and providing care to inmates in the closely controlled yet often challenging environment of the prison estate.

‘One of the things that often strikes you is that every prison is sort of very different and set in its ways and yet there are these common themes across them,’ he says.

‘There’s so many logistical barriers to good care [in prison] so while we talk about equivalence of care, that you’re meant to be

LOCK AND KEY: A prison offi cer shuts the entrance to the healthcare wing of HM Prison Pentonville, London

A GROWING PRISON POPULATION, STAFF SHORTAGES, AND INMATES’ DRUG MISUSE ARE JUST SOME OF THE ACUTE CHALLENGES FOR THE DOCTORS TRYING TO DELIVER HIGHQUALITY CARE.

TIM TONKIN REPORTS

trying to give [inmates] the same range and standard of care that you would give in the community, it’s often very difficult to do that.’

Segregation

With UK prisons spanning a broad range, from maximum security to open facilities, experiences of the doctors working in them, and the resources available to them, can vary, thus making a ‘typical day’ hard to define.

Dr Pickering says as well as running clinics similar to what might be expected in a community GP setting, another critical responsibility of doctors working in a prison is monitoring and assessing those inmates confined to a segregation unit.

‘If the prisoners are in segregation for fighting or trading drugs or something like that, then they have to be seen by a doctor every 72 hours, regardless of whether there’s anything wrong,’ he explains.

‘There’s always a challenge as the doctor because often you’re traipsing around with a prison offi cer and in some places, they don’t want to open the [cell] doors, so you might just be looking through the door flap and asking the inmate if they’re OK. The rules say you’re meant to assess their physical and emotional and mental state, but how can you do that through a closed door?’

Personal safety is a consideration likely to preoccupy anyone entering a prison for the first time and may be a factor deterring some doctors from even entertaining the idea of working in a secure environment.

In his experience, however, Dr Pickering says there are misconceptions as to the safety risk of his job.

‘You’re generally much safer working in a

PICKERING: A referral to A&E is

prison than you are walking through the town centre on a Saturday night,’ he says.

‘There are things you’ve got to be alert to, you’re meant to put the patient further away from the door than you so that if they do get aggressive you can exit quickly, and you’ve got panic buttons in the room.

‘It’s a much more controlled environment and there are always prison officers around and risk assessments being done.’

Complicating factors

One of the most significant challenges facing doctors working in prisons is the almost constant requirement to balance the health needs of inmates with the limitations imposed by shortages in prison officer staffing.

This balancing act is often most acutely felt when doctors believe that an inmate might or indeed should be referred to secondary-care services outside the prison.

Using the example of an inmate attending a clinic with an injured hand after punching a wall, Dr Pickering outlines the number of factors that might need to be considered before reaching a clinical decision.

‘[In the community] you’d just say, “Pop down to A&E and go and get it checked out”, but in prison you first have to consider things like, has the inmate done this deliberately so that they can try to get out of the prison as part of an escape attempt?,’ he says.

‘You may say to someone that they should probably go to A&E for the chest pain that they’re suffering, but it’s not a simple case of them just going to A&E. They have to get handcuffed, strip searched, and then get taken out handcuffed to a couple of officers and perhaps wait around like that for hours.

‘Sometimes you really do have to think quite laterally, and you’re having to make some of these prioritisation decisions that you just wouldn’t have to make normally [in the community].’

This difficult balancing act is one that prison doctor Amanda Brown knows only too well.

Having started out in a traditional communitybased general practice role, Dr Brown has spent the past 18 years working in a variety of men’s and women’s prisons in England.

She says that on more than one occasion during her career as a prison doctor she has found herself being ‘cross-examined’ by a prison governor and essentially asked to justify her request that a particular inmate be transferred to

‘There’s so many logistical barriers to good care in prison’

‘The rules say you’re meant to assess their physical and emotional and mental state, but how can you do that through a closed door?’

no simple matter

hospital for treatment.

‘Probably the most frustrating thing for me is referring patients to outside appointments,’ she says.

‘Certainly [at] Wormwood Scrubs it could be so tricky to get patients out to important outpatient appointments. And I can remember for example, there was a man in there for quite a long time with renal failure and three times a week he had to go for dialysis. So that took a precious resource, at least two prison officers to escort him.

‘Depending on the risk of the prisoner, it could take two or three officers to escort someone to hospital, which obviously cuts out the staff for the running of the prison.’

Responsibility for the commissioning of primary and public healthcare services in prisons was transferred from the Home Office to the NHS in 2006, although from this year services could also be commissioned by ICS (integrated care systems).

The range of health services available to inmates can vary hugely from prison to prison, with some prisons possessing on-site secondary care facilities such as dialysis or sonography.

Dr Brown’s place of work, HMP Bronzefield, offers a range of healthcare services including physiotherapy, podiatry, dentistry, mental health and an optician.

As a remand prison, however, the patient population at Bronzefield can often prove to be a fairly transient one, with inmates only staying for a few weeks before being released or transferred.

Dr Brown says that delivering continuity of care to patients under such circumstances can be extremely challenging.

‘A woman might, for example, have just got to the point where she’s going to have a hip replacement. She then comes to prison for

maybe six weeks or two months, so she’s lost that slot [for the operation].

‘If she’s going to be in prison for a long time, we’d have to re-refer them to a local hospital which means they then go to the back of the queue. [Alternatively] we might refer a patient and get an appointment through the day after they’ve been released.’

Awash with drugs

Addiction and the use of drugs by those in custody is a health issue that even those who have never set foot inside a prison are likely to be well aware of.

In its most recent report into prison health, the Commons health and social care committee notes that 28 per cent of men and 42 per cent of women prisoners report having a drug problem upon arrival in prison with 13 and 8 per cent developing issues with substances while incarcerated.

Jake Hard has spent 16 years working as a GP in prisons in England and Wales.

Now clinical director at HMP Cardiff he also serves as an expert witness on healthcare in prisons and is the former chair of the Royal College of GPs’ secure environments group, a multidisciplinary UK-wide network promoting access to high standards of care for those detained by the justice system.

Having a long-standing clinical interest in treating substance misuse, he gave evidence to the Health and Social Care committee’s inquiry into prison health in 2018 and has seen at first hand the significant harm drugs can have in prisons, on inmates and the health professionals there to care for them.

‘I’ve seen over the years, the implementation of opioid substitution

BICKNELL: Services are a ‘distance away’ from the quality to which clinicians aspire

‘Probably the most frustrating thing for me is referring patients to outside appointments’

HARD: Witnessed eff ects of spice

outbreaks in the prison estate.

In response, the prison service took the step of implementing a series of restrictions to protect the vulnerable patients. This included inmates being locked in their cells for up to 23 hours a day to reduce transmission of the virus.

A study published last year by the HM Inspectorate of Prisons What Happens to Prisoners in a Pandemic? concludes that, while the measures had been effective in reducing cases and deaths, it was unclear what the effect of the strict and extensive period of lockdown may have been on many individuals’ mental health.

therapies, methadone and buprenorphine and I’ve subsequently seen, with buprenorphine, the considerable illicit trade of buprenorphine in the prison estate which had a significant impact,’ he says.

‘Then we had a substantial issue with the arrival of psychoactive substances within secure settings which was devastating for lots of reasons.’

Dr Hard says he witnessed some of the harrowing consequences from psychoactive substances often known as spice.

‘I’ve seen some of the destructive effects on patients of psychoactive substances. I have seen incidences of people suffering selfinflicted injuries as a consequence of using these drugs.

‘Groups of people under the influence and severely intoxicated and cases such as these have a profound impact on healthcare staff and prison staff.

‘One example I can think of was, there was a time when we had about eight people under the influence [of spice] and some were on the floor vomiting and hallucinating or fitting. You can imagine the effect that has on your nursing team resources and your GPs at that point in time.’

COVID’s impact

As with every other part of society, COVID-19 presented huge challenges to prisons, with the day-to-day lives of inmates and in the delivery of healthcare.

A modelling exercise conducted by HMPPS (HM Prison and Probation Service) and Public Health England in April 2020 concluded that measures were required to avoid excessive prisoner deaths, which would have been the case if no actions were taken to avoid

secure settings’

Indeed, in its report, the Nuffield Trust reveals a mixed picture as to the pandemic’s effect on mental health in prisons, with the report noting that, while the rate of self-harm per 1,000 men in prison fell by 13 per cent in 2020, it increased by the same percentage in the women’s prison estate.

‘From an infection prevention control point of view, the measures that were put in place were completely understandable and helped to avoid what could have been a significant number of deaths,’ says Dr Hard.

‘The measures put in place in the prison estate endured for longer than the measures that were seen in the wider community, and this included being locked in their cells for 23 hours a day, but were ultimately intended to minimise the impact of further outbreaks.’

The BMA forensic and secure environments committee is responsible for supporting and improving the conditions of doctors working in prison settings, with the committee planning on holding a special conference next year to this end.

FSEC chair Marcus Bicknell says the pandemic and prevailing challenges mean healthcare standards are still not at the level staff and inmates deserve.

He says: ‘Prison remains a challenging place for healthcare workers to deliver care. NHS England Health and Justice has adopted a helpful, inclusive partnership approach to improving services, but workforce pressures are extreme, which adversely aff ects the delivery of safe GP and psychiatric care, and we are a distance away from being able to deliver the quality of health service which we aspire to.’

‘We had a substantial issue with the arrival of psychoactive substances within

DATTA AND DATTA: A half-century in general practice

LANCASHIRE TELEGRAPH

GOING STRONG

Things are about to change for Mridul and Saroj Datta. The couple have made it their life’s work to run the general practice in Blackburn that Mridul set up 51 years ago. They have been GPs to four generations of some families and, at 82, they are still working.

But Saroj Datta has decided to retire next March.

It’s not going to be easy: when she was on leave recently following surgery, patients kept asking for ‘Auntie’.

Her husband, Mridul Datta, is not ready to quit, however. His own father, an obstetrician in India, set the bar high. ‘The day my father died, he saw four patients that evening. And he was 85 and a half. He insisted on the half.’

quickly. They were on call 24/7, often did home visits and had three children. For 14 years, Mridul was also running gynaecology clinics locally and working as a locum consultant around the country.

Their ability to connect culturally with immigrant communities and Saroj’s four languages meant patients have remained loyal.

‘Patients were like family in those early days,’ says Saroj. ‘And the ones that have stayed with us from that time still have the same relationship with us.

‘I feel I’ve still got a lot to contribute, including teaching younger doctors’

Drs Datta are exceptional but not unique: there are more than 15,700 doctors over the age of 65 in the UK who are still licensed to practise with the GMC.

Doctors are retiring early in their droves, their hand often forced by unsustainable workloads, burnout or the pension tax trap. But many continue well past retirement age, contributing in many different ways.

Because, as most will tell you, being a doctor is far from just a title.

‘Patients were like family’

For Drs Datta, general practice is a ‘vocation’. That’s how they have sustained a busy practice in a multicultural community for five decades, much of it with only locum support.

They came to England in 1965, initially just for their postgraduate training in obstetrics and gynaecology, but then stayed. They became fellows of their medical royal college but consultant posts for international medical graduates were rare.

Mridul set up in general practice in 1971, in a converted terrace house. Saroj joined him in 1975, after a stint in public health.

They started from scratch and their caseload grew

‘In general practice, it has been said that half of the patient’s illness goes if they feel you are part of them, that you are really listening.’

Mridul reduced his hours a few years ago – but he missed full-time work. ‘I did not pressurise him: Gordon Brown did,’ Saroj says. But Mridul still works eight sessions, and Saroj is down to four, although she still does much of the admin.

For Saroj, it’s the relationships that are hard to walk away from, including her team, but she knows it’s time to ‘hang up her boots’. Mridul, meanwhile, a fourth-generation doctor, resists his family’s repeated calls for him to retire: medicine is inextricably bound up in his identity.

‘If I became a danger to my patients, I’d retire that same day,’ he says. ‘But I feel I’ve still got a lot to contribute, including teaching younger doctors. A trainee from Iraq told me: “In our country, they say: When the fire is out, life is not worth living.” I take that as a challenge.’

Return, retire, return

The first time Jo Cannon retired was at 58, the culmination of a stressful, demoralising year.

The inner-city practice where she was a senior partner underwent a CQC (Care Quality Commission) inspection, and for the first time in her career, she was summoned as a witness at a coroner’s inquest, twice in six months. No

It’s pretty clear why any doctor would want to retire right now. But what drives those who want to stay, sometimes into their 80s? Seren Boyd finds out

blame was attributed to her, but it took its toll.

‘I took it all quite personally and was running out of steam,’ says Dr Cannon. ‘Then a friend of my age retired, and it was almost like an epiphany.’

She joined the NHS GP Retention Scheme, aimed partly at doctors around retirement age, and for two years did four sessions a week at a different practice, within cycling distance of her Derbyshire home.

She retired again in February 2020 – but within weeks had responded to the GMC’s COVID call-up. ‘I realise now I wasn’t quite ready to leave medicine, given how quickly I responded,’ Dr Cannon says.

‘My heart was still in it.’

experience and it was a waste to stop altogether,’ says Dr Goodhart. ‘We were very aware there’s a shortage of doctors and if we could help with that, it would be a win-win.’

They had to join the NHS Scotland Performers List, undergo safeguarding training, and arrange indemnity insurance, but onboarding was straightforward.

They spent five weeks, each doing four sessions a week, supporting a GP practice in Kirkwall. It was a steep learning curve, but they had good support, and felt valued.

‘We didn’t want to undermine the practice in any way or take a different approach,’ says Dr Graffy, ‘but we were a fresh pair of eyes. There’s nothing more rejuvenating than starting from scratch and learning new skills.’

And their work meant they were welcomed and gained a much better picture of community life than the average tourist. ‘Being a GP is a licence to curiosity,’ says Dr Goodhart.

Sense of camaraderie

On his last day at work as a consultant surgeon in King’s Lynn in 2016, Surjait Singh’s daughter asked the kind of question only a daughter can ask.

‘Once a doctor, always a doctor. It’s very much part of your identity’

‘So, Dad, is this right? When you go into work today, all the people in the hospital will say, as they always do, “Good morning, Mr Singh.” But when you walk out, you’ll just be an old Indian bloke carrying a briefcase?’

Since then, she’s been back at her old practice, now working two sessions and focusing entirely on patients, not paperwork.

The requirements – CPD (continuing professional development) and supervision – are far from onerous. Time is factored in for CPD: her mentor is an old friend.

‘Now I’m doing the best part of the job and my colleagues see me as a bonus. It’s just very hard to let go of the last bit. Next year I will reduce to one session a week. I’m fading away like the Cheshire cat.’

‘Cushion the fall’

Jonathan Graffy also enjoyed the phased withdrawal that the GP Retention Scheme allowed him for 18 months before he and his wife, Clare Goodhart, retired officially in March, both in their mid-60s.

But Dr Goodhart had been a partner at a Cambridge practice right up to retirement and feared it might be like ‘falling off a cliff edge’.

So they began looking for ways to ‘cushion the fall’, keep their hand in and retain their skills. A working holiday on Orkney, job-sharing a maternity locum, provided the perfect opportunity.

‘We both felt we’ve got all this knowledge and

Mr Singh recalls the conversation with wry humour. ‘Very perceptive: that’s how quickly it changes. But once a doctor, always a doctor. It’s very much part of your identity: it’s who you worked really hard to become.’

He had always prided himself on supporting patients all the way through their hospital stays. So when he took planned retirement at 60, he did not consider working part time.

But he wanted a phased retirement, not a ‘crash landing’, and there were other interests he wanted to pursue. Chief among them is his longstanding role as an examiner for the Royal College of Surgeons FRCS: this involves working with trainee surgeons and colleagues and enables him to update his knowledge regularly.

‘I’m still very much in the world of surgery, not in the operating theatre but meeting with, learning from and sharing experiences with other surgeons,’ says Mr Singh. ‘A big part of being a consultant was the camaraderie and learning from each other. I feel that’s still available to me.’

Since retirement, he’s also been busy as a member of the faculty at the Cambridge anastomosis course, working as a clinical supervisor at a COVID vaccination centre, serving as deputy chair of the BMA retired members conference, and even operating on hernias

CANNON: ‘ I wasn’t ready to leave medicine’

(LEFT) AND GRAFFY: Keen to keep their skills updated

for a charity in Ghana.

One of his most fulfilling roles is volunteering with the BMA’s peer support scheme, mentoring struggling doctors and those undergoing GMC investigation. He is passionate about this work, believing it to be a potential solution to the NHS’s recruitment, morale and retention issues.

‘The ones that remain feel so stretched, so isolated, so unsupported.

‘We’re almost 50,000 doctors short and the most experienced, the most knowledgeable are being let go’

He has lobbied, through the BMA, for doctors to be given ‘protected time and space for confidential reflection, with a mentor of their choice’. He hopes the NHS and GMC declare this ‘best practice’, to encourage employers to provide it as standard.

‘We’re almost 50,000 doctors short and the most experienced, the most knowledgeable are just being let go,’ says Mr Singh.

Untapped talent

‘Retired doctors are a potential source of support as they have the wisdom and expertise: they’ve lived it themselves. [Mentoring] would provide a sense of purpose and giving back after what, for most of us, have been privileged careers.’

The BMA has been collaborating with the NHS to create appropriate, attractive ways for retired doctors to contribute, and lobbying to ensure that returning to work does not adversely affect their pensions.

An enhanced version of this piece will be found in our online supplement for retired members in December.

The positive experiences retired doctors have in returning to work are often marred by frustration at red tape and technical hurdles. Tom Kinloch retired from general practice on Merseyside in 2019, having worked for 34 years in the practice where his parents were GPs before him. He retired slightly early, partly because of pension taxes – but was keen to contribute and support former colleagues as the pandemic unfolded.

He was one of about 30,000 doctors who gained temporary emergency registration with the GMC in spring 2020, and NHS England suggested he applied to the CCAS (COVID Clinical Assessment Service). He did – and heard nothing further. Ultimately, he secured work as a CCAS assessor through his own contacts, from his time as chair of the local medical committee. The same thing happened when he applied to support the COVID vaccination drive. Online applications disappeared into the ether. It was through local NHS England contacts that he became lead GP at a local vaccination hub. He found both roles hugely rewarding – but the recruitment process deeply frustrating.

‘It was a national crisis, and the whole country was falling apart,’ says Dr Kinloch, a member of the BMA retired members committee. ‘Several colleagues readily volunteered as I did, but didn’t have the local contacts. Eventually they just gave up.’

In September, the temporary GMC registration given to doctors such as Dr Kinloch was extended till 2024. But, given that its original intention was ‘to support the response to the pandemic’, he’s not sure how he can help – and nor are NHS administrative staff he has spoken to.

‘There are things I could do to help my old practice – field some queries, medicine reviews perhaps – so they could concentrate on face-to-face contact with patients. But it is far from clear what we can offer or be asked to do. They need to tell us. If you have got the skills and there is a need, it feels a little as if there’s a moral obligation to get involved.’

GOODHART

SINGH: Supports doctors who are struggling

THE FIGHT GOES ON

With BMA support, the widow of a doctor who took his own life while under GMC investigation has accepted a settlement from his former employer. Her focus is now to hold the regulator to account.

Peter Blackburn reports

‘It is exhausting – absolutely exhausting. But I would like to see some long-lasting change – some change that will have a real impact on the protection of doctors. That would be the satisfaction for me. This is a journey and we are only at the first steps.’

Viji Suresh has been campaigning for more compassionate regulation of doctors and a health system which values the wellbeing of staff for more than four years. And she isn’t giving up any time soon.

This campaign was borne out of personal tragedy. On 2 May 2018, Ms Suresh’s husband, Sridharan Suresh, took his life after receiving a letter from the GMC informing him it had opened an investigation and he would have to appear before an interim orders tribunal. Dr Suresh was ‘blindsided’ by the notification. Just hours later he sent an email to his wife saying he had done nothing wrong but could go on no longer.

Dr Suresh, a consultant anaesthetist at North Tees and Hartlepool Hospitals NHS Foundation Trust, had been under police investigation at the time following allegations of sexual touching made by a teenage patient undergoing sedation for dental extraction – although an inquest into his death in 2020 heard that the drugs used to sedate the patient are ‘well-known’ to produce hallucinations and

ADRIAN DON

SURESH: Campaigning for more compassionate handling of complaints

‘Too many doctors have lost their lives – it is time the profession demands change’

heightened sexual feelings, the description the victim gave did not match Dr Suresh’s appearance and the police later closed the case with ‘insufficient evidence’.

Dr Suresh had been told by his trust he would not be referred to the GMC, but the police made a third-party referral and the trust did not inform Dr Suresh, despite knowing the action had been taken.

Ms Suresh has been fighting for recompense and widescale action from Dr Suresh’s trust and regulator, the GMC, since his death. The BMA has supported Ms Suresh’s legal cases against the GMC and the trust to help drive system change in how doctors are dealt with when under investigation.

BMA council chair Phil Banfield says: ‘We are proud to support this case. It must not take more tragedies to force those who hold sway over doctors’ lives into action. We need better systems and processes to protect the wellbeing of doctors and we need them urgently.’

Ms Suresh has now accepted the trust’s offer of an undisclosed settlement and says that, while no amount of money can compensate for the loss her family has suffered, she intends to focus efforts on holding the GMC to account.

She says: ‘They have always accepted that they made mistakes. This life cannot be valued with money. But for the sake of the profession and our campaign we had to accept and progress to move to the next stage – especially to see the GMC take accountability.’

GMC investigations are feared among doctors. Each year there are thousands of fitness-to-practise enquiries, the majority sent by members of the public. While the large majority are closed during ‘initial triage’ stages, even those cases which do not last the distance can have a huge effect on the health and wellbeing of doctors.

Ms Suresh says: ‘The GMC investigations make the doctors feel marginalised, under suspicion and excluded from their own fellow professionals – there is an extensive sense of isolation when a doctor goes through professional distress.’

Ms Suresh’s medico-legal adviser Rajendra Chaudhary adds: ‘The GMC has the power to take everything away from doctors… Doctors have worked so hard, for all their lives, to build that professional life and when it is under threat that feeds despair. The GMC knows this. It has been told this by the experts it appointed to look into these issues.’

The GMC has commissioned investigations around the links between doctor suicide and FTP investigations, with an independent review carried out in 2014 by Sarndrah Horsfall and a later GMC review led by Professor Louis Appleby. In correspondence with the BMA the GMC has admitted its processes carry ‘real and immediate risk to life for any doctor’ and pledged to continue to ‘improve the way we handle FTP cases’. The BMA and Ms Suresh believe the GMC must take greater accountability and work to address these problems, however.

Demand for change

Last month, Ms Suresh and supporters organised an event in Middlesbrough which saw esteemed experts and medical professionals come together to call for action in this area. The conference was chaired by former BMA council chair Chaand Nagpaul and included the screening of a documentary made about Dr Suresh’s story.

Opening the event, Dr Nagpaul said: ‘It should be a never event that any doctor should be put into that position of taking their own life.’

Ms Suresh, supported by the BMA, is committed to continuing the legal action against the GMC but is also calling on doctors to unite over their treatment by the healthcare system and regulator – urging the profession to come together ‘with steel, determination and an anger for change’. Ms Suresh and colleagues have drawn up a charter of rights for doctors which they believe should be adopted across the board. The charter suggests no doctor’s life should be lost because of GMC processes, no doctor should be subjected to unfair and inappropriate FTP investigation and no doctor should suffer discrimination at the hands of the GMC.

To accompany the charter, a survey has been put together asking for doctors’ views on issues behind each aspect of the charter, including asking doctors whether there should be an independent scrutinising body checking the appropriateness of each GMC referral, whether all referrals should be anonymised, whether there should be laws on timelines of GMC investigations and compensatory measures for breaches and whether the GMC should have the power to carry out separate investigations where doctors have been found not guilty in the courts. Ms Suresh says: ‘Too many doctors have lost their lives – it is time the profession demands change. The profession should demand protection of their health and respect for their wellbeing.’

SRIDHARAN SURESH

Your BMA

Barriers. Obstacles. Boxes.

When I look at the systems which govern our training and working lives that is what I see. Barriers to training and development. Obstacles to work-life balance which are exhausting to overcome. Boxes trapping us in unhealthy and unnecessary ways of studying, training, progressing and working.

In an NHS under such phenomenal pressure – which needs its doctors more than ever – this is beyond bizarre.

We have 132,000 vacancies in the NHS in England alone, we have one of the lowest ratios of doctors per population in the 38-member OECD (Organisation for Economic Cooperation and Development) and there are more than seven million people on the waiting list for secondary-care intervention. By the BMA’s estimation we would need another 46,300 doctors purely to meet the OECD average.

The numbers are frightening. And at a time when we are so desperate for an adequate workforce – when our patients desperately need a well-staffed NHS – shouldn’t we be pulling down these barriers, getting rid of the boxes that trap us and finding solutions to the obstacles in front of us?

Every year we have limits on the number of training programme places offered in this country. We know the numbers aren’t enough – that we can’t create the junior doctors and consultants we need using these equations.

For those in training there are seemingly endless hoops to jump through – rules which seem far more likely to push people away from medicine than support them to thrive in this profession. Why are there limits on the amount of time it must take to navigate between the start of a training programme and the end? Why are there limits on the years taken out of training? Why is there a limit on the number of exam attempts?

Maybe these rules suit some people – those who are likely to have a more traditional, linear route from the start to the finish of their training. But that doesn’t mean they are the right rules for everyone – and it certainly doesn’t mean they are appropriate in an NHS which desperately needs to recruit to, and retain, its workforce. Have these rules considered people who are parents, those who are carers, people with mental or physical health issues, those with disabilities, or those who have partners or children

who need support? How do these rules support medical students or doctors who may have diagnoses of – or are on incredibly lengthy waiting lists for support for – a wide range of physical or mental issues which make traditional work and study difficult?

As doctors, and as a system, we are so keen to demand evidence for what we do – evidence-based medicine is our bedrock. But I haven’t seen any evidence for the way we do so many of these things. Who do these barriers, obstacles and boxes serve? It is hard to see how they serve doctors, the NHS or our patients.

There are countless examples across the health system. There are some 325,000 doctors on the GMC register but the NHS fails to get the most out of so many of those. For example, locally employed doctors or people pushed to take locum roles because they aren’t given the flexibility or opportunities they want elsewhere.

Nobody benefits from a lost tribe of doctors who aren’t given every possible opportunity for progression and development.

Ultimately, I think it comes down to valuing people. And, here, we need radical action – and a concerted sense of commitment for change across the system.

I challenge anyone in the rooms where decisions are made which affect doctors’ lives to ask themselves whether they are holding that value at the heart of what they are doing – at the core of the decisions they make. If you are not, perhaps it is time to ask yourself why you are putting barriers and obstacles in the way of doctors we desperately need to thrive.

Whatever you are going through, whatever obstacles or barriers you face, whatever boxes you feel trapped in –you are not alone. Firstly, we are your trade union; contact our team if you need our help. The BMA’s free 24/7 wellbeing and counselling services are also here for you and your dependants as well as non-members.

You can email me at RBChair@bma.org.uk

Dr Latifa Patel is chair of the BMA representative body

Doctors need to be supported to thrive if the NHS is to survive this staffing crisis

@drlatifapatel

on the ground

A doctor felt work was being dumped on her, and was intimidated when she asked for a review

It’s often called the ‘art of delegation’, but those who have work dumped on them by senior colleagues tend to refer to it a little less politely.

A specialty doctor felt she was being given not just too much work by her clinical supervisor, but that the work was of a consultant level, and outside her job plan.

The doctor was experienced, probably more so than many of her colleagues who were consultants, but this tended to mean she was put upon, with work being delegated informally and unfairly.

She asked for a job-plan review. Such reviews should be conducted annually but if working arrangements change, and are not in line with the job plan currently in place, doctors and managers can request a review at any time.

These meetings are usually informal and conducted without the doctor being represented. But when our member went along to this one, she found it very intimidating.

A senior manager seemed to have his own personal agenda and demanded a formal job plan be fi nalised by the end of the day.

It seemed to make a mockery of best practice for such meetings, which are supposed to be constructive, allow discussion and negotiation, and where the outcome should be a mutual agreement.

The doctor took sick leave, owing to work-related stress, and got the BMA involved. The BMA employment adviser attended sickness-review meetings with the doctor, and it seemed to prompt the employer to start behaving in a more humane manner.

They acknowledged the stress the doctor was under because of her colleagues crossing boundaries in their acts of delegation.

They had done it because she was the most experienced specialty doctor, but had not made allowance for how much work they had given her. They committed to a different approach.

Highlighting practical help given to BMA members in difficulty

This is an experience that will be familiar to many specialty doctors, who are asked – and often pressured – to take on work from consultant and junior doctor colleagues, particularly when staffi ng gaps appear.

With the help of the adviser, the doctor agreed a job plan with which she was satisfi ed.

She wrote to the adviser: ‘I will remember all the advice and guidance you have given and I know I can come back to you for advice in the future. I am very grateful to you and the BMA for helping me through this issue and bringing it to a closure.’

BMA members seeking employment advice can call 0300 123 1233 or email support@bma.org.uk

the doctor

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

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

@TheDrMagazine

@theBMA

The Doctor is published by the British Medical Association. The views expressed in it are not necessarily those of the BMA. It is available on subscription at £170 (UK) or £235 (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: 379 issue no: 8360 ISSN 2631-6412

Editor: Neil Hallows (020) 7383 6321

Chief sub-editor: Chris Patterson

Senior staff writer: Peter Blackburn (020) 7874 7398

Staff writers: Tim Tonkin (020) 7383 6753 and Ben Ireland (020) 7383 6066

Scotland correspondent: Jennifer Trueland

Feature writer: Seren Boyd

Senior production editor: Lisa Bott-Hansson

Design: BMA creative services

Cover photograph: Alex Cauvi

Read more from The Doctor online at bma.org.uk/thedoctor

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