At the limit
A life outside How reducing your working hours can keep you in medicine
‘War zone’ Desperate conditions in hospitals impacting on doctors
Chilling effect Fuel poverty becomes a major public health issue
3
At a glance
As the ballot deadline looms, junior doctors report stress and poor morale
4-9
On their shoulders
GPs face an unsustainable workload, a toxic media climate and a rising tide of abuse
10-13
Chilling effect
As fuel poverty becomes a major public health issue, GPs have been prescribing warm homes in a pilot scheme
14-17
A life outside
How working less than full-time is helping doctors stay in medicine
18-19
A winter like no other ‘War zone’ conditions in hospitals having a profound impact on doctors
20-21
The gift of life
A doctor tells why he donated his kidney to a stranger
22 Your BMA
Helping members attend the annual representative meeting
23 Viewpoint
The pitfalls when your patients are doctors
This month, the BMA consultants committee announced it would hold a consultative ballot to determine whether consultants in England would be prepared to take future industrial action. On 20 February, the ballot of junior doctor members in England will close – with the BMA encouraging votes in favour of strike action.
The Government has been warned repeatedly. Every day, ministers refuse to engage on meaningful solutions, they walk blindly into a staffing crisis that is harming patients. Many of the issues which lead us to this point are laid bare in this magazine.
GPs are being pushed beyond their limits. General practice is dealing with rising demand amid declining GP numbers. In the face of this pressure, it is scandalous that mainstream media and politicians have scapegoated GPs. We put the record straight by visiting practices across the country and reporting what working life is really like. I would encourage my colleagues in secondary care to take time to find out just how different being a GP has become in recent years. Better understanding of each other’s reality unites us as a profession against the real issue here: sustained underinvestment across the NHS.
The BMA has highlighted that the country is getting sicker – and the NHS is left picking up the pieces of a society where inequalities are widening. We speak to doctors trying to keep patients well with schemes such as warm-home prescriptions.
We hear from doctors working in emergency departments across the UK – where colleagues find quiet places on wards to cry, patients die on trolleys in corridors, and staff return home from shifts wondering how to pay their bills.
Amid this workforce crisis, we investigate whether more flexible working arrangements could help reduce burnout and improve retention.
We also tell the story of GP Richard Armitage who recently donated a kidney to a stranger – preventing them from requiring dialysis three times a week. After four decades working in the NHS, the compassion doctors show never ceases to amaze me. This is why we are fighting for the future of our profession.
doctor
‘I do question whether it is worth staying in the NHS, as the current situation is totally unsustainable. The conditions we’re working in make it a daily battle to keep patients somewhat safe [and] I have come into work when ill because I know my trust is understaffed and I want to keep patients safe.’
This is how one junior doctor summed up their experience of working in today’s health service to the BMA.
As the deadline for voting in the ballot on possible industrial action in England looms closer, results from the latest association survey of junior doctors has exposed the shocking extent of desperate working conditions and rock-bottom morale.
Taking in the views of nearly 3,000 junior doctors in November and December last year, the survey reveals 71 per cent of respondents reported having turned up for work while feeling unwell during the previous three months.
Meanwhile 78 per cent told the BMA they had felt unwell during the previous 12 months as a result of work-related stress, while 60 per cent described their morale as very low, negative or low.
Junior doctors have seen more than a quarter of their salaries disappear since 2008. It is clear that year after year of real-terms
bma.org.uk/thedoctor
pay cuts have had a damaging effect on the morale and wellbeing of junior doctors and has exacerbated the recruitment and retention crisis, at a time when under-staffed and under-resourced services must deal with unprecedented levels of demand.
Just 6 per cent of those responding to the survey said they were always able to take breaks during working hours in full, while 38 per cent said they never or were rarely able to.
The march towards possible industrial action among junior doctors in Scotland has moved closer, following a unanimous decision on 26 January by the BMA UK council to approve an application by the Scottish BMA junior doctors committee to ballot members.
BMA SJDC chair Chris Smith (pictured left) said a ballot would open before the end of March, while urging the Scottish Government to return to the negotiating table over doctors’ pay.
He said: ‘This is an important step forward in our battle to win full pay restoration for Scottish junior doctors and finally make a huge difference to the morale of a workforce that is on its knees and working in an NHS collapsing around them.’
The deadline for returning ballots for junior doctors in England is midday 20 February.
By Tim TonkinGPs are working under greater pressure than ever before, but added to this is a toxic media climate and a rising tide of abuse from a minority of patients. In the fi rst of a two-part study, they tell our writers why change is urgently needed
Dave Triska is used to pressure: he is ex-army and came to this quiet corner of Surrey direct from a tour in Afghanistan.
Take that mid-December day, during the Strep A spike…
‘For about 30 seconds, I had the same visceral response as when a daisychain IED went off in the compound in Afghanistan, and all these injured people were streaming towards me,’ he says, without hyperbole. ‘Then you pull your big boy pants up and get on with it.’
On the Tuesday after the New Year bank holiday, they had 459 contacts, more than double their pre-COVID average, and declared a ‘black alert’.
By noon, they’ve had almost 200 contact requests, to be dealt with today by two nurses and five doctors, including them. Neither of them ever sleeps on a Sunday night: a normal Monday is 11 hours long.
But there are days, many days, when he and his managing partner, Lis Galloway, feel the workload at Witley Surgery is out of control.
It feels like ‘being morphed into an urgent care centre’; the next nearest is 30 minutes’ drive away.
It is a Monday morning in January and Drs Triska and Galloway are huddled over their computers, back-toback in their triage ‘hot room’.
They’re good at flex. The whole team, including reception staff, have had change management training and adopted digital tech enthusiastically: they switched to telemedicine in 2017. In terms of efficiency, access and case management, they’re ‘probably doing the best medicine we ever have’, says Dr Triska. But it’s not enough.
The reasons behind such a surge in demand are complex, and not unique to Witley village.
Their 11,000-strong patient population is among
‘This is a car crash. If I get this wrong, someone might die’EMMA BROWN
the oldest in the UK, typically still living independently: more than half have longterm care needs. They’re also well-educated and well-read. Dr Galloway winces at a request for ‘a referral today’; a prescription of statins requires a detailed discussion about enzymes.
Increased health anxiety since COVID and ‘uncontrolled transmission’ of winter viruses have played a part. But the fallout of secondary care delays is devastating.
Dr Triska gives a ‘not uncommon’ example: patients with severe rheumatological pain who have lost jobs waiting for a diagnosis and plummeted into depression. Previously, they would have been seen within two weeks and could have expected a resolution within seven months. Today, they have little prospect of help for either condition.
Mental health issues now account for about 40 per cent of Dr Triska’s caseload. He has had one patient seen by a psychologist locally in five years. Last Friday he spent hours trying to find appropriate help for a suicidal patient – and failed. ‘My threshold for “this is bad” is quite high but this is a car crash. If I get this wrong, someone might die.’
The pressures are largely hidden from patients. The waiting room is quiet today, a reflection of effective online triage, remote consulting and the decision to move the dispensary hatch to an external wall.
Despite high patientsatisfaction ratings, ‘negativity’ has increased, says
receptionist Sam. A few weeks ago, they called police when a patient became physically aggressive with one of her colleagues. Staff cars have been vandalised, anti-vax propaganda pasted on the door.
The disgruntled come
the moral imperative in healthcare: we’re all traumatised because we’re not delivering the care we want to, we’re being trashed and we can’t trust our leaders to look after us. We’re on our own.’
By Seren Boydpreloaded with mediafed arguments, says Dr Galloway. ‘They assume we’re withholding a service, putting barriers up, and we’re really not.’
The big ‘unseen work of general practice’ is the risk it holds, she says. And, worst of all, there’s no back-up, guidance or leadership.
‘We can say we’re full but if an unwell child comes to us at 4pm, we’re not going to turn them away. You look to local and national leaders and there’s just silence.’
Innovation in the way primary care is delivered is vital, says Dr Triska, but that is impossible without rebuilding trust.
‘We’re rapidly losing
‘It’s a vicious cycle of worry – and that is very stressful.’
York GP Abbie Brooks is scrolling through the list of people requiring urgent, same-day, appointments, and reflecting on failures in publichealth messaging, lessons from the pandemic left unlearned and communities who seem to have forgotten how to self-care for even some of the most minor illnesses.
It’s barely 8am and the list of patients reads: cough, tonsils, cough, cough, ear, tonsils, cough. Among the litany of cold and flu-type symptoms a patient who has much more obviously concerning symptoms –suicidal ideation or possible
cancer symptoms – crops up every so often, but the vast majority who need triaging follow a familiar theme.
‘It’s usually not that bad in December,’ Dr Brooks, who has been a partner here for four years, says. But this is Wednesday, 14 December, 2022. Not only is the entire NHS system in absolute crisis, but there has also been an increase in cases of invasive group A Streptococcus –with print and broadcast media, parenting forums and conversations outside the
are worried about that too. Those worried parents race for appointments to secure the now even more coveted tablets and fluids. In this maelstrom it is hard to escape the feeling GPs are vulnerable to the effects of whatever is happening in society – so often the ones picking up the pieces when everything else is falling apart.
Dr Brooks’s first faceto-face patient of the day, though, has none of those symptoms, and provides a timely reminder about the importance of general practice amid the chaos which threatens to overwhelm services.
He has rung the surgery to raise concerns about a lump in his neck which he says has been there for ‘quite a long time’ but has recently begun to worry him much more significantly. When the patient arrives he is clearly incredibly nervous and, ultimately, reveals he has convinced himself that he has ‘some sort of awful cancer’.
compassion is totally focused and absolutely undivided.
Dr Brooks also finds time to check a skin lesion, to discuss what to be aware of around new and existing moles, and to make it feel much more likely that this patient will call his GP next time he has a worrying symptom, rather than trying to ignore it. It is just one encounter of many during a day which feels like brilliant general practice – where and when it is most needed, but so hampered by strain from elsewhere.
Given the pressures on the service and what seem to doctors like attacks from government ministers and the media, not to mention increasing levels of expectation and abuse from the public, it is genuinely quite moving to see the effect of the dedication of doctors working in primary care.
‘I don’t want to put people like that off,’ Dr Brooks says.
school gates ablaze with talk of an outbreak of scarlet fever. Across the country, parents and families are worried –many want reassurance and many want antibiotics.
The ‘vicious cycle’ Dr Brooks references is in full swing; more people want appointments. Those who get them want solutions – and not just to be told to give themselves time to recover.
As a result, there is a shortage of antibiotics and now parents and families
The lifting of the worry in the room is palpable – so powerful it is almost vicariously relieving – when Dr Brooks is able to diagnose a cyst in the skin of no real concern.
It is an interaction which reveals so much about Dr Brooks and the specialty. On top of the mountain of scarlet fever concern, this was a week in which there have been yet more media stories which feel like barbs for doctors – one of them suggesting GPs might somehow be drafted in to work in ambulances during strikes – and yet Dr Brooks goes about her work as if each patient is the only thing on her mind: that care and
‘We are incredibly busy but I don’t want people like him thinking twice about phoning us. Prior to that consultation I was thinking “this could be leukaemia or lymphoma, what do I need to do to make sure I don’t miss something”. If it had been that I would have had to do a full check of his lymph system.
‘This is the thing, our interactions can be joyous. We’ve taken so much worry away from him. But we do need that time and space to get to know people, to give them a chance to say everything they want to say, to get everything off their chest… And that’s really difficult in the current environment.’
By Peter Blackburn‘We need time to get to know people, to give them a chance to say everything they want’
Health services across NHS
Ayrshire and Arran were on an emergency footing when The Doctor visited Largs Medical Group. On 10 January, the health board had asked GP practices to see urgent and emergency care patients only, and it was not clear when this situation would end.
‘Generally speaking, our days are busy at the moment,’ says Rachel Fraser, one of the 11 GPs at the practice, which serves a population of just over 13,000.
‘We’ve switched to a system where our morning appointments are routine and afternoons are emergency – aligned to the fact that the health board is on an emergency footing at the moment. We had a surge owing to Strep A and the flu, which seems to have reduced
a bit this month, so it feels a bit less pressured. But every day our appointments are filled – we really don’t have any spare capacity.’
Largs is a charming seaside town in Ayrshire which is perhaps most famous for its association with the Vikings and for its ice cream parlours, notably Nardini’s.
It’s also a sizeable schlep by public transport to the nearest hospitals, Crosshouse in Kilmarnock (two buses or a train and a bus, taking well over an hour) and Inverclyde, which is closer but is actually run by neighbouring NHS Greater Glasgow and Clyde health board. Given that it also has a sizeable older population, and significant
new Scottish GP contract, which was agreed in 2018, but still in the process of being implemented.
This involves the presence of a multidisciplinary team, including a mental health practitioner, first-contact physiotherapist, pharmacists and pharmacy technicians, and a community link worker.
As well as its own nursing team, there is also access to district nursing, health visiting, and midwifery on site.
These additional roles have largely been welcomed by the local population and demand is high, but not everybody is happy with services offered by the practice, and this takes a toll on GPs and staff.
pockets of deprivation (although not compared with some of its neighbouring settlements), this can be a problem.
The vast majority of healthcare in the town and its surrounds is delivered by Largs Medical Practice, which offers a wide array of services, thanks in part to the
‘There’s an active local Facebook group which has been really quite difficult and challenging, particularly for our staff, who are on the front line,’ says Dr Fraser.
‘There still seems to be this negative media rhetoric that practices are not open, that your GP is “not working” and that’s completely not true. In
‘There still seems to be this negative media rhetoric that practices are not open’FRASER: No spare capacity Ayrshire
fact it’s the absolute opposite.
‘We’ve been working throughout and are offering more appointments than ever.’
The balance has changed, she adds, with a higher proportion of telephone consultations to help build more capacity into the system.
‘We’re using every single minute of the whole day to make sure that patients are safe when they come to our practice, but admin staff are on the front line and are dealing with the public on a daily basis.
‘They get the real abuse. I understand that individuals are frustrated at not having the same service from the NHS, but services are in crisis and there’s a finite resource.’
GP partner Colin Jamieson is also feeling the brunt. He has taken the decision to cut his sessions in an attempt to preserve his mental health.
‘I’ve never worked as hard as I have in the last three years – it’s been relentless,’ he says. ‘I do consider myself
a resilient person, and I’ve always been able to ignore negative media attention, but it just started to get to me. It’s not just the mainstream media, it’s the local Facebook group – it’s local, and it’s personal.’
Around six months ago he had what he called ‘a proper, bona fide meltdown’. ‘For the first time, I ended up on antidepressants. You know what, I’m tough. I’ve been tough for a long time, but human beings have their limits, and I absolutely reached mine.’
GPs feel obliged to carry on, he says, because they don’t want to let colleagues or patients down. But he has taken the decision to cut his patient-facing hours. ‘It’s to preserve my sanity,’ he says. And he’s not joking.
In a neighbouring room, GP registrar Shivraj Vittalraj is looking forward with enthusiasm to a career in general practice. ‘It’s an amazing field,’ he says.
‘I feel the patient-doctor relationship is great in this specialty because I’m looking at the patient as a whole. It’s the continuity of care –you’re the family doctor.
‘You’re not treating them as a problem [in isolation] – it’s more of a complete package, and I’m very happy with that.’
That’s not to say that
challenging.
‘We’re seeing so many patients, and with those numbers, we can’t do justice to everyone. We’re trying to do our best, but we’re humans as well.’
By Jennifer Truelandbma.org.uk/thedoctor
‘We’re seeing so many patients, and with those numbers, we can’t do justice to everyone’
‘Human beings have their limits, and I absolutely reached mine’JAMIESON: Human beings have their limits
VITTALRAJ: Values doctor-patient relationship
Cold homes are robbing patients of their health. Doctors tell Tim Tonkin why fuel poverty needs to be seen as a major public health issue – and how GPs are helping some with heating on prescription
In her two decades spent working in general practice, Becky Haines says she has never seen fuel poverty play as significant a factor in her patients’ health as she has in the past couple of months.
Speaking to The Doctor, the Gateshead GP says health issues relating to fuel poverty and cold homes were historically something she tended only to encounter among older or homeless patients, and rarely among those of working age in accommodation.
Since the beginning of this winter, however, Dr Haines says she now regularly encounters patients of all ages and backgrounds with complaints relating to physical and mental health that are being exacerbated by living in homes many admit they simply cannot afford to heat and keep warm.
‘I can’t previously remember ever having conversations where it [fuel poverty] was a primary focus of what we talk about, whereas it’s not uncommon now,’ she says.
‘In a deprived area, such as where I’m working, it’s now normal that people can’t afford to have adequate heating in their home, and that’s shocking to me. People are coming in and talking about being cold and how their bills and finances are the most stressful thing in their lives at the moment, so it is the biggest thing affecting their health.
‘I feel afraid. I think people are going to die because they’re cold. I know that every winter that does happen, and that’s shocking enough, but this winter it’s going to be worse, because of the number of people who are unable to keep themselves warm.’
Dr Haines is, unfortunately, far from alone in her experiences.
Like many other parts of the world, the UK faces a ‘perfect storm’ of factors contributing to fuel impoverishment.
A surge in the cost of commodities such as gas, oil and coal following the peak of the COVID-19 pandemic was then further exacerbated by Russia’s invasion of Ukraine in February last year.
Coupled with record inflation and a broader cost-ofliving crisis, more people than ever are facing the stark reality they may not be able to afford to heat their homes.
The seriousness of the situation was made evident by figures published by fuel poverty charity National Energy Action, which warned that the number of UK households in fuel poverty could hit 8.4 million by April this year, almost double the 4.5 million in this position in October 2021.
The health implications of fuel poverty are varied, with a report published by University College London’s Institute of Health Equity warning that cold homes can cause or worsen a range of health issues including respiratory and cardiovascular illness, musculoskeletal and rheumatological conditions, diabetes, dementia, mental health and childhood development.
Published in August 2022, the institute’s report warned that with an estimated 63,000 excess winter deaths in England in 2020-21, around 10 per cent of these are believed to be directly
‘I think people are going to die because they are cold’
attributed to fuel poverty.
Those most at risk of ill health resulting from the cold include infants and children, older people and those with pre-existing health problems.
Dr Haines says the effect of fuel poverty on those in her care is often most apparent during long-term condition reviews, in which patients with pre-existing health issues are citing cold and the struggle to keep warm as health concerns.
‘Although it sort of feels obvious that being cold is going to make you feel more unwell ... I’ve really noticed that patients, especially ones who are coming in for their longterm condition reviews, are mentioning how being cold is affecting them,’ she says.
‘People complain of the cold in their houses affecting their asthma or their chest, lots of people with chronic pain are saying how their pain is a lot worse at the moment because of not being able to afford to heat their homes.’
In Scotland, Wales and Northern Ireland a home is deemed to be in fuel poverty if more than 10 per cent of its household income is spent on heating, leading to an overall
inadequate standard of living.
In England, fuel poverty is determined by a home having an energy efficiency rating of band D or below and if, after heating bills, remaining household income falls below the official national poverty line.
Alongside the human cost, the financial burden to health posed by fuel impoverishment is also considerable, with the NHS estimated to have spent £2.5bn on treating illness connected to damp and cold in 2019.
‘It’s really hard when someone says to me that their pain is a lot worse because their house is cold,’ says Dr Haines.
‘You don’t want to just increase people’s painkillers because that’s not going to help them in the long run. We’re lucky in my area in that we’ve got a really good social prescribing system and there are warm spaces in Gateshead that people can be referred to, and that can help.
‘Ultimately, however, if your house has not been heated at all, in this weather, then even if you go to a warm space for a few hours a day, you can come back to that cold house and sleep in that cold house. Which
is a really terrible position to be in.’
The unprecedented rises in energy prices early last year prompted the Government to provide financial assistance to households, through a one-off scheme of incremental discounts to energy bills totalling £400 over a period of six months. But for those on low incomes it may simply not be enough.
This situation has in Gloucestershire led to an initiative that in a bygone era might have seemed inconceivable – that of domestic heating being made available on prescription.
Part of a joint project between One Gloucestershire, the county’s integrated care board, sustainability charity Severn Wye and non-profi t innovation fi rm Energy Systems Catapult, the Warm Homes Prescription aims to help clinically vulnerable people in the county keep their homes heated.
Under the terms of the scheme, fi nancial assistance with paying energy bills is available to those under the age of 60 who receive free
‘You don’t want to just increase people’s painkillers because that’s not going to help them in the long run’
prescriptions and have a chronic respiratory condition or to those over 60 who are struggling to meet their energy costs.
Gloucester GP Hein Le Roux has been closely involved in the initial piloting of the scheme in 2021 and with the prescription’s current iteration, which will see around 150 people have their heating bills met up until March this year through the Household Support Fund.
He says that while limited in its scope, the prescription is a good example of how primary care services can collaborate with other organisations to deliver public health management initiatives without adding drastically to GPs’ workloads.
‘Through social prescribing we’ve had [things like] art on prescription for people with depression and weight loss on prescription ... but this [heating on prescription] is a first,’ he says.
‘[In the 2021 pilot] we ended up getting 30 patients and based on the success of that pilot, we’ve now got funding for 150 people. Out of a population of 670,000 this is not huge but it’s a start, and if energy prices were low as they were last year, we would have actually been able to reach a lot more people.’
Rolling out the prescription involved first identifying patients known to have severe, chronic health conditions and then drawing on the knowledge of social prescribers working within general practices to determine which of this group was in, or at risk of, fuel poverty.
bma.org.uk/thedoctor
Those meeting the criteria of being most at risk are contacted by social prescribers, rather than GPs themselves, and advised that they qualify for assistance with meeting their energy bills.
Dr Le Roux admits that while it is difficult to measure the extent to which the prescription has improved health or reduced hospital admissions of vulnerable patients, he believes engaging with patients on heating can often facilitate other health interventions.
‘In the public health medicine way of working it’s not just one magic bullet but it’s usually several different marginal gains [and] I think this [initiative] brings into play another concept – that of the care bundle,’ he says.
‘These are the people that we [general practice] aren’t very good at reaching. We discovered that lots of people in that severe segment hadn’t turned up for vaccination or annual review, and just a simple phone call had then got them to come to several different interventions that would help.’
BMA board of science chair David Strain says his committee is continuing to examine and lobby on issues such as the costof-living crisis and its impacts on individuals’ and communities’ health.
He says that while access to support with heating and access to warm spaces for vulnerable patients through social prescribing initiatives is to be commended, it is also important that providing such care did not overly add to the
existing clinical burdens faced by many doctors.
He adds that, with coldrelated illness likely to present challenges to health for the foreseeable future, it is vital the Government does all it can to increase the support made available to those struggling with the cost of energy.
He says: ‘Fuel poverty and cold weather are going to be a major public health issue for the long term, particularly with the energy price cap set to be removed in April. Even with the war in Ukraine and with other situations that are driving the cost of energy, prices will inevitably continue to go up.
‘The BMA will be lobbying for the fuel cap to remain in place [until] next April [2024] as without it, the impacts of fuel poverty, both on individuals and households and the NHS, will be even worse than this year, irrespective of other support measures that are put in place.
‘Helping people to stay warm not only protects their health but helps to ease demands on hospitals and other services at a time when the NHS is facing unprecedented pressure and crisis.’
‘Fuel poverty and cold weather are going to be a major public health issue for the long term’
‘The BMA will be lobbying for the fuel cap to remain in place until April 2024’
In the thick of a workforce crisis, talk of reducing your hours can provoke strong reactions – but not necessarily those you would expect.
Once, working LTFT (less than full time) might have been considered the preserve of parents, or some unusual exceptions such as elite athletes.
But increasingly, doctors are choosing not to cram every waking hour with clinical work and are working more flexibly, for a much wider range of reasons.
Whether they are juggling other responsibilities or health issues, favouring portfolio careers or a better work-life balance, advocates of LTFT all agree: it is why they are
still in medicine.
So, amid a workforce crisis, could more flexible working arrangements reduce burnout and improve retention?
Back from the brink
David Baglow and Phil Sherrard have no doubt going LTFT is the reason they are still practising doctors.
Both anaesthetists in Sussex, Dr Baglow is a specialty trainee 7, while Dr Sherrard is a consultant. They speak openly about the health crises which have forced them to re-evaluate their relationship with work.
Five years, ago, Dr Baglow sustained a serious head injury, and had to learn to walk straight and function again.
Working less than full time is an option now open to far more doctors – and for many it’s what keeps them in medicine. Seren Boyd reports
Eight months later, he had a stroke. These two significant interruptions to his training have left him with some lasting ‘central fatigue’ – and a fresh set of values.
He has reduced his clinical hours to 80 per cent, creating space for his work as a BMA rep, an advisory role with Surfers Against Sewage and time for himself. Dr Baglow works at the hospital where he was an ICU patient, and no one has ever questioned his decision to go LTFT.
‘I definitely feel like this is a second chance at life: everything is a bonus,’ says Dr Baglow. ‘Going LTFT has enabled me to think about my goals, but also to make the most of the moment.’
For Dr Sherrard, meanwhile, COVID stripped away all the things that brought balance to the long hours at work, especially his singing. (He sang back-up to Barbra Streisand at the O2 Arena.)
In 2021, his mental health ‘tanked quite impressively’ and he was signed off for six months. Returning to work, he found that trying to combine an exacting full-time job with recovering and singing was too much.
‘Work was taking all my energy and I got bitter and angry about it,’ he says. When a consultant colleague suggested he consider reducing his hours a few months ago, he was initially hesitant. But dropping five clinical hours a week has changed everything.
‘I’m probably 10 hours a week busier than I was before, but it doesn’t feel like that because I’m well rested, happy and less stressed. And the
department is getting better work out of me, not as much but better quality.’
More and more doctors, across grade and specialty, are choosing to reduce their hours, despite the cut in pay.
The GMC’S National Training Survey for 2022 suggests 17.1 per cent of trainee doctors are working LTFT, compared with 9.1 per cent in 2013. A 2022 survey of trainees by the Royal College of Physicians and the Royal College of Physicians and Surgeons of Glasgow found that three-quarters of respondents not LTFT were considering it.
The trend is likely to grow: last year, COPMeD (Conference of Postgraduate Medical Deans) extended eligibility for LTFT work to those applying ‘for their wellbeing or through personal choice’, after BMA lobbying.
The picture varies across specialties: while LTFT is common in general practice and emergency medicine, it’s less common in surgical
specialties, for example.
And while Drs Baglow and Sherrard’s trust offers various flexible arrangements including annualised contracts, other trusts are less progressive. When Laura Owler first asked to reduce her hours as a foundation year 1 doctor two years ago for the sake of her mental health, she was met with resistance. No one else in her cohort worked reduced hours.
‘My training programme director said I needed to think of my colleagues because they would be picking up the extra stuff, and made comments like, “but you seem fine?”.’
But she wasn’t: with no time or energy left for anything but work, her mental health declined and she was signed off for two months. In her next rotation, support from the trust’s champion for flexible training meant she was able to reduce her hours to 80 per cent for her FY2 last year. Two others in her cohort soon followed her lead.
‘I knew it was the only way that I was going to keep
‘Going LTFT has enabled me to think about my goals, but also to make the most of the moment’
working and stay healthy,’ says Dr Owler, now an FY3 locum in emergency care in Scotland. ‘I’m more switched on and invested when I’m at work now. I’m never going to work full-time again.’
GP registrar Lucy-Jane Davis’s decision to prioritise her children and work LTFT means her training has been protracted – and longer than most. She doesn’t work school holidays either.
But she would argue the NHS workforce is full of people like her ‘who don’t fit the norm’: her husband, also a doctor, works LTFT for the same reason.
Employers and team leaders need to be much more flexible if they want to retain staff, she says. Her own bosses in Devon understand, but she still comes across those who don’t consider childcare responsibilities a good enough reason for needing to leave on time. Her children’s nursery threatened to report to social services parents who were
more than half-an-hour late for pick-up.
She worries that, in a culture of overwork, those working LTFT are somehow considered lesser. ‘I’ve worked in departments where the comments were always, “you don’t seem to be here very much”, just because their part-time days didn’t coincide with mine. But in other units, consultants have said, “this registrar works part-time but actually they’re the heart of the unit because they’ve been here for so much longer than everybody else”.’
Better access BMA representatives, including its LTFT training forum, have played a key role in lobbying for better access to and arrangements for LTFT working.
They have pushed hard, for example, to secure positive steps such as extending eligibility for LTFT to include lifestyle choices. Dr Davis has lobbied successfully for NHS pension contributions for LTFT workers to be based on
actual earnings, not full-time equivalent salary. The BMA has produced Good Rostering Guidance for staff and employers.
But there are still many issues to iron out. Going LTFT has implications for length of training, as well as pay. While theoretically qualification is based on competency not duration of training, it’s common for someone working 80 per cent LTFT to have to train for 20 per cent longer regardless, says Kiara Vincent, an ST5 working LTFT in emergency medicine.
‘In theory, you should do pro rata every type of shift and get the same breadth of experience as everyone else, but in practice that often doesn’t happen,’ says Dr Vincent.
Furthermore, in some trusts a trainee working 80 per cent LTFT does 40 hours, where in others, a 40-hour week is full-time. Contractual provisions ensuring that training LTFT should not be a hindrance to later career progression are not always upheld either.
Dr Vincent, who is also a BMA rep and doctor to a Leicestershire rugby team, regularly comes across LTFT
‘Work was taking all my energy and I got bitter and angry about it’
‘I’m more switched on at work now. I’m never going to work full-time again’OWLER: Reducing hours the only way to stay healthy VINCENT: Emergency medicine trainee and rugby club doctor OLIVIER POINTER
trainees whose rotas and pay cheques are wrong or late. A new rotation can mean a change of non-working day, causing problems for those with other jobs or childcare responsibilities. And where training opportunities fall on non-working days, LTFT trainees are obliged to come in regardless.
Dr Vincent wanted a portfolio career, but she also feels full-time emergency medicine is not sustainable, at least at the moment.
‘Our rotas are designed for “x” number of people working 48 hours, so as soon as someone’s off, you’re short. There’s no slack. And the more senior you get, you could be making hundreds of
decisions in a shift – and if you get decision fatigue, you may make the wrong one.’
Switching to work LTFT is not always a choice. Plenty would argue their hand has been forced by pressures, from pension tax to punishing schedules.
Poor pay means it is increasingly common for junior doctors to have a second, better-paid job, says Dr Vincent. Some are going LTFT so they can routinely pick up locum shifts, which are always readily available.
Meanwhile, some LTFT doctors are still working full-time hours, reportedly. Whatever your decision
BMA Law’s personal injury scheme is a no-win no-fee service for BMA members, offering you and your family expert advice and representation in the event of an injury caused by the fault or negligence of a third party. Whether it’s an accident at work, in a public place, or a disease claim, we have you covered.
– We operate on a not-for-profit basis, so unlike other lawyers, we don’t take a ‘success fee’, which can be up to 25% of damages
– We can often recover costs for your trust or practice, including sick pay advanced and locum cover
– If you received hospital treatment after a road accident, a successful claim ensures recovery of costs for the NHS trust providing treatment
Don’t
bmalaw.co.uk/personal-injury
about how much you work, it must not be swayed by the demands of a broken system, says London consultant psychiatrist Jan Wise.
Dr Wise has worked parttime for the NHS for most of the past 20 years, partly to care for his daughters, partly to develop a portfolio career, including with the BMA.
He insists doctors shouldn’t feel beholden to work more hours than they are contracted to, or comfortable with.
‘Putting in more time does not make the difference,’ says Dr Wise. ‘What makes the difference is doing your job with kindness and compassion, within the time allotted to do the task, so you also have time to recuperate.’
bma.org.uk/thedoctor
let a personal injury put a strain on your finances. For a free assessment, contact us today
have witnessed many of my colleagues finding a quiet place [on the ward] to cry because the pressure is too much.’
This was the heart-breaking admission submitted by one hospital doctor in Scotland to the BMA’s pressures portal, on the unimaginable and unsustainable situation facing many of the country’s emergency departments this winter.
Describing one recent shift, the doctor painted a demoralising, yet increasingly common, picture of a hospital unable to cope, with every bed and corridor filled with patients, 10 ambulances queuing outside and with the average wait time for a patient’s first assessment coming to eight hours.
‘It was one of the worst shifts I have ever experienced but it is like this almost every time I go to work now,’ they explain.
‘Even worse is to come home from shifts like this. [Shifts] where I have had to be several doctors for the day, where I’ve been assaulted and shouted at, where I’ve watched people die and wondered whether it’s because I didn’t see them fast enough.
‘Now, with a cost-of-living crisis and years of pay erosion, I get home and wonder whether I can afford to even put the heating on tonight.’
Weekly data published on 26 January by NHS England reveals that 95 per cent of beds across all adult general and acute hospital wards in England were occupied by the week beginning 22 January.
Data for this date also shows that the number of patients staying in hospitals in England for seven to 21 days hit 97,196 compared with 87,080 in 2022.
Pressure on beds is not a phenomenon limited just to England, with hospitals in every part of the UK experiencing huge challenges around being able to discharge patients safely and appropriately, and thus allow new cases to be admitted.
‘Over the last month or so things have just really escalated and become so much more difficult,’ says associate specialist in emergency medicine at Belfast’s Royal Victoria Hospital Siobhan Quinn. ‘This time last year, we might have had 30 to 40 patients on trolleys waiting to get admitted to the ward, whereas now it’s gone up to 80, and it’s been at this level now for the past three or four weeks.
‘There are a significant number of patients occupying inpatient beds, who are medically fit for discharge, but can’t get home because there isn’t the appropriate care package or family support, or there’s something that
Doctors are having to treat some patients in corridors, lacking the time or space to give lifepreserving treatment. They tell Tim Tonkin that the ‘war zone’ conditions are having a profound effect on them
‘I’ve been assaulted and shouted at, I’ve watched people die’
‘IPEEL: Conditions take enormous toll QUINN: Discharges are being held up
they need in the community that isn’t available for them. This has been going on [in Northern Ireland] for such a long time it has been causing moral injury. It’s very upsetting for the doctors and the nurses. Many of the nurses leave crying, some of them even have told me they come into work, crying before they’ve even set foot in the place.’
A report published last month by the Lords public services committee described the situation in emergency healthcare services as a ‘national emergency’, with overcrowding and delays in care endangering patients and presenting ‘a serious risk to the sustainability of the National Health Service’.
The report, which drew on evidence compiled before the onset of pressures seen this winter, makes clear that a rise in demand coupled with the difficulty in discharging patients owing to insufficient community and social care services, is driving the unsustainable situation.
It is these factors, along with chronic understaffing, that are contributing to appalling and previously unthinkable scenes in many emergency departments of patients waiting or having to be treated in nonclinical rooms and even corridors.
‘During my last 10 on-calls I have not seen one patient in a bed or even a trolley for assessment,’ a hospital doctor based in Swansea tells the BMA Wales pressures portal. ‘We are using cupboards, borrowing rooms in outpatients and I have had patients with drips lying on the floor. Often patients in the waiting rooms have not even been given food and drink. We recognise emergencies such as hyperkalaemia but are unable to even give immediate life-preserving treatment due to lack of space and staff.
‘This is warzone medicine with no safe place for us to hide,’ warns an emergency medicine staff, associate specialist and specialty doctor from the north of England. ‘Watching people reattend as they were discharged under extreme pressures, watching patients share rooms with strangers, assessing trauma patients in the view of everyone in the middle of the emergency department, having no private space for people to air their emotional and physical pain is not only harmful to patients but to those of us who look after them.’
Ambulance backlogs, and the enormous waiting times faced by patients so far this winter, has changed many
bma.org.uk/thedoctor
doctors’ perspectives as to what a good or bad day now looks like in emergency departments.
‘A “nice day” now is patients only waiting six or seven hours [to be seen] compared to 12,’ says Lailah Peel, a junior doctor working in the west of Scotland.
‘Most patients are really understanding and are generally really nice. They will thank us and tell us that they know how busy things are. There have definitely been situations where patients aren’t getting painkillers as quickly as they should be, or their antibiotics as quickly as they should be.’
Dr Peel, who is deputy chair of BMA Scotland, says having to work under such incredibly pressured conditions is taking an enormous toll physically, mentally and emotionally on many emergency department staff.
She adds that she fears that such unbearable conditions could lead to an entire generation of young doctors being put off pursuing a career in emergency medicine.
‘We’re all at that point of burnout, with people being constantly asked to work extra shifts or to provide cover, people are just absolutely exhausted, and it weighs quite heavy on you.
‘We [doctors] are all quite stoic and we’re all coping until we’re really, really not coping, and I think that’s something that’s very scary. It feels like we’re all kind of hanging on in there by the tips of our fingernails and asking ourselves “can we keep going?”.’
With the BMA this month set to launch a consultative ballot of consultants in England, consultants committee deputy chair Simon Walsh warns many frontline doctors are now at breaking point.
‘Although we are moving out of winter, the enormous pressures facing urgent and emergency care services remains acute for hospitals across the UK,’ he says.
‘From shortages of beds and staff to the extensive waiting times facing patients, the situation in many emergency departments is unsustainable and frequently unbearable for the doctors and other healthcare staff subjected to it.
‘With the BMA preparing to contact consultants in England as part of a consultative ballot over the potential for future industrial action, the Government can no longer ignore the mounting calamity in our health service and must meaningfully engage with the medical profession to find solutions to the crisis.’
‘It feels like we’re hanging in on there by the tips of our fingernails’
‘People have been saying how brave I’ve been, but I’m trying to downplay how big a deal it is.’
Richard Armitage, a GP in Nottingham, gives a modest assessment of his recent kidney donation, which has prevented the recipient of his organ from going through dialysis three times a week.
While the majority of kidney donations are from concerned loved ones, or the deceased, Dr Armitage volunteered his for no reason other than selflessness.
To put his generosity into perspective, there were just 68 non-directed altruistic living kidney donors in 2021-22. Transplants of living kidneys typically last 20 to 25 years, compared with 15 to 20 years for deceased kidneys.
‘I don’t know who the recipient is,’ he explains. ‘But I know they’re in the UK, have late-stage renal failure and had to have dialysis three times a week. They will benefit from the kidney much more than I would miss it.
‘From my point of view the kidney is a gift, without any conditions attached. So I don’t mind who gets it; and I hope it works for them.’
There were 2,868 adult kidney transplants performed in the UK in 2021/22, and there are about 5,000 people in need of one.
For a donation to work there must be a match of tissue and blood type among donor and recipient. So, when people offer but can’t give to their loved ones, it may require an altruistic donor to kick-start the process – a bit like a first-time
home buyer triggering a property chain.
NHS Blood and Transplant’s UK Living Kidney Sharing Scheme used a computer algorithm to match Dr Armitage with two other donors and three recipients and the hospitals in question embarked on a logistical mission to make it all happen. Six operations, which take two to four hours, had to be carried out on the same day, with the kidneys transported to their recipients’ hospitals while being kept alive.
The complexity of organisation led to some delays. The match was made in July 2022, with an operation due in October postponed to 23 November as someone in the chain caught COVID.
And that came after delays since Dr Armitage decided to go ahead in 2019, owing to the pandemic, because his mother had a palliative diagnosis, and to give himself time to settle into his role after completing his GP training.
Dr Armitage says the operation itself was straightforward. ‘On the day, I went into hospital and the anaesthetist made me laugh. That’s all I remember.’ After a routine three nights’ recovery at Nottingham City Hospital, he was home –and back to work within two weeks because he felt well enough much sooner than the recommended six weeks. ‘It was all really smooth.’
He has a 10cm scar that ‘looks like I’ve had a caesarean section’ but which is ‘quite well-hidden’ around the level of his underwear.
‘It’s very much concealed, though I did want a memento,’ he says.
Being a medical professional made the process
‘They will benefit from the kidney much more than I would miss it’
For GP Richard Armitage, the chance to improve health extends not only to his own patients, but to the stranger to whom he donated one of his kidneys. He tells Ben Ireland about the sense of meaning and satisfaction it has brought to him
easier, he adds, even if his surgical experience is limited to four months on a urology rotation as a foundation year 1, some 10 years ago.
‘I’ve worked in hospitals and am familiar with surgery and anaesthetics – so it was less daunting,’ he says. ‘There was a lot of preparation work. I had a lot of tests and met a lot of professionals. They could speak to me like a colleague because we use the same [medical] language.’
He would like to encourage more doctors to think about donating a kidney, too. ‘I want to show that a normal person who works in the NHS and sees patients all the time can add this into their lives. It’s a very personal choice but I suppose I’m just trying to lower the barrier and persuade people to at least consider it.’
Having a medical background helped Dr Armitage, 34, understand and weigh-up the ‘very small risk’ of having high blood pressure or going through dialysis in the future.
‘I did a lot of reading up, looked at the journals, checked the long-term survival statistics and was reassured,’ he tells The Doctor. ‘I’m a relatively young guy in good health and I know a lot of people live with one functioning kidney – and are often unaware of that until an incidental finding on a CT or ultrasound scan.
‘On the other side of the equation, the person who gets the kidney will no longer have to have dialysis. Occasionally there were doubts, but I just kept thinking how massively the recipients will benefit.’
Though coming at it from a doctor’s point of view, Dr Armitage first learned about altruistic kidney donations and the effective altruism movement ‘through an economic lens’ by reading American Nobel laureate Professor Alvin E Roth’s book Who Gets What and Why back in 2017.
Not only has he donated his kidney, but he gives 10 per cent of his salary to charity and travelled to Ukraine in 2022 to give medical aid to displaced people via the charity UK-Med in the city of Poltava, east of Kyiv.
‘When I found out we do altruistic organ donation through the NHS it immediately appealed to me,’ he explains. ‘It seems like a really easy way to do a lot of good.
‘It’s kind of a utilitarian calculation. I’m aware of the risks, find them acceptable and am willing to go ahead with it because the benefits to the
bma.org.uk/thedoctor
people in the chain are enormous. At the same time, I feel like I’ve got something out of it. I’ve done something meaningful and have a sense of satisfaction.’
It’s hard to argue with his logic when he feels in good health, is proud of helping improve someone else’s life, and gets a sense of pride from it all.
And while he doesn’t know who is benefitting from his kidney, Dr Armitage is safe in the knowledge that they are doing well because of a message from the donor team who have told him the recipient now has ‘a new lease of life’.
– The number of patients registered on the kidney transplant list this year increased to 5,023
– Kidney transplants from living donors increased by 106% to 884, while transplants from deceased donors increased by 17% to 2,263
– 100 kidney transplants were made possible by the paired living kidney donation programme (17 two-way and 22 three-way exchanges)
– There were 68 non-directed altruistic living kidney donors, leading to 94 patients benefitting from a living donor transplant.
Source: NHS Blood and Transplant
ARMITAGE : ‘I just kept thinking how massively the recipients will benefit’
‘I’ve got something out of it. I’ve done something meaningful and have a sense of satisfaction’
During the early days of my BMA activism, I found myself tasked with making the arrangements for the medical students’ and juniors doctors’ dinner.
During this process, I was approached by another member who advised that they would be unable to attend the meal as they were convinced their complex dietary needs would make eating anything from the menu all but impossible.
After carefully listening to this member’s various requirements, we were able to ensure the venue’s kitchen made suitable adjustments, in such a way that this individual was able to join their friends and colleagues rather than be excluded.
While this anecdote might seem rather inconsequential, it in fact serves as an excellent metaphor for the kind of change in ethos I and your annual representative meeting team are committed to bringing to the ARM.
The ARM is the most significant policymaking event in the association’s calendar, yet I know most of you don’t know what it is and many of you would struggle to attend let alone have input into its proceedings.
Historically, ARM has required participants to take the best part of a week off work thereby potentially resulting in a loss in earnings or necessitating the arrangement of locum cover for some of our GP colleagues, and of course our hospital colleagues finding it difficult to secure trade union or professional leave. Add the need to travel, and source carer support, it is understandable many members who would wish to add their voices to policymaking feel unable to. It is my belief the ARM and the BMA should be moulded around the needs and priorities of the membership rather than the other way around.
To this end, I am proud to announce that this year’s conference, which will be taking place in Liverpool on 3-5 July, will see important changes designed to broaden and facilitate accessibility and inclusivity. This includes the introduction of 83 additional seats available via BMA divisions, and specifically targeted at new attendees to ARM.
I would strongly encourage new members to apply
@
for these seats, particularly if you’ve never been to an ARM before and if you aren’t involved in the electoral structures of the organisation.
This year’s conference will see the debut of a spectators’ gallery, the aim of which will be to allow doctors and medical students from the ARM’s host city the chance to observe proceedings and access the other exhibitions and facilities of the conference.
While those attending ARM as observers will not be able to vote on motions, it is my hope that having the chance to see conference in action will inspire many to attend as delegates in future.
It is of course worth noting that, for all those outside of Liverpool wanting to follow the debates and decisions of this year’s ARM, the conference will, once again, be streamed in its entirety live via the BMA website.
Equality is one of the core principles of the BMA and something which runs through the heart of ARM, but equally important is the concept of equity.
Putting yourself forward as a speaker at ARM is one of the most important contributions a member can make, and I know from experience how daunting it can be to stand and address a packed-out and expectant auditorium.
Recognising public speaking is not as straightforward for some members as it is for others, this year’s ARM will, for the first time, see reasonable adjustments made to speaking-time allowances depending on an individual’s needs.
Evolving and reshaping our structures to meet the needs of our membership is crucial to this, and we will always strive to support and empower members by making the changes you need.
For us to do this though, it is vital we hear from you.
If you would like to get in touch to share your ideas or views, please write to me at RBChair@bma.org.uk or @DrLatifaPatel – my DMs are always open.
Which patients do you find the most challenging, if not slightly dread?
We learn early in our careers not to show it but I think we all have a mental list of those who are ‘difficult to deal with’, or who we would rather avoid. And for some of us, this list includes doctors.
This might seem strange. We hope patients will have an insight into their conditions, we want to be able to communicate well with them. When it’s a fellow doctor in front of us, then that’s a head start isn’t it?
Actually, there is a hatful of potential pitfalls. These have been identified in academic studies and may well ring true with your own experience.
Our medically qualified patients might feel patronised by our reflex to explain complex issues in simple ways, although I would note this doesn’t only happen when one is treating doctors – I had a patient rather tersely ask if I could ‘please say atrial fibrillation’ rather than refer to an irregular heartbeat.
Some doctor-patients are overly economical with their complaints and concerns; they know how busy we are, and they don’t want to bother us.
Sometimes, when we treat them, we leave the therapy adjustments and follow-up needs to them, which may well save on clinic time, but the responsibility is still with us as the treating doctor and our doctor-patients might over-estimate or underestimate their needs.
One way of addressing this, some think, is to act as
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
if you don’t know the patient’s profession.
This has a simplistic fairness to it, but I strongly believe it’s not practical. We want our patients to take an active interest in their conditions. It makes no sense to encourage all other kinds of ‘expert patients’ but ignore this type.
The biggest argument against it is that it feels plain wrong. I discovered this with a new GP a few years ago (my current GP, Dr Jothi, is however excellent). He was too engrossed with his screen to look up as I entered the consultation room, and mostly to fill the silence I introduced myself and mentioned that I was a physician.
‘Yes, I’ve got your details here,’ was his welcoming response. That was perhaps less a carefully planned attempt to de-medicalise the patient than someone too preoccupied to notice even if smoke had been pouring from my trousers. But it felt wrong, and not because I was desperate to flaunt my years as a consultant but because it was part of my identity, and possibly relevant in terms of how I related to medical information.
We need to acknowledge when our patients are doctors. Professional courtesy doesn’t mean preferential treatment. Assume nothing, perhaps use it to mutual advantage in their care and their understanding of it, but always acknowledge it. While there may be words that patients and doctors sometimes shy away from, ‘doctor’ should not be one of them.
Radhamanohar Macherla, now retired, was for more than 20 years a consultant physician with Barts Health NHS Trust
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: Emma Brown
Read more from The Doctor online at bma.org.uk/thedoctor
Including a spectacular range of excursions: Days 1 – 7: 4-star cultural tour
• Dubrovnik (World Heritage): Walk through the picturesque old town (World Heritage).
• Adriatic coast: Panoramic trip along one of the most beautiful coasts in the world.
• Ston: 3.4-mile-long fortified wall – the second longest wall in the world after the Great Wall of China.
• Peljesac Bridge: magnificent cable-stayed bridge
• Split: Tour of mighty palaces, columns and historic squares. The Palace of Diocletian (World Heritage) is one of the bestpreserved Roman structures in the world (admission included).
• Trogir (World Heritage): Gorgeous old town on a small island.
• Porto Montenegro: Fashionable marina in Tivat.
• Omis: Harbour town & former pirate colony.
• Počitelj: One of the most interesting villages in the Balkans with city walls, mosques and caravanserais.
• Visit of a modern rug production business
• Medjugorje: Famous Christian pilgrimage where the Virgin Mary is said to have appeared to 6 young people.
• Trebinje: Particular sites to catch include the historic city centre ”Kastel”and the Osman Pasha Mosque.
• Craftsman tradition in the jewellery and leather factory.
• Budva: Walk through one of the oldest old towns on the Adriatic coast.
• Kotor (Word Heritage): One of the most beautiful bays on the European Mediterranean coastline.
Days 8 – 15: FREE relaxation in a wonderful 4-star hotel on the Adriatic
A week of relaxation in your 4-star hotel! Relax in the hotel‘s spa area, which includes a sauna, and take a break by the outdoor pool. Return to Dubrovnik on day 14. On the 15th day, we fly back to the UK.
Sensational rate for you as a reader of THE DOCTOR from only
For entry to Croatia, Bosnia-Herzegovina and Montenegro, UK citizens should have 3 months left on the passport on the date of the last day of the planned visit and the passport should be less than 10 years old. A stay of up to 90 days is permitted without a visa. Nationals of other countries are advised to inquire at the embassies of Croatia, Bosnia-Herzegovina and Montenegro about the entry requirements applicable to them.
* Plus bed tax of up to 2€ (approx. £1,73) per person/night (last revised: november 2022) in Croatia, Bosnia-Herzegovina and Montenegro, to be paid on site. A deposit of 20% of the tour price is payable upon receipt of written booking confirmation. The balance must be paid 80 days before departure. The price applies on 22 November 2023 for flights from Manchester. For other travel periods the prices in the flight schedule apply. This offer and any booking only applies to the recipient and accompanying adults and is subject to the booking conditions and privacy policy of RSD Travel Ltd which can be found online at www.rsd-travel.co.uk or made available on request. Note: minimum number of participants 30 people for each travel date. Cancellation no later than 20 days before the start of the trip, if this is not achieved. Estimated group size is 38 people and RSD advise that this tour is not suitable for persons of reduced mobility. Subject to misprints and changes. Photographs appearing in this advertisement are illustrative examples of what you may expect from the hotels we use. The 8 day extension can only be used when booked with and in conjunction with the cultural tour and not separately.
# Holiday price increase p.p.: £49.
Package includes:
(Price when booking the following separately)1
Return flights with a reputable airline2 £3461 to and from Dubrovnik, incl. hotel transfers
£659
7-day 4-star cultural tour of Croatia & £6591
Montenegro and the 4 most famous UNESCO World Heritage Sites
- 7 nights in a double room in selected 4-star hotels (national category)
- 7× tasty breakfast
- Fascinating round trip in our modern, air-conditioned travel coach with a spectacular range of excursions and admissions (as per itinerary)
OUR GIFT: FREE 8 days of relaxation £2441 in a 4-star hotel on the Adriatic
- 7 nights in a double room in a 4-star hotel (national category)
- Free use of hotel facilities: attractive outdoor pool, heated indoor pool and wonderful spa area
Qualified, English-speaking cultural tour guide
Combined price per person £1,2491
£244 £1,249
Price difference per person – £1,0001
Your rate per person from only £249*
Optional services at attractive conditions: Gourmet package: The package includes half-board, i.e. delicious buffet every evening with international specialties during the 7-day cultural tour: only £139 per person instead of £1541
£154
Your advantage code! DOC111110
1 The combined price of individual components if booked seperately was calculated on 30 December 2022 for the travel dates 22 November to 6 December 2023. Flight from Manchester to Dubrovnik and Dubrovnik to Manchester on www.expedia.co.uk (cheapest, cancellable available flight including luggage), transfers airport hotel airport on www.holidaytaxis.com, Royal Neptun Hotel, Hotel Jona, Hotel Grace, Hotel Casa del Mare Blanche, Mali Hotel Porat, Hedera Residences Kumbor and La Vita e Bella II on www.booking.com, excursions on www.viator.com and www.getyourguide.com. The comparative price for the gourmet package is based on the standard prices of our partner (www.nbktouristic.com). Between the date of the price comparison and the date of travel, these prices may go up as well as down.
2 e.g. charter flights with Freebird Airlines (well-known charter airline company), Aegean Airlines (best European Regional Airline 2014-2017 according to the Sky Trax World Airline Award) or Croatia Airlines (Star Alliance Member – largest aviation alliance in the world).
All the flights and flight-inclusive holidays in this brochure are financially protected by the ATOL scheme. When you pay you will be supplied with an ATOL Certificate. Please ask for it and check to ensure that everything you booked (flights, hotels and other services) is listed on it. Please see our booking conditions for further information or for more information about financial protection and the ATOL Certificate go to: www.caa.co.uk
