One with a wage, one with a loan
Would apprenticeships create two types of medical student?
Homeward bound Bucking the trend on out-of-area beds
Fighting back GPs win back thousands in property fees
Fairness What does it look like in a struggling NHS?
3
At a glance
Consultants set dates for possible industrial action
4-7
Two tribes?
How medical apprenticeships could create a two-tier training system
8-11
Fair’s fair
Striving for equity in a struggling and under-staffed NHS
12-15
Homeward bound
Why the out-of-area beds crisis doesn’t have to be inevitable
16-17
Speaking up
An interview with the BMA president, a champion for public health
18-19
Free to roam
The sessional GPs making the most of the fl exibility the role provides
20-21
Fighting back
GPs win back thousands of pounds in a BMA-backed case against NHSPS
22 Your BMA
Industrial action set to dominate the BMA annual representative meeting
In this issue of The Doctor, the former BMA president Raanan Gillon and I talk about fairness. It’s something we’re passionate about, but I accept that when we talk about values in general terms they can seem a bit abstract. However, a glance through the other content in this issue reveals how fairness – or the lack of it – cuts through almost everything we experience in our working lives.
With applications for the first medical degree apprenticeships likely to open next year, NHS England says the courses will offer the same training and standards as the traditional undergraduate route. The BMA has long supported widening access to medical training, and condemns the crippling debts which students are forced to accrue. But as well as some serious practical issues to consider, there is a fundamental question of fairness – will a two-tier system be created in which some students are paying to learn and some are being paid? I look forward to this issue being debated at next month’s BMA annual representative meeting in Liverpool. There is certainly no fairness in vulnerable patients with severe mental health problems being sent hundreds of miles away from friends or family for treatment for lack of beds. It is heartening in this issue to see examples of NHS organisations that have managed to reduce their reliance on outof-area placements.
I am delighted that justice has at last been granted to the GPs who were stung by enormous and unfair charges from NHS Property Services. Legal action backed by the BMA resulted in the practices being saved from bills of thousands of pounds which may have threatened their existence.
Sessional GPs describe how they use the flexibility their position gives them to benefit healthcare projects overseas, in the armed forces, as well as improving services for patients at home.
‘Energetic’ is very much a word I’d apply to the BMA president Martin McKee. Our interview reveals his remarkably wide-ranging areas of expertise, from Brexit, to austerity, to the effect of the COVID-19 pandemic. Martin speaks up for those affected by thoughtless, unfair and unjust policies. Ours is a profession with a conscience. Martin embodies just that and it’s a potent reminder that our fight for our members is also a fight for our patients and the public’s health.
Keep in touch with the BMA online at instagram.com/thebma twitter.com/TheDrMagazine
Hospital consultants in England will go on strike on 20 and 21 July if their industrial action ballot, which closes on 27 June, is successful and the Government continues not to make a credible pay offer.
Repeated real-terms pay cuts have seen consultants’ take-home pay slashed by 35 per cent since 2008/09. The BMA is demanding a fair pay award for 2023/24 and a commitment to redressing long-term pay erosion.
Two days of Christmas Day-level cover, meaning emergency services continue while routine services are paused, have been outlined as the proposed form of action.
The potential strike dates have been set out before the end of the ballot to give trusts and colleagues ample notice to prepare, given consultants’ roles cannot be covered by other staff.
BMA consultants committee chair Vishal Sharma said: ‘Strike action is not inevitable and it is well within the Government’s gift to present us with a reasonable offer that would stop industrial action. But if this isn’t forthcoming, we are committed to action that is effective and safe.
‘Consultants do not take decisions around industrial action lightly, but this isn’t just about pay – it’s about protecting the future of the NHS.’
Meanwhile, specialist, associate specialist, and specialty doctors in England have written to health secretary Steve Barclay calling for urgent talks to end the ‘appalling’ practice of excluding them from annual pay uplifts.
BMA SAS doctors overwhelmingly backed a motion to ballot members in England over whether to take industrial action to secure pay restoration. SAS doctors have suffered a realterms pay cut of a quarter in the last 15 years.
SASC UK chair Ujjwala Mohite said: ‘SAS doctors have quietly borne the brunt of working through enormous backlogs of care made worse by the pandemic, but without urgent steps to ensure they feel appreciated, their patience and goodwill will soon run out.’
It came as junior doctors in England prepared to undertake a third round of industrial action. When The Doctor went to press, a 72-hour strike was set to take place from 14 to 17 June.
A re-ballot is to take place from 19 June to 31 August in a bid to extend the BMA junior doctors committee mandate. Co-chairs Vivek Trivedi and Rob Laurenson said: ‘[Rishi] Sunak and [Steve] Barclay just don’t get it. Tell them again.’
Junior doctors in Scotland were voting on whether to accept a pay offer of 14.5 per cent over two years from the Scottish Government. The consultative vote closed on 12 June.
By Ben IrelandBecome a doctor with no tuition fees and get paid while you train – that’s the promise of a new apprenticeship scheme. But will it lead to a two-tier training system?
Ben Ireland reports
Applications for the first medical degree apprenticeships are likely to open next year.
NHS England says the new five-year undergraduate pathway for aspiring doctors involves ‘the same training, at the same high standard’ as medical school.
Medical apprentices will attend universities, must pass medical degree exams and the medical licensing assessment (UK MLA), and ‘meet all requirements’ of the GMC before their foundation years.
The GMC is yet to approve any medical degree apprenticeship programme, but told The Doctor it is ‘supportive of the principles behind apprenticeships’. It says it ‘would need to be content that any proposed programmes met our standards’.
Degree apprenticeships are an established training route for professions such as nursing and physician associates, as well as engineers and solicitors. Whether they would be appropriate for medicine is still up for debate.
Advocates say apprenticeships can widen participation in medicine and help plug hospital workforce gaps in areas struggling to recruit, but critics fear the model could create a two-tier system, cause rifts and exploit those who sign up.
With partial funding confirmed for the first 200 places, questions remain.
Guidance from February says apprentices will receive ‘all the same training as a medical student following the established route’ with ‘no element, academic or practical’ omitted. The statutory requirement is for apprentices to spend 20 per cent of their time ‘off-the-job’, but this would be ‘considerably higher’ for medical apprentices.
What is asked of apprentices dayto-day, and how they’re supervised, will be down to participating trusts, which will work with medical schools to design courses. Apprentices will work as ‘trainee medical practitioners’ at a level ‘suitable to their stage of training’.
As employees, they will be entitled to annual leave and a pension as well as pay. They will be ‘supernumerary’, so not counted as part of the staff.
Penny Sucharitkul, a final-year medical student and Doctors Association UK representative, questions what apprentices’ work will entail, and at what point it begins.
She says: ‘There are only a few things you can do as a first-year student on the wards. You can’t just be an HCA [healthcare assistant] – that involves clinical experience, which you have to develop. When you do a degree, it’s a gradual approach to placement. You’re not just left to walk the wards. You’re supervised the whole time.
‘The reason we do a five-, six-year degree is to understand things like why we’re stopping certain medications. You learn that on placement. It’s not just taking instructions.’
Raymond Effah, co-chair of the BMA medical students committee, is urging participating trusts to publish course structures as soon as possible. He asks: ‘If you’re working every day, when are you on placement? Is work your placement? If so, how is it different from a university course?
‘Realistically, it’s not possible to have an apprentice – or student on placement –working in a capacity that benefits the trust from day one. In my first year, I shadowed people. It was only by year four or five I really benefited the team, by taking bloods and things like that.
‘If they employ apprentices in HCA roles, it’s not going to teach them much of use to a doctor in the long run. I’ve done HCA work while at medical school. I enjoyed it but it wasn’t applicable to my medical degree. I learn more in lectures.’
Sir Sam Everington, an east London GP who was co-chair of the medical apprenticeship steering committee at Health Education England before it merged with NHSE, argues: ‘This is not just about getting brilliant students through an academic course. This is about producing confident and capable doctors. You’re training them for the NHS.
‘If you think about it, current teaching of postgraduate specialties is apprentice training. So why do people have a problem with undergraduate apprenticeship training?
‘When I trained 40 years ago, it was about making doctors the font of all
knowledge. Now, it’s much more about helping people make choices.’
Jahangir Alom, a specialty trainee 1 in emergency medicine who studied on a widening participation programme, says the BMA must engage with the apprenticeship process to iron out unknowns. ‘It is happening,’ he says, noting the course structure ‘has to be approved by the GMC’ so ‘standards can’t be lower’.
NHSE says it is important to ‘ensure apprenticeship students are adequately supported and have time for private study’ which is ‘expected to be completed in contracted hours’.
Ms Sucharitkul says: ‘The reality is, doctors’ teaching happens sporadically. Basically, it’s when they’re free. We study in between, but if you’re paid to be there and have responsibility for patients, emptying catheters, taking bloods or whatever, you might miss teaching. When are you going to have time to study?’
Dr Alom says doctors’ teaching time is ‘a wider issue that’s not specific to the apprenticeship programme’ that would ‘still exist if you increased traditional medical school places’. He adds: ‘If the apprenticeship looks like an inappropriate amount of work, we can revise curriculums if we engage.’
Sir Sam believes apprenticeships can be ‘part of a wider change’ to medical education –including who is teaching.
‘People will say we haven’t got resources
‘There are only a few things you can do as a first-year student on the wards. You can’t just be an HCA’
to teach these extra people,’ he says. ‘But teaching comes in all shapes and sizes. People will say you can’t have HCAs teaching phlebotomy. But they’re highly skilled; they’re exactly who should be teaching medical students to take blood.
‘Everyone in a teaching hospital should be a teacher. Many young doctors I’ve talked to don’t see the point in lectures, they’re quite capable of learning via the internet or in the library.
‘About 95 per cent of my work is patternrecognised. You learn pattern recognition through apprenticeship training. Let’s go back to basics and ask what we need to teach and how we teach.’
Apprentices will not pay tuition fees, which are currently up to £9,250 a year and often leave graduates in multiple tens of thousands of pounds of debt when they qualify.
Ms Sucharitkul, a young carer from a family in the lowest income threshold, accepts the lack of debt is ‘a huge carrot’ but warns: ‘These places are going to be very, very competitive and I’m worried the widening access students who really need it aren’t going to get on this scheme.’
She fears animosity between students and apprentices. ‘What if two of us are training on the same ward, one is a student paying £9,250 a year and the other is being paid to be in the same teaching sessions. Does that create a sour feeling?’
Mr Effah adds: ‘A lot of medical students are going to be saying, “Why can’t I swap onto the medical degree apprenticeship course?”.’
Medical apprentices will be paid. How much is down to trusts. The national minimum wage for apprentices is £5.28 an hour but those aged 19+ are entitled to the national minimum wage for their age once they have completed their first apprenticeship year. This is £9.50 for those aged 23+.
‘The idea of being paid while studying is going to be attractive,’ says Mr Effah. ‘But if you’re a [physician associate] on a decent wage, are you going to step that down to £5.28 an hour? That’s a huge drop, especially if you have kids.’
Ms Sucharitkul questions if this is enough to live on without another job, which she says ‘would be more unrealistic than it already is as a medical student’.
Dr Alom says it is not uncommon for students to balance their study with other jobs. ‘When I was at med school I worked as an HCA every Sunday because the NHS bursary wasn’t enough,’ he says, though he accepts ‘it’s incredibly tough’.
One of NHSE’s aims is to offer a route into medicine for people from deprived backgrounds for whom tuition costs are a barrier, including those who already work in the NHS in other roles.
It notes a ‘majority of medical students come from a small section of society’ and has not set an upper age limit on the apprenticeship.
It cites the Government’s 2020 Social Mobility Commission’s report which concludes ‘apprenticeships are one of the few indisputably effective tools of social mobility’ currently available.
Entry requirements will be set by participating trusts. NHSE says they should be ‘comparable’ to medical degree entry requirements but ‘flexible’ and include ‘contextual factors’ to ‘minimise barriers and optimise opportunity for applicants from a diverse range of backgrounds’.
NHSE says this approach also means employers can ‘invest in future talent that can
‘There are massive challenges and issues with traditional medical school’ALOM: Ringfenced money available
‘This is about producing confident and capable doctors. You’re training them for the NHS’EFFAH: Students may want to swap to the apprenticeship course
be encouraged to remain in their area’.
Sir Sam says this gives trusts an opportunity to ‘grow your own’.
He believes ‘every medical school should have a geographical responsibility to recruit’, noting research he was involved in which found that ‘if you recruit people to medical school locally, they’re much more likely to stay local and be there permanently’.
He says this continuity would benefit the apprentice and the employer.
Ms Sucharitkul believes the Government should instead fund more medical school places, reduce tuition fees, improve bursaries and restore junior doctor pay.
‘The [current] system works, it just needs to be funded properly,’ she says. ‘There’s very strong evidence that by supporting current students better they’re less likely to leave. Retention is the problem. It’s like there’s a bucket with holes in it and we’re just filling the bucket with more water, hoping it doesn’t spill.’
The apprenticeship levy – which employers with wage bills of £3m or more pay into –provides part of the funding. For the pilot scheme, NHSE is also contributing.
Employers hosting apprenticeships must still provide some funding, which is expected to come out of their existing budgets.
Dr Alom says the NHSE contribution is ‘ringfenced money that will train more doctors’, adding: ‘We either use it or we don’t.’ But Mr Effah says apprenticeships would neither fix the retention crisis or be a principal way to get more doctors into the NHS.
Sir Sam believes apprenticeships are the future of medical training: ‘There are massive challenges and issues with traditional medical school. My view would be: Let’s move everything to apprenticeship training.’
The 200 pilot places will be in addition to the current government cap of 7,500 medical school places a year in England. The BMA has been lobbying for a huge expansion of traditional medical school places, replacing the current ‘restrictive’ cap.
Its current policy is that the association is ‘concerned by proposals to establish a medical apprenticeship scheme that will lead to a twotier system’.
bma.org.uk/thedoctor
The issue is set to be debated again at this year’s BMA annual representative meeting in Liverpool next month. The draft motion asks the representative body to consider apprentices as ‘a vital experiment in addressing the shortage of doctors in deprived and underdoctored areas’ with trusts to ‘actively recruit from those areas’.
It insists assessment standards should be ‘the same as via traditional medical schools’ and calls for lobbying for ‘golden handshakes’ to encourage qualified doctors to work in relevant areas ‘to ensure adequate supervision and mentorship’.
Ultimately, the BMA wants to see more doctors trained and retained, with England’s medical workforce short of 46,300 doctors compared with the OECD average. It backs the campaign for a liveable NHS bursary for medical students and wants ‘a greater concerted effort’ to widen participation.
Dr Latifa Patel, chair of the BMA representative body, says: ‘It remains to be seen whether future apprentices, medical schools and employing organisations can navigate the complexity of implementing medical degree programmes to meet individual apprenticeship needs, while adhering to the exact same high standards of training experienced by traditional medical students.
‘As it stands, we don’t have the basic bread and butter of how it will work. Given the substantial unknowns, we continue to have concerns about the proposed model.’
‘The current system works, it just needs to be funded properly’
EVERINGTON: ‘Let’s move everything to apprenticeship training’
It is New Year’s Eve and you are the most senior doctor on duty. You are hugely under-staffed, owing to sickness. During the night, you have three cardiac arrests and five MET calls. You phone eight people to tell them their relative has died. And you are still a junior doctor.
Medicine today can feel very unfair – for that Sussex registrar, for patients on waiting lists, for an overstretched, underpaid workforce.
Amid shocking inequalities and scant resources, talk of fairness in medicine might seem pie in the sky.
But it’s precisely at times such as these that values should be discussed and defended. That’s the belief of former BMA president Raanan Gillon and current council chair Phil Banfield – and they want to start a conversation about how to make medicine fairer.
‘For me, fairness sits above all other BMA values,’ says Prof Banfield. ‘It’s
central to how we do business, how we behave with each other, how we interact with society, how we practise medicine.
‘It’s important to talk about this now because our health service is being actively dismantled – and we need to be crystal clear about what we stand for if we’re going to try to preserve all that’s good about the NHS.’
Their timing is not arbitrary. The WMA (World Medical Association) recently added ‘fairness’ to its International Code of Medical Ethics, thanks partly to Prof Gillon’s lobbying on behalf of the BMA.
But does fairness as a principle translate into the British context of a failing health service and an increasingly unequal society? Is it even possible to try to uphold it?
Professors Banfield and Gillon suggest that it is – and offer their thoughts as a discussion-starter.
Fairness should be a fundamental value in how patients and staff are treated, but in a struggling and under-staffed NHS, it often takes a back seat. Two leading doctors tell Seren Boyd why it matters, and what fairness should look like in practice
Prof Banfield’s personal manifesto championing fairness is hard to disagree with – although, as he admits, he’s led by the heart.
He has a clear vision for his role as BMA council chair and as a doctor: ‘If something’s unfair or unjust, I can’t resist leading with my chin into the fight,’ he says. ‘I’m unafraid of what others think of me.’
As a consultant obstetrician in a deprived area of North Wales, he’s in regular contact with health inequalities: they present at his antenatal clinics every week. He often thinks back to a young woman who came to reception cradling what she said was an abandoned baby she’d found.
‘But it just didn’t feel right so we spent a long time talking to her,’ says Prof Banfield. ‘It turned out that she’d given birth to the child, hadn’t told anyone, hadn’t got any money, and thought that this was the best thing for her baby.’
He’s also concerned about lack of fairness in the workplace, which often manifests as disrespect. That might be a patient’s family being kept in the dark because they ‘wouldn’t understand’ the technicalities of treatment – or a consultant who introduces himself by his full name and title, and his junior colleague by her first name.
Prof Banfield’s definition of fairness is closely related to equality and treating people as individuals.
‘We have to try to put ourselves in other people’s shoes. I can never fully understand what it’s like to be them, so perhaps I should listen to what they’re saying and feeling.’
Upholding fairness, outworking it in practice, stems from this fundamental belief in the need to value people as individuals, for Prof Banfield.
In organisational culture, this means promoting diversity and inclusion. But it can also be as simple as
recognising a colleague is facing challenges in their health or personal circumstances – perhaps by sending them home.
‘Your effectiveness, efficiency, patient safety, productivity as a team, these are all linked to people being able to contribute to the best of their abilities,’ says Prof Banfield.
Dismantling unnecessary hierarchies is an important part of this too, he believes. Prof Banfield has made it a priority to flatten BMA structures –including the decision not to differentiate between ‘senior’ and ‘junior’ members – and he hopes these changes will influence workplace culture too.
‘When I was a theatre porter at 18, this man came bouncing down the corridor in his white boots, stuck his hand out and said, “Hi, I’m Steve George, I’m the houseman”. And I said, “Hi, I’m Phil, I’m only the porter”. And he said: “You’re never ‘only’ anything. If the porter doesn’t get the patients, we can’t operate”.’
Prof Banfield is struck by NASA’s example, where hierarchies shift depending on the task at hand. ‘They’ll switch between leader and follower, depending on what the task is and who has the best skills to lead it.
‘In medicine, sometimes the only difference between me and the person who’s starting out or qualifying is that I’m older. We need to recognise we’re all in this together.’
Prof Banfield acknowledges these are ambitious goals, especially in the current climate. But he’s also adamant that every practical step, however small, can help make medicine fairer – whether it’s protecting whistle-blowers or being active bystanders who call out poor behaviour. ‘We can all influence attitude and culture, and model good behaviour. The world isn’t fair but it’s our job to try to make it fairer.’
‘If something’s unfair or unjust, I can’t resist leading with my chin into the fight’
How can we be just and fair when there’s not enough to go around? How do we agree on what’s fair? While every doctor wants to do their best for each patient, the current reality in the UK is that medicine is fraught with dilemmas and competing claims.
Prof Gillon, emeritus professor of medical ethics at Imperial College London and retired GP, believes that today’s pressures demand a more deliberate, committed focus on fairness. But he’s not so naïve as to believe that’s easy.
‘I believe that most of us agree that we ought to try to be fair, but we don’t necessarily agree on what we mean by that.’
Prof Gillon suggests that a first step might be to adopt ‘fairness’ as both a personal and an organisational value or principle. He’d like to see ‘Be fair’ enshrined as a BMA behaviour principle, for example, alongside ‘Be professional, accountable, kind, representative and respectful’. And he’d like doctors to commit to at least trying to be fair.
On behalf of the BMA, he was part of the drafting group responsible for adding ‘fairness’ to the WMA’s International Code of Medical Ethics, relating it to the rights of both patients and health professionals. This was one of the aims of his BMA presidential project on fairness in 2019-2020.
Along with ‘beneficence, non-maleficence and respect for autonomy’, fairness is one of four ‘prima facie’ principles of medical ethics identified by Beauchamp and Childress, whose approach Prof Gillon has long advocated. All four are now reflected in the WMA’s International Code.
Prof Gillon insists that ‘high-level’ principles such as these are practical tools, not abstract aspirations. They provide a framework for decision-making, a point of reference against which options can be weighed. But they need to be thought about, specified, contextualised, ‘translated’ into practical action.
‘With a crash call, you do what you know you have to do
because it’s been worked out from first principles and agreed and practised in advance. Likewise, we should think about the ethical problems we encounter in medicine and try to agree in advance on how to deal with them, using those four principles to help us.’
Like Prof Banfield, Prof Gillon wants to see greater equality in the workplace – but he adds an important qualification.
Fairness is just one of four principles, and these may conflict. And there are many different substantive theories of fairness or justice, which may also conflict, as legal battles over the withdrawal of life support painfully prove.
In this moral minefield, the different substantive theories of justice do at least agree on Aristotle’s ‘formal principle’ of justice or fairness, which says: ‘Equals should be treated equally and unequals should be treated unequally in proportion to the relevant inequalities.’
For example, the NHS doesn’t withhold treatment from patients who have knowingly exposed themselves to risk, whether skiers or drug users. But it tends to give precedence to people in the greatest medical need (where greater need is a ‘relevant inequality’).
‘At least part of medical care and medical ethics is to say: those people need to be treated differently from others – “unequally” – because they need it more. Treating people equally is crucial, but so is treating people unequally!
‘So, let’s start with Aristotle’s formal principle and work together on the morally difficult task of deciding when it is fair to treat people equally and when it is not fair to do so.’
He stresses, as Aristotle did, that medical ethics is not an exact science. ‘Medicine’s full of hard choices but committing ourselves to trying to be fair, whatever we mean by that, is an important starting point.’
A longer version of this piece is available at bma.org.uk
‘I believe that most of us agree that we ought to try to be fair, but we don’t necessarily agree on what we mean by that’
‘Iremember it really well. It was September 2019, before COVID hit, and we had got to something like 50 people OOA [out of area] on our worst day and it was just creeping and creeping. It got to a point where we just thought, this is not acceptable and we’ve got to do something.’
Samantha Wood is head of service for mental health, inpatients and urgent care services at Leicestershire Partnership NHS Trust, the organisation responsible for mental health services in one corner of the East Midlands. She recalls the moment of reckoning which forced action – the beginning of a process which has seen her trust massively decrease the number of vulnerable mental health patients sent miles away from home, instead looking after them in their homes, communities and local hospitals.
Ms Wood says a patient flow team was created, to be led by her and head of nursing Saskya Falope. Their efforts to drive change were soon accelerated by the effects of COVID-19 where, suddenly, across the health service, bureaucracy went out of the window and transformation and innovation were encouraged – even rushed through – rather than stifled, as is so often the case. ‘We were given permission to try things out,’ consultant psychiatrist Samantha Hamer says.
The team was able to set up an urgent mental health hub where patients could be seen in a much calmer environment than an emergency department and with more direct access to the specialists they required.
Dr Hamer and her colleagues feel this approach allows patients to be treated in environments more suited to their care and relieves pressure on services which are crumbling in the face of rocketing demand – with patients who could be treated better elsewhere, not automatically taken into acute services and clinicians given headroom to make the best decisions about admissions and discharges.
The hub, the team say, comes without the immediate pressures of turnaround targets in an incredibly busy and stressful emergency department setting.
‘It can take longer to ensure they have the right support and the right assessments, but you don’t have to just say: let’s admit because we’re stuck here. That’s been really helpful,’ Dr Hamer adds.
On top of this they set up a communityenhanced rehab team with money clawed back from the costly practice of sending patients to private hospital beds OOA. There are other useful tools, too, such as the use of a crisis house and a system where healthcare professionals directly access the ambulance call stack to divert resources and patients to the right places.
The team’s work came in recognition of a problem which was becoming overwhelming in Leicestershire, like much of the country. Each month, significant numbers of patients were being sent miles away from home to costly private hospital beds due to a lack of capacity in the system and relentless, increasing, demand in communities. The use of OOA beds, doctors agree, is a poor solution for both patients and the health service with vast amounts of money leaving the NHS and patients left isolated away from support networks.
Data, published by NHS England, showed that 380 patients were sent OOA inappropriately during January 2023 alone. Of those patients, 59 per cent were placed more than 100km away from home and 46 per cent were on those hospital wards for more than 30 nights. Almost all these beds are run by private firms and come at a significant cost to the NHS.
Not all of the progress comes from improving services or improving patient pathways, however. The team is quick to credit increased communication with partner organisations, a change of culture and a sense that everyone is in it together. During COVID, staff from the trust
‘It got to a point where we just thought, this is not acceptable’
Thousands of patients are being sent to mental health beds far from friends and family, but it doesn’t have to be inevitable. Peter Blackburn and Ben Ireland meet the NHS teams who have bucked the trend
‘We were given permission to try things out’
OKOLO: Close working between agencies boosts effi ciency
set up weekly meetings with all the relevant representatives from local authorities, charities and social care providers and each patient who needed a hospital bed or needed discharging was discussed in detail. For the first time it crystallised the sense that these individual cases were real people, not easily thought of as numbers, Ms Wood says.
The enthusiasm of the team is abundantly apparent, and it appears their efforts are having a real effect. Figures released to The Doctor under the Freedom of Information Act suggest the trust initiated 162 ‘inappropriate’ OOA placements in 2017/18 followed by 168 the following year. In stark contrast, the most recent annual total – the trust now reports in calendar rather than financial years – was just two.
Dr Hamer says: ‘Overall we’re really pleased because it does mean we are not sending patients miles away.’
It is an achievement which will likely make a big difference to the lives, and recoveries, of patients as well as to the wellbeing of staff and the finances of the organisation, with private OOA beds often very costly.
There are still significant challenges for staff in Leicestershire, not least with access to social care packages and housing increasingly difficult, and ambitions for mental health trusts to have bed occupancy levels of 85 per cent while keeping patients in house.
The efforts to drive change in Leicestershire are in line with progress the Government promised to make – pledging to end the practice of OOA placements by the end of March 2021. However, in the April issue of The Doctor we revealed that vulnerable patients with mental health conditions are still being sent hundreds of miles away from family and friends.
James Eldred, a consultant psychiatrist in the south-west of England, identifi es the effects of isolation on patients, the potential for degrading relationships between clinicians and patients and families, and the strain on staff trying to communicate with unfamiliar organisations and keep tabs on patients all around the country. He says patients can feel ‘unwanted’ and staff ‘demoralised’ by a problem they often feel is spiralling and getting ‘away from them’.
BMA consultants committee mental health lead Andrew Molodynski adds: ‘Being put in the back of a locked ambulance and transported to somewhere you’ve never heard of is traumatising, distressing and scary. While there are some occasions when patients need specialist treatment, and local systems are overly pressurised, that this situation is endemic despite the current chancellor pledging to end it while he was health secretary clearly shows this Government does not value these incredibly vulnerable people enough.’
North Staffordshire Combined Healthcare NHS Trust is one of the few organisations
‘It means we’re not sending patients miles away’ELDRED:
OOA placements have a negative eff ect on staff and patientsCHARLIE BIRCHMORE
around the country which provided figures showing a significant drop in ‘inappropriate’ OOA placements to The Doctor
The statistics suggest that the trust placed patients OOA 82 times in 2017/18, but that number decreased to 20 the following year and has not been above single figures for any financial year since.
Dennis Okolo, the chief medical officer for the trust, says the organisation has always been keen to ‘prevent’ and ‘reduce’ admitting patients to private beds miles away and has put a lot of initiatives in place locally to avoid doing so.
Many of the projects Dr Okolo describes will be familiar to doctors across the country but, in a package, together, they are helping the team to avoid use of OOA placements. Dr Okolo says all patients who have been deemed to require a bed automatically go to the trust’s home-care team to justify their need for that bed and to ensure they cannot be cared for in their own environment.
Beyond that Dr Okolo says on-call doctors are encouraged to be part of assessments because they are more likely to know and understand patients and can make decisions with greater clarity.
He also identifies intense reviews of discharges, close work with local authorities, the liaison psychiatry team in the local emergency department, high-volume service user focus, having a strong personality disorder service, and a local psychiatric intensive care unit, as among the reasons for being able to manage demand efficiently.
Despite the moments of success, areas such as Leicestershire and North Staffordshire
have reported there remain significant concerns for the future – in those areas and across the country.
The first piece in The Doctor ’s Paucity of Esteem series – published in March – revealed massive increases in demand and pressure across the mental health system, and huge rises in the number of mental health patients presenting at emergency departments in crisis and being trapped there for days or even weeks as a result of the pressure on, and state of, services elsewhere.
Doctors fear pressures are only likely to get worse owing to the cost-of-living crisis, the fall-out from the pandemic and the effects of austerity politics.
The Doctor has spoken to a wide range of mental health professionals and experts across the country while producing the Paucity of Esteem series and suggestions to tackle the issue of OOA placements have been varied.
All, however, unanimously agreed that the workforce is an urgent issue with huge numbers of vacancies and a growing sense of burnout among those in position.
The BMA is urging the Government to expand the number of inpatient mental health beds in England so NHS England can finally meet the missed target to eliminate inappropriate OOA mental health placements.
The association is also supporting the Royal College of Psychiatrists’ recommendation that all new integrated care partnerships conduct service-capacity assessments and target investment towards services driving inappropriate OOA placements locally.
As Dr Eldred says, OOA placements are not a ‘healthy thing from anyone’s point of view’.
‘The Government does not value these incredibly vulnerable people enough’
OOA between zero and seven in the following three years
The BMA presidency is the latest in a string of high-profile roles for Martin McKee, a doctor described as an ‘inescapable presence’ in the arena of public health. He talks to Peter Blackburn about Brexit, the economy, and his upcoming presidential project which aims to inspire doctors
‘Ithink many people have really undergone a severe bereavement response.’ Martin McKee says, when asked whether he feels a sense of grief, now more than seven years on from the announcement of the infamous 52 to 48 result of the UK’s Brexit vote.
Professor McKee has not become any less animated about the topic in the years that have passed. In his office at BMA House in Euston, central London, he details serious issues around the loss of health workers, Horizon Europe, and becoming a rule-taker with the European Medicines Agency and other regulators, with great authority and pace.
There are few people in the world more qualified to talk about the relationship between Brexit and health. Prof McKee is professor of
European public health at the London School of Hygiene and Tropical Medicine, research director at the European Observatory on Health Systems and Policies and a past president of the European Public Health Association, among many other notable roles. Internationalism and health have been passions of a lifetime. At the age of just 16 the young Prof McKee was asked whether he saw himself as British or Irish during an interview to study at Newcastle University. His response? ‘European.’
Above all, the tragedy Prof McKee – and so many others across the health and care landscape – identifies is that Brexit has had a brutal and immediate effect on the UK economy, with severe knockon effects for health.
‘It is blindingly obvious Brexit is a major problem,’ he
tells The Doctor. ‘But when you have both major parties in England unwilling to confront the reality of Brexit that’s even worse because that undermines public faith in politics. It is clear to everyone this is a grave concern.’
Prof McKee, who has published more than 50 books and more than 150 academic papers, also worries where the UK’s relationships with European partners leave the country to deal with incoming threats, all of which have a massive potential effect on health, from conflict and terrorism to pollution, food insecurity and disinformation and artificial intelligence.
In his career he has vociferously argued, for a long period, against austerity politics owing to their effect on health. In recent years those
‘It is blindingly obvious Brexit is a major problem’
tragic effects have become increasingly clear.
‘The reality is that starting with older people and now with younger people – particularly through deaths of despair (suicide, drug overdose and alcoholism) – we have been seeing a long-term decline in health which has been running for nearly a decade now,’ Prof McKee says.
‘I first wrote about stagnating life expectancy back in 2013 or so and we were among the first to do that. Back then people were saying maybe it’s a statistical blip. There’s been a huge amount of denial. But there can be no more.’
He adds: ‘One of the things we know is that one of the major determinants of people’s health behaviour is their answer to the question: “Do you think the future will be better than the present?” If you think it’s going to get worse, what’s the point in investing in your health?’
Prof McKee played a significant role in the discourse around the COVID-19
bma.org.uk/thedoctor
pandemic as a member of the group of scientists called Independent Sage who hosted weekly briefings on the latest developments and sought to provide politicians and the public with independent scientific advice. He also worked with the European Commission during the pandemic response.
Prof McKee still feels the UK has not ‘learned the lessons’ –or reflected on and responded to the ‘blunders’ and ‘scandal’ – from COVID-19 including the decimation of public health, the failure to invest in contact tracing, and the ignorance of previous learnings from pandemics.
He also feels significant failings were made in a lack of communication with procurement experts, laboratory staff, and latterly, patients with long COVID.
Hope for the future doesn’t always feel particularly easy to come by given the state of things in health and care, the economy and wider society.
But what are Prof McKee’s hopes – particularly with a general election looming, apparently likely in autumn of next year?
He says: ‘There does basically need to be a green “new deal” and we need to look at what Franklin D Roosevelt did after the Great Depression. There’s a Nye Bevan quote –assuming he did actually say it – from around the time the NHS was set up: “Why do I need a crystal ball when I can read a book?” I think that applies now. We know what works. We need a significant Keynesian solution of infrastructure investment and conversations about higher taxes to ensure inclusive growth with all the stakeholders across society involved.’
While Prof McKee would like to inspire action from politicians, he is also hoping to use his tenure as president of the BMA to inspire doctors, too. Each year the BMA president has a specific project focused around something they are passionate about.
For Prof McKee this means a series of podcasts produced by staff at the BMA where doctors who have done inspirational things in their lives in and away from medicine, speak about their ambitions and what drives them.
‘I’m hoping the people I interview will inspire others to follow and to communicate beyond academic journals,’ Prof McKee says.
‘These are people I see as role models – people I truly admire. I hope a generation of young doctors will follow in their footsteps.’
Find out more about the podcast at bma.org.uk/ inspiringdoctors
‘We have been seeing a long-term decline in health which has been running for nearly a decade now’
MANFOR ALL
SEASONS:Prof
McKee has been influential in issues including COVID and Brexit
From before he had even entered medical school, Luke Turley knew that his wideranging interests and ambitions were likely to make a traditional, linear career path challenging.
Having studied music alongside his chemistry and biology A-levels, much to the consternation of his tutors, Dr Turley went on to complete his medical qualification and foundation years, while trying to figure out what his path in medicine should be.
Deciding general practice offered the broadest range of clinical experiences, Dr Turley became a GP working on a sessional basis.
It is a choice he credits for having enabled him to work across an incredibly diverse range of settings including the prison estate, the armed forces, healthcare projects overseas and, most recently, helping to run a small hospital in the Outer Hebrides.
‘I thrive on the unknown and the new, I like to travel, and I have a habit of saying “yes” to things,’
explains Dr Turley. ‘Without being a sessional GP, I wouldn’t be able to do most of the things that I do in my career or even a lot of the stuff outside of my career.’
Raising awareness of the sessional GP role, the flexibility it can provide to those who pursue it as a career path and the benefits it can give to the health service, was the focus of a week of activities and events hosted by the BMA earlier this month. While the partnership model in general practice remains vitally important and the ultimate goal many GPs aspire to, Dr Turley believes many doctors working in primary care do not always give full consideration to it.
‘I think for my generation of GP registrars it was almost sort of drummed into you that when you qualified there were three jobs or phases to being a GP,’ explains Dr Turley.
‘First you start off as a locum with different practices until you find a practice that you like and you join as a salaried GP, before eventually going for a partnership.
‘Without being a sessional GP, I wouldn’t be able to do most of the things that I do in my career’
Being a sessional GP allows doctors to work in a varied number of scenarios – and to build in travel, too. Tim Tonkin speaks to two people who have made the most of the roleDr Singh (furthest right) during his time in Nepal Dr Turley teaches first aid and basic life support to members of Sierra Leone Red Cross
‘It was only after finishing my MRCGP that I realised there were so many other aspects to general practice that were never publicised and that I never knew that I actually had the opportunity to do.’
Having worked as a portfolio GP since 2008, Dr Turley has had the opportunity to work in a range of different environments developing skills and experience, much of which he has been able to apply to his work as a community GP. These experiences include working as a prison GP and later helping to found a company providing healthcare services to the prison estate, and providing care to service personnel in the British Army and Royal Navy, both at UK bases and during training exercises in locations such as Cyprus and Kenya.
His work with the MoD overseas in part led him to participate in short-term, charity-led projects aimed at developing health services in parts of Africa, most recently in Uganda teaching emergency medicine and maternity care skills to health professionals based in rural locations.
Before entering general practice, Jatinder Singh had been an anaesthetics trainee but had ultimately decided a career in this specialty would limit opportunities for one of the aspects of medicine he most cherishes, patient contact and interaction. Working as a GP in Manchester, Dr Singh quickly realised that, as well as caring for patients in the community, he was eager to pursue other interests and saw sessional work as a way of going about this.
‘When I started general practice, I did the traditional five-day setup, and then fairly quickly started to kind of become more of a portfolio GP. I did a little bit of work with the clinical
bma.org.uk/thedoctor
commissioning group as the prescribing lead for North Manchester. This led to me becoming involved with the LGBT Foundation and Pride in Practice.’
Combining his interest in tackling health inequalities and his work with the LGBT Foundation ultimately led Dr Singh to get involved with local clinicians in setting up the Indigo gender service, a pilot scheme aimed at addressing the health needs of trans and nonbinary patients.
Dr Singh has also worked overseas with organisations such as PHASE Nepal which provides care and support to remote communities in Nepal, and UK-MED, an organisation that delivers frontline medical services in natural disaster and conflict zones.
‘I was deployed to Ukraine last year; it was my first ever deployment in the conflict zone,’ says Dr Singh. ‘[This work] gives so many different opportunities to explore provision of healthcare in low-resource and high stress settings and you get to work with lots of passionate people from all over the world. I think (being a sessional GP) that’s the main reason why I’ve been able to do all these things.’
These are just some of the examples of positive experiences and outcomes that have been experienced by those undertaking careers as sessional GPs. The BMA has and will continue to support sessional GPs, as demonstrated by its Sessional GPs week.
As part of its sessional GP week, the BMA has produced a range of resources designed to inform and support doctors including a guide for salaried GPs to get the most out of their careers, a webinar on maintaining personal wellbeing and guidance on digital locum banks.
BMA sessional GPs committee co-chairs Samira Anane and Bethan Roberts say they hoped the event would draw wider attention to the contributions of portfolio GPs and empower those doctors already working in such roles.
‘We hope that highlighting the diverse nature of work being done by sessional GPs will demonstrate the enormous value that these doctors bring to the GP workforce. We also hope that promoting the various resources available to sessional GPs can help support individual members and that the sessional committee and the wider BMA area available to members who need support.’
‘This work gives so many different opportunities to explore provision of healthcare’
GPs who faced crippling charges by an NHS organisation, and possible closure, have won back thousands of pounds in a BMA-backed case.
Relief, vindication and survival.
These three words are perhaps the best summation of the recent outcome of a lengthy and complex legal challenge involving five GP practices backed by the BMA, and NHSPS (NHS Property Services) – the body responsible for managing and maintaining NHS properties in England.
The case, which concerned a long-running dispute on the basis upon which NHSPS was levying charges for services to the practices as well as the amounts it was demanding, had been hanging over the
practices for the last few years.
Coinciding with the enormous stress and challenges of the pandemic, the legal challenge saw NHSPS bring a counterclaim against the five practices in which they demanded payment of historical service charge claims amounting to hundreds of thousands of pounds and threatening the very existence of some of the practices.
Ultimately, however, NHSPS was unable to provide sufficient evidence to verify all of the charges it was seeking to recover, with the result that it drastically
‘It’s been such a relief to know years of stress and frustration are now finally over’
revised the sums being claimed, with one practice seeing more than 80 per cent, over £400,000, reduced from the total amount NHSPS was claiming.
While the judge presiding in the case has emphasised the outcome does not form a legal precedent, the enormity of the final settlement cannot be understated for the practices involved.
‘It’s been such a relief to know years of stress and frustration are now finally over,’ remarks one practice member who wishes to remain anonymous.
‘If we had paid what we were being asked to by
Tim Tonkin reports
NHSPS, then our practice would not have survived, which would have impacted thousands of patients. We couldn’t have done this without the BMA’s support and the lawyers who assisted us on their behalf.’
Practices threatened
Set up in 2011 under the provisions of the impending 2012 Health and Social Care Act, NHSPS is a limited company wholly owned by the Department of Health and Social Care, with the secretary of state for health as its sole shareholder.
Its purpose was to take on the ownership and maintenance of almost 4,000 NHS properties, including GP practices, following the abolition of primary care trusts, the bodies previously responsible for this role.
After NHSPS published its consolidated charging policy in 2016, many GP practices found themselves facing steeply inflated bills for rent and other services, despite the fact they possessed existing contractual terms pre-dating the charging policy and/or NHSPS.
There have been reports of practices facing serious financial burdens, and even having to consider whether they will be forced to hand back their general medical services contract and shut their doors to patients.
Criticism of the remit and function of NHSPS and how it levied charges for rent and services were apparent even before the BMA’s legal challenge, with a 2019 report of the Parliamentary public accounts committee
bma.org.uk/thedoctor
describing NHSPS as an organisation ‘created with a muddled objective’ and one that was ultimately ‘set up to fail’.
The same report noted around half of the debt owed to NHSPS, which in March 2019 stood at £576m, was under review, with tenants having challenged bills on the grounds they were ‘based on inaccurate information or inappropriate apportionment of costs’.
While the settlement between NHSPS and the practices represented by the BMA has resulted in varying reductions in the cost of claims, three of the five have seen reductions of more than 50 per cent of the original sums being sought.
BMA GPs committee premises lead Gaurav Gupta has been involved in the case and the fate of the five practices at the heart of it, from the very beginning
Speaking of his enormous relief at the outcome, Dr Gupta says it remains vital other GP practices concerned they may have been inaccurately charged in their rental and service bills, raise the matter with NHSPS in the first instance, and consult the BMA if they feel they require further guidance or support.
He says: ‘I am delighted that, with support from the BMA, these five practices have been able to achieve long-awaited reductions to their NHSPS service charge claims.
‘This is a groundbreaking lawsuit, and these settlements vindicate the practices’ assertion that, for years, NHSPS has
been claiming unduly high levels of service charges without sufficient reason or justification.
‘This outcome should give hope of a fair resolution to the other NHSPS tenants struggling with rising service charges and resulting disputes.’
A spokesperson for NHSPS said: ‘We are pleased to confirm NHSPS has reached a settlement with five GP practices, recovering a substantial amount of the charges that had been disputed.
‘This follows the High Court’s judgement in NHSPS’s favour in June last year which determined the legal basis for charging in the cases.
‘We are keen to progress discussions with the wider GP community to resolve outstanding charges.
‘For these five cases, the judge determined that the practices should pay the reasonable cost of services reasonably provided. We look forward to working with individual practices to agree a way forward.
‘We are pleased the BMA has recommended its members “engage with NHSPS on a good faith basis” and support the judge’s comments urging the GP community to work with NHSPS to provide relevant information and work constructively on any outstanding matters.’
The BMA has created guidance for practices in a similar position, to help advise them on what to do if they are also facing disproportionate service charges.
Visit bma.org.uk/ nhspropertyservices
‘If we had paid what we were being asked to by NHSPS, then our practice would not have survived’
With the BMA annual representative meeting nearly upon us, I’ve been reflecting on the journey we have been on during the past 12 months, and the juncture we as doctors and as a union now find ourselves at.
I cannot think of another period during my more than 13-year involvement in the BMA in which the association has undergone so much rapid evolution and growth while also extending our efforts to become more relevant and innovative in how we represent our members.
With 185,000 doctors and medical students from across the UK now part of our BMA, we benefit from the largest membership at any point in our history, and at a time of unparalleled importance for our profession and the NHS. This clearly represents a great achievement for our union and is a sign of strength and a powerful statement of intent going forward in terms of what we together can, and no doubt will achieve.
At the same time our increased numbers also present challenges. With more members than ever before, ensuring that we are able to represent the views and needs of the wealth of diversity in our ranks as a trade union and professional body, is more difficult yet also more critical than ever before.
Accessibility and representation are particularly important for those groups who still remain underrepresented in leadership positions in healthcare and medicine, namely women, ethnic minorities colleagues, colleagues with disabilities, long-term health conditions and carer responsibilities and members of the LGBTQ+ community.
It is with this in mind that this year’s ARM will seek to be the most open, engaging and diverse meeting in our association’s history. We really want and need to hear from you.
Many of you will already be aware of the measures we have taken to encourage this, from increasing the number of places for attendees and opportunities to observe the ARM, to reasonable adjustments being made for speakers and completely changing our platform to enable fairer and inclusive representation in debate.
@drlatifapatelAs with previous years, the ARM also provides free childcare facilities in the form of an on site crèche, with a view to ensuring that those with parenting responsibilities are not needlessly excluded from voting and debate. Those with other carer needs may also be able to access funding – please do get in touch.
ARM will be livestreamed for those without a seat and I strongly encourage virtual observers to engage with us via social media. This is the meeting which decides the direction of your BMA.
Having your say can also mean putting yourself forward and standing to be an elected representative for your colleagues, with ARM seeing elections to a number of important positions in the BMA. The nominations process, which is open to all association members, is now under way with the window for applications open until 3 July. The recently published agendas for this year’s conference demonstrate the range of issues and topics ARM always seeks to encompass and address. As I have already alluded to, however, this year’s conference is likely to be dominated by a particular area of concern, that of pay and industrial action.
With so much at stake there may be differences of opinion among you all on how we move forward, and this is exactly why I would urge all of you who wish to become active members of your association to engage in full with this year’s ARM. I know as doctors we like to be heard and we pride ourselves on speaking out on behalf of our patients when seeking to defend their interests.
What I’m asking now is that you speak on behalf of yourself, and get involved in your association and trade union, on behalf of yourself, your peers and colleagues and people who might not be otherwise represented.
If you would like to get in touch with the BMA and learn more about how you can get involved with your BMA, please write to me at RBChair@bma.org.uk or @DrLatifaPatel – DMs always open.
Dr Latifa Patel is chair of the BMA representative body
You
Cuts to consultants’ pay mean you are effectively working for free for four months every year. This risks pushing consultants out of the NHS and patient care suffering. Vote yes for an NHS consultants want to work in, and that junior doctors can see their future in.
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
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