ARM 2023: Doctors gather with renewed determination
Junior doctors Support strong for continuing action
Shaken to the core Doctors rethink lives after near-death experiences
Save Our Surgeries
GPs launch campaign for better conditions
3-7
ARM 2023
News from the BMA annual representative meeting
8-11
The fight goes on Government refusal to enter meaningful pay talks intensifies the resolve of junior doctors in England
12-15
Back from the brink Doctors who have had a close encounter with death describe how they have gained new perspectives
16-19
Unsafe and unsustainable GPs in Wales take action to ‘save our surgeries’
20-21
A dedicated life A GP who served his community for 50 years looks back
22 Your BMA Reflections on an inclusive ARM
When I was elected BMA council chair, I knew we faced many challenges ahead as we sought to redress years of eroded pay, underinvestment and worsening morale. Even after decades witnessing the incredible care and compassion doctors show in the most difficult of circumstances, I could never have predicted the pride I feel one year on – with our union focused on delivering for its members and thus for our patients. Across the UK doctors have shown energy and passion, taking a stand collectively for what is right and demanding our expertise is valued for what it is worth.
At last week’s BMA annual representative meeting I said we had become an association ‘undaunted’ by the threats of Government and willing to do ‘what it takes’ for our profession and for our country. I meant every word and if ministers aren’t already on notice that we will not stop until we succeed, they should be now.
It was an immense pleasure to meet so many members, colleagues and friends at the ARM in Liverpool. The debates we had, and the policy made, guide the vital work we do in the year ahead as we advocate for doctors and the NHS as powerfully as we possibly can. In this edition of The Doctor we include some of the highlights and talking points from the ARM for those who were unable to attend or watch online.
In our feature on a new BMA Wales campaign, ‘Save Our Surgeries’ we hear from GPs whose working conditions are having a pitiless effect on their lives. One doctor describes the feeling of being ‘constantly tortured’ by her thoughts. Our colleagues in general practice are working harder than ever – providing remarkable care for communities in the face of extreme rising demand as well as abuse from patients and gaslighting from Government and the media. The BMA in Wales has produced a plan to save general practice; as I said in my opening address at the ARM – if we lose general practice, we lose the NHS.
Also in this issue we speak to Yorkshire GP Hanume Thimmegowda, who recently celebrated 50 years of working in the NHS – and is still serving his community in his 80s. He speaks movingly about his ‘immense passion’ for his vocation in life. We also speak to two doctors about their close encounters with death, and how those experiences influenced their attitudes to life and work.
We are the product of our rich and diverse experiences, good and bad. They make us human, with a need to be cared for and appreciated for who we are. We are doctors, and we are your BMA.
Keep in touch with the BMA online at instagram.com/thebma twitter.com/TheBMA
Doctors are ‘fighting back’ to improve patient care, battle against years of pay erosion and stem the tide of colleagues leaving the country.
BMA council chair Phil Banfield told the annual representative meeting in Liverpool ‘we see hospitals falling apart and ambulances stacked outside emergency departments’, and that catastrophe had arrived after years of warnings from doctors.
He said the BMA would ‘do what it takes for our profession and for our patients’.
Professor Banfield praised the ‘vigour and spirit’ of junior doctors in England for taking industrial action, commending also the support their colleagues had shown for them.
He said: ‘Listening to their stories, as I have, it soon becomes clear how many junior doctors are struggling every day with student debt, the costs of being shoved around the country in a training lottery. The price of exams rising as the bills stack up – housing and energy costs going through the roof.’
The BMA would meet the Government without preconditions to resolve the issues, said Prof Banfield, who had written to prime minister Rishi Sunak on the day of his speech to urge him to join ACAS-facilitated talks.
Prof Banfield also highlighted the other, overwhelming ballot mandates granted to juniors in Scotland and consultants in England.
He said GPs in England were starting
preparations for an indicative ballot if the Government failed to negotiate a new contract that was fit for purpose, adding that ‘GPs have had enough of being scapegoated for a conscious policy of chronic underinvestment’.
Doctors’ struggles for pay restoration and better working conditions were for future generations as well as the current one, he told the ARM.
‘To lose these battles is to accept and assent to the exodus of doctors from this country. It is to allow the managed decline of our oncegreat health service and our profession. It is to reconcile ourselves to year upon year of pay erosion and the casual disregard for our expertise.’
Prof Banfield said the Government had disregarded the NHS workforce crisis, and with it a waiting list of more than seven million in England alone, and doctors emigrating en masse to Australia. While it had finally come up with a strategy last week, there were
not the doctors to train the future workforce.
He said the BMA would continue to give strong support to whistleblowers, with the NHS having a ‘culture of fear’ in which only 40 per cent of BMA members said they were content to report errors. He highlighted the case of the Isle of Man medical director Rosalind Ranson, backed by the BMA, who won a large settlement after facing bullying and harassment when she raised concerns with the island’s response to COVID.
‘I am in no doubt some NHS employers are guilty of the same tactics. And they need to know the BMA won’t allow this any more. If regulators won’t hold you accountable, we will call you out for the safety issues you have sought to hide.’
The most fundamental question, said Prof Banfield, was what doctors were worth.
‘You know it,’ he said. ‘You are invaluable. The patients we save and care for know what we’re worth. This country knows what we are worth.’
The Government’s long overdue workforce plan will not succeed unless urgent action is taken on paying and retaining existing staff, doctors agreed.
A vast majority of doctors at the BMA annual representative meeting backed a motion expressing deep concern at the worsening NHS workforce crisis and condemning the failure of workforce planning by successive governments.
The Government announced its 15-year workforce plan for England last month, acknowledging the huge shortage of staff across the NHS. It set out to double medical school places to 15,000 by 2031. But despite a ‘renewed focus on retention’ noted in the plan, it made no mention of pay restoration – with junior doctors and consultants in England due to take industrial action this month in a bid to secure pay restoration to 2008 levels.
Shropshire GP Antony Lempert asked: ‘Why has it taken until we are in crisis for there to be a plan? Is it a workforce solution or is it another vacuous distorted promise?
‘It recognises the need for a huge increase in doctor numbers, but unless the current disputes are resolved satisfactorily the students and newly qualified will be fortunate to gain any experience from the remaining doctors who will be running a daily marathon because many more colleagues will have left.
‘Without pay restoration it is like trying to fill a leaking bucket because new doctors will feel equally undervalued and leave. It’s time to fix the leak, not ignore it.’
He was supported by Kent GP Reshma Syed, who said: ‘When will the Government realise there is no point in training new doctors if they are subjected to conditions that are untenable?
‘You need a skilled and fully qualified workforce who are paid exactly what they’re worth – and that’s not what is happening today.’
Dr Syed warned GP partners are also ‘fighting for our very existence’ and ‘may join in and take a stand’ in the future.
‘The lack of appropriate pay and conditions is the sole cause of the exodus of doctors out of the profession,’ she said. ‘Overworked, underpaid, burntout doctors impacts on the deliverance of safe patient care.’
She added: ‘It is time the Government realises we are not the problem, we are the solution. But only at the right price. Only if we are valued will we serve our NHS.’
Calls to stand in solidarity with doctors who have voted to take industrial action,
and for appropriate and urgent pay restoration, were also debated.
However, David Randall, a consultant from London, said ‘35 per cent pay restoration is the wrong goal and strike is the wrong approach’, urging his colleagues instead to press for a lower pay rise.
But the motion was carried with more than 90 per cent of votes in favour, after BMA deputy council chair Emma Runswick noted that between 1,600 and 1,700 doctors had relied on the support of the BMA’s strike fund to take industrial action.
The Government’s handling of recent pay disputes with public sector workers is reminiscent of the Winter of Discontent, say doctors.
An ARM motion raising concerns that the Government has ‘no grasp of the real scale of the crisis in either the NHS or social care’ – despite a long-awaited workforce plan being published the previous week – passed overwhelmingly.
It urged the Government to listen to the concerns of frontline health staff and deliver the investment the NHS and its workforce urgently need, saying the Government has offered ‘little of substance’ to improve recruitment, retention and morale.
Tyneside GP George Rae (pictued above), chair of the BMA northeast regional council, tabled the motion.
He said: ‘The gravity of how desperate things have become on the frontline has simply not got through. The Government in England has earned the reputation for absolute abdication of responsibility for the public’s health.
‘Look at how the Government has handled the junior doctors strike and has not come to the negotiating table realistically.
‘Does it not recognise that junior doctors have come to this point of action after years of pay cuts and as a result of utter exasperation caused by working in an NHS which seems to have little respect for its workforce?
‘Does it not recognise the long-standing
feeling of junior doctors, and indeed of all doctors, of being undervalued?’
‘Crisis? What crisis?’
Dr Rae compared claims by prime ministers Rishi Sunak and Boris Johnson to be on top of issues in the NHS to the behaviour of former Labour prime minister Jim Callaghan who in the winter of 1978-79 was quoted as saying ‘Crisis? What crisis?’ at a time when litter was piling up in the streets and bodies were not being buried.
While it was a paraphrase by a tabloid newspaper rather than anything he actually said, it successfully conveyed the impression that he was out of touch.
‘He didn’t get it,’ Dr Rae told ARM delegates. ‘Where have all the secretaries of state been over the last 10 years? Have they not got
it? Have they not realised, until Friday, that there’s a workforce problem? Did they not realise that the waiting lists were long, long before COVID?’
Dr Rae said the number of vacancies and future vacancy projections identified in the Government’s workforce plan showed the scale of the crisis in the NHS.
‘The massive, untenable workload and successive pay cuts are haemorrhaging doctors and nurses faster than we can replace them,’ he said.
‘How much more can actually be squeezed out of a really exhausted workforce? The Government has offered little of substance to improve recruitment, retention or morale and there is no doubt that if we don’t get pay restoration things will get worse.’
The socialist thinker and academic Raymond Williams once observed that ‘to be truly radical is to make hope possible, rather than despair convincing’.
It is a maxim and mindset Professor Sir Michael Marmot (pictured above) subscribes to, even if he readily concedes there is plenty to despair about when it comes to the state of health equity and social inequality in the UK in 2023.
A former president of the BMA, and global authority on the determinants of health and the role of social justice in wellbeing, Prof Marmot is the author of the landmark 2010 study Fair society, healthy lives: the Marmot review, with this seminal piece of work itself revisited and reappraised in 2020’s The Marmot Review 10 Years On
It was with these credentials in mind that Prof Marmot was invited to present the second instalment of the Victor Horsley lecture at this year’s BMA annual representative meeting in Liverpool, in which doctors and medical students had the opportunity to hear Prof Marmot dissect the factors which have contributed to disparities in health outcomes. These include the fact that UK life expectancy, which until 2010 had been increasing around one year every four, has now shrunk by 0.9 years in women and 1.2 years in men.
Meanwhile health and physical development among UK children has been similarly stunted, with the average height of five-year-olds in the UK now ranked 101 out of 200 similar nations, having been 69th in 1985.
‘Our five-year-olds are now seven
centimetres shorter than fiveyear-olds in the Netherlands,’ explained Prof Marmot.
‘The genes didn’t change in that time. Genes determine the heights of individuals. It’s nutrition, infection, poverty, stress [that determine the heights of groups].
‘What we can say is [between 2010 and 2020] we [the UK] had the slowest improvement in health equity of any rich country except Iceland and the USA.
‘I’m concerned with health and the determinants of health, particularly now that the healthcare system is under such threat [and] there have been three huge recent challenges to health inequalities; the decade of austerity, the COVID pandemic, and the cost-of-living crisis.’
While the role of social status in determining an individual’s health outcomes is not a recent observation, understanding the complex interplay of how global events and subsequent government policy have a direct effect in shaping these outcomes is not always straightforward.
Around the time he was publishing his 10 years on
review, Prof Marmot had made clear that the then unfolding COVID-19 pandemic would expose and exacerbate existing health and social inequalities.
The antecedents, however, go back much further, and in many cases are the logical conclusions of political choices and government policies enacted since 2010, with Prof Marmot pointing out that public sector spending had been 42 per cent of GDP in 2009/10 shrinking to 35 per cent by 2019/20.
He said that having recently listened to an interview with George Osborne in which the former chancellor asserted that austerity had helped to drive growth and make the UK’s economic model one that other countries had sought to emulate, he found it laughable.
‘The pandemic is a crisis, but I would argue that the magnitude of health inequalities we had in 2010 should have been a crisis, and yet we chose to cut public expenditure and make things worse,’ Prof Marmot said.
‘George Osborne was the architect of the austerity, I was listening to him on a podcast while I was out for a morning walk today [and] was so annoyed I got a blister.’
‘
That which we call a rose…’ Shakespeare so often has the right words for a situation, but there was one debate at the BMA annual representative meeting in July, where Juliet’s famous line on names not mattering would simply not have cut it.
That which we call a ‘junior doctor’ feels vile esteemed by the title, and they would argue it entirely fails to capture the weight of responsibility required.
Staffordshire foundation year 1 Sai Ram Pillarisetti told the ARM: ‘This title of junior doctor has proven misleading and indeed demeaning to the general public, it may imply lack of experience or competence, creating a misunderstanding about the work we do and the qualifications we hold.’
There was nothing junior about their responsibilities, he said, adding that the title failed to distinguish between doctors with differing levels of experience.
‘Every day these so-called junior doctors act as the first point of contact for sick and unwell patients on the ward, they’re in theatre operating on your loved ones, and they’re leading teams across various specialties in our health service,’ he said.
This has been a subject of debate for some time.
Consultant orthopaedic surgeon Scarlett McNally was asked last year to write a report by Health Education England. A survey conducted for the report found more than three-quarters found the term ‘junior doctor’ inappropriate and
almost half thought ‘trainee’ should be avoided.
Professor McNally recommended four titles – foundation year ones, central doctors, registrars and consultants.
‘Central doctors’ would generally be within five years of qualification, and largely occupy the ground previously held by senior house officers.
Unwanted title
The difficulty inherent in any renaming exercise was acknowledged at the ARM by East of England anaesthetics trainee Ciaran Scott who said that attempting to educate the public about the capabilities and responsibilities of junior doctors might be a better use of time.
Recognising the challenges highlighted by Dr Scott, Manchester medical student Noor Al-Saffar said, however, that abandoning the ‘junior’ title was a correct and important step in redefining the way doctors were perceived.
‘There have been several anecdotal studies which have shown that junior doctors have experiences where patients have asked for a senior doctor because they don’t believe in the competency of these doctors,’ she said.
The motion urged the BMA to discontinue the use of the terms ‘junior doctor’ in all forms of communication, and use ‘doctor’ instead.
What was clear from the debate is that experience comes thick and fast to doctors, and that there is nothing ‘junior’ about what any doctor has to do.
As Shakespeare said, perhaps more helpfully: ‘Experience is by industry achiev’d, And perfected by the swift course of time.’
AL-SAFFAR:
There’s nothing junior about junior doctorsChanging title would improve perceptions
The Government’s refusal to enter meaningful pay talks with junior doctors in England has only intensified their push for a fair settlement.
By Seren Boyd and Peter Blackburn
For all the cheers and camaraderie at the recent BMA rally in Oxford, none of the junior doctors taking part wanted to be there. But they felt they had no choice.
On the first day of their latest 72-hour strike, the message from the doctors and placards assembled in Bonn Square was clear: We have no option but to strike. Things cannot go on like this.
‘Going on strike is an absolute last resort,’ said event organiser Matt Bilton, a locum doctor working in emergency medicine. ‘But morale is at rock bottom: it couldn’t be any worse. And it has been this way for a long time. We have reached the point where, if we do nothing, then nothing changes.’
Four months in to the junior doctors’ industrial action, the Government has made only a 5 per cent pay offer in response to the BMA’s demand for full pay restoration. But junior doctors’ resolve is not wavering.
In Oxford, there was no sign public support for them was wavering either: buses and cars honked their support; a busker used his microphone to urge the Government to pay
WINTER:
doctors more; an older passerby hijacked the microphone to demand the same.
‘Last cry for help’ However, there is a price to pay for strike action, and not just in lost earnings.
Laura Wilkins, a foundation year 1 doctor in the Thames Valley deanery, is one of the juniors paid £14 an hour for a 48-hour-plus week.
Staff shortages – including frequent planned rota gaps – mean she can be left carrying the crash bleep on a night shift, responsible for all medical emergencies in the hospital. She is committed to striking – but wishes she didn’t have to.
‘This is the last cry for help to try and rescue our profession,’ she said. ‘[Striking] is horrible: it’s not a thing anyone does lightly.
‘But it’s so demoralising as a doctor not to be able to provide safe and effective care for patients, day in, day out. It’s awful. I want them to get the world-class care we can provide if there’s enough of us.’
Fellow striker Richard Shoulder, a core trainee 1, spoke of feeling ‘guilt’ about joining the stoppage –
but insists change is non-negotiable.
‘I hated leaving work yesterday knowing that we’re leaving colleagues to pick up the slack,’ said Dr Shoulder. ‘Everyone striking here today probably has relatives and friends on waiting lists. We all feel conflicted. But we have tried to make ourselves heard, and people aren’t listening.
‘We’re at a crisis point in terms of numbers,’ he said. ‘You have to stop people leaving: you can’t magic up these skilled professionals, people who want to do this job and who bring the right characteristics to do the job well.’
In several other cities, junior doctors joined BMA rallies, demonstrations and marches as part of June’s three-day walk-out. The sense of solidarity was as strong as people’s anger at government intransigence.
This latest strike coincided with the publication of a BMA survey of junior doctors in England, which found the Government’s inadequate response had left 89 per cent of respondents ‘feeling less valued than they were before
‘It’s so demoralising not to be able to provide safe and effective care’
‘We’re at a crisis point in terms of numbers’
‘Ultimately, it’s for the patientsONWARD TOGETHER: Junior doctors on the march in Manchester
the dispute started’.
In Manchester, hundreds of junior doctors staged a rally outside the NHS ConfedExpo conference, where health secretary Steve Barclay gave a speech.
Maleeha Malik, an F1 in north Manchester, said she felt ‘completely demoralised’ by the Government’s lack of response.
‘I don’t think they care about anyone. But we feel together.’
Addressing the rally, BMA junior doctors committee co-chair Vivek Trivedi spoke of his colleagues’ ‘unwavering
determination’ to press on.
‘The road ahead may be bumpy, and sacrifices will have to be made, but if we continue united, we will be victorious.’
Rebecca Vitarana, another F1 in north Manchester, agreed: ‘This definitely has given me a sense of hope. This is not just for money: we don’t want to feel desperation every day at work. This is about more doctors staying so the NHS is safer.’
Meanwhile, in Birmingham, more than 1,000 people joined a lively rally in Centenary Square, with music, speeches, media
crews, cheers and chanting, before marching around the city centre.
As BMA regional coordinator and event organiser Melanie Sutton said in her speech, the show of unity demonstrated commitment: ‘Solidarity is the way that we will win this fight.’
Speaking later to The Doctor, she said: ‘So many members of the public came up and said they supported us. The message of £14 an hour has really struck a chord, and people understand that delays at hospitals are the Government’s fault and are a political choice.’
Two female junior doctors, who wanted to remain anonymous, interrupted their journey from the picket line to the Birmingham rally to help a man with a serious head wound who had fallen in the road. They used a BMA flag to staunch the flow of blood until an ambulance arrived.
‘The way they selflessly intervened demonstrates the level of responsibility they feel, all day every day,’ said Mrs Sutton.
In Bristol, a patient left his hospital bed to join the picket line for a time.
Junior doctors are being re-balloted about continuing industrial action beyond August.
In his speech to the Oxford rally last month, Dr Bilton, chair of the BMA Thames Valley regional junior doctors committee, urged his colleagues to vote in favour of more strikes and voiced his frustration with politicians on all sides.
‘This definitely has given me a sense of hope’Junior doctors on a rally and march in Birmingham FAIR PAY: Dr Wilkins (centre) wishes she didn’t have to strike
‘It is an outrage that we face no choice other than to be here today in the city centre, rather than at work,’ said Dr Bilton.
‘Rishi Sunak puts his hands in his pockets, has a rummage around, and offers 5 per cent, pocket change. Meanwhile, Keir Starmer calls for more medical students, missing the point entirely. Fix the leaky bucket by pouring more water in? Good one.
‘We all know that the status quo cannot continue. We must hold out for a pay deal that will retain doctors in the UK and the NHS.
‘We’re not just standing up for ourselves: we’re standing up for the future of the profession in this country. Let’s tell them again. Let’s keep on telling them until they hear us.’
Listening to this speech, F1 Molly Winter held a placard referring to the £93bn of ‘pandemic waste’, including £4bn of unusable personal protective equipment, and to the £30bn cost of Liz Truss’s disastrous ‘mini-budget’.
‘Money is produced for the projects the Government cares about, and they should care about this,’ said Dr Winter, who was a graduate medical student.
‘Yesterday I sat on a stepladder at work because there aren’t even enough chairs. I’m someone who came into medicine because I care. I’m not going to follow the money and go somewhere else. I want to be in the NHS,
‘I want to fight for the NHS. This is about pay restoration, good working conditions and, ultimately, it’s for the patients.’
bma.org.uk/thedoctor
A further five days of industrial action in England was planned by junior doctors from 13 to 18 July, after The Doctor went to press, and consultants are due to strike for 48 hours from 7am on 20 July, providing Christmas Day-levels of cover.
There was an 86 per cent vote for industrial action amongst consultants, with a 71 per cent turnout.
BMA consultants committee chair Vishal Sharma says: ‘We know consultants don’t take the decision around industrial action lightly, but this vote
shows how furious they are at being repeatedly devalued by Government. Consultants are not worth a third less than we were 15 years ago and have had enough.’
Meanwhile, junior doctors in Scotland have agreed to suspend strike action after being offered a 12.4 pay rise in 2023/24. For the following three years, the Scottish Government has committed to negotiate further annual pay rises on top of inflation.
The BMA Scottish junior doctors committee has recommended members accept the offer.
‘Solidarity is the way that we will win this fight’GATHERED: Junior doctors in Manchester PETER BLACKBURN
‘You’re still here – make the most of it’
David Baglow’s mother tells him he has used his nine lives.
He nearly drowned while surfing. A car slammed into him while he was cycling to work, causing serious injuries. He suffered traumatic brain haemorrhages and then, eight months later, a stroke. And all this before he reached 41.
Dr Baglow survived and was able to continue his anaesthetic specialist training. He is now working in London and determined to make the most of life. He has a healthy respect for death and doesn’t take the risks he once did – but he’s not ‘fearful of the end’.
‘It’s the only certainty in life that everyone shares,’ he says.
‘I was annoyed, furious, at myself when I was underwater. I was thinking about my mum and sadness towards her after I was hit by that car and my vision was narrowing. And it was about three or four months after what happened to my head that I started to realise the gravity of it all.’
Of all his close shaves with death, it was the brain haemorrhages that were hardest to recover from, not least because they remain unexplained. Sussex police told him foul play was the most likely cause.
He doesn’t remember anything of that evening in the pub with friends, or the week before. He knows he wasn’t drinking much, which friends confirmed, as he was preparing for a big bike race. He disappeared during the evening and was found 11 hours later by police, collapsed outside the pub’s fire exit. Assuming he was
drunk, police took him home but within hours he had been admitted to ICU. His recovery took 18 months.
‘In hospital, I remember trying to walk and feeling like I was on a ship on stormy water. And I remember a horrific shuddering pain in my head from sound, lights, movement, seeing NHS written all over me, and nothing making sense.’
When he later returned to the same hospital as a trainee anaesthetist, some consultants would react to him standing in front of them with tears in their eyes. He appreciates how ‘hugely lucky’ he is.
‘And I’ve accepted that survivor guilt will subconsciously never leave me.’
Yet, it was something that happened in his teens that had the most profound effect.
Two days after a New Year’s Eve party at a friend’s house, the then 16-year-old David had a call from the friend’s father to say she was seriously unwell with meningitis. She died the next day.
‘At the funeral her dad said he didn’t want people to say her death at 16 was a waste, because she had done so much with her life. And he told us, basically: “You’re still here: make the most of it.” We didn’t discuss it at the time, but it motivated every single one of us. It definitely put the wind in my sails.’
Dr Baglow, who is deputy chair of the BMA south-east coast regional council, has made some important choices to affirm life: he works less than full time, for example, and always makes time for exercise.
But he also feels strongly
‘I remember a horrific shuddering pain in my head from sound, lights, movement’
How does a close encounter with death influence your attitude to life and work?
Two doctors tell Seren Boyd how confronting their own mortality has shaped their views on life
that we as a society should be more open and matter-of-fact about death and preparing to die. He’s fascinated by the idea that the pattern on fishermen’s jumpers may have helped identify them if they drowned and washed up elsewhere – a recognition of death woven into life.
Dr Baglow questions the way death is used as a fixed point in shared decision-making.
‘Medical professionals may say things like, “If you don’t have this operation, you’ll probably be dead in six months.” But we don’t often discuss quality of life, which, in my opinion, is much more important than the length of time you have left.
‘We should be talking about independence, self-respect and dignity in death and having these conversations much earlier, rather than risk freaking people out by waiting till it affects them directly.’
He insists his attitude to death is personal and recognises that not everyone is so relaxed. He tries harder now to relate to patients, gives them more time and genuine conversation, recognising their feelings of isolation.
‘A patient the other day was shaking with anxiety and
I gave him a little fist bump. I said, “There’s nothing I can say to make you feel better, but I promise I’ll treat you the way I’d want to be treated.” It’s about giving them connection, making them feel they’re not alone.’
Above all, he’s learnt gratitude.
‘When I was discharged from ICU and went on the trauma ward, I really liked watching the seagulls outside the window. It was a constant I found consoling.
‘Later, when I was working in that hospital, I went to see a patient who was in that same bed and asked if they liked the seagulls. Then I told them I’d been in that bed once. And they opened up, as if in a confessionary, and said, “I really like them too!”
‘Whenever I walked into that hospital, I’d look up at the window and think, “I’m so lucky”.’
He’s known for his life-affirming tweets, his beaming smile and his raw honesty about all that’s led him to this point.
Psychiatry registrar Ahmed Hankir makes no secret of the fact that his battle to regain his own mental health took him close to death.
Today he goes by the moniker ‘The Wounded Healer’ in his award-winning advocacy to tackle stigma around mental health – a phrase borrowed from Jung. He talks openly about parts of his life which were dark and difficult, because he wants it to help others. And because he feels it helps him too.
‘A lot of us feel forced to sanitise our stories but that doesn’t do justice to our reality,’ says Dr Hankir. ‘I’m proud of overcoming the obstacles and surviving and, dare I say, thriving.
‘You’ve heard: “Physician, heal thyself.” But what about, “Physician, reveal thyself?” By revealing, we can heal not only others, but ourselves.’
It was Dr Hankir’s determination to become a doctor that helped him overcome huge disadvantages and setbacks over years. He describes his current post at South London and Maudsley NHS Foundation Trust as his ‘dream job’.
But it was that same ambition that often made his journey so challenging.
The backdrop to much of his childhood was conflict. His parents moved to Northern Ireland in the early 1980s, to escape the fighting in their native Lebanon; Dr Hankir and his twin were born in Belfast. ‘My mother always said that at least in Belfast you’d get advance notice there would be an explosion: we didn’t have that courtesy in Lebanon.’
When Dr Hankir was 12, the family returned to Lebanon, still in the grip of civil war. But it became clear the children would not thrive there. And they were ambitious.
Dr Hankir’s father had won a scholarship to study medicine in Cairo, while their grandfather had sold hummus from the back of a donkey in Haifa. In 2000, Dr Hankir and his twin moved back to the UK.
Britain was not a safe haven. At 17, he witnessed a man being kicked to death outside the
‘We don’t often discuss quality of life, which is much more important than the time you have left’
kebab van where he worked in Malvern Hills. And he was often met with racism and Islamophobia, another strand of his campaign work today.
‘I was very outgoing, and I didn’t understand why when I would say, “Good morning,” people wouldn’t reciprocate. I was called an ajnabi [‘foreigner’ in Arabic] in Lebanon and a “Paki” in England. I always felt like an outsider.’
Dr Hankir had to support himself financially, through both sixth-form college and university. He was working up to 60 hours a week, cleaning, stacking shelves, anything to make ends meet.
Despite all this, he won straight As and a place at medical school. He loved his studies but found it hard to integrate. He was surrounded by privilege while working 16-hour shifts in a fastfood outlet.
Then, in 2006, in his third year, ‘multiple factors’ conspired to push him to the brink.
Images on TV of the conflict erupting in his hometown in Lebanon triggered severe distress. His behaviour changed and he fell out with his flatmates. ‘I must have had some kind of unconscious attachment towards them because they were like family to me, but I wasn’t family to them.’
He also, he alleges, suffered psychological abuse from a staff member he considered a ‘mentor and father figure’.
‘I confided in someone, he manipulated me, he deceived me. But he was never held accountable. I was a BAME medical student, a Muslim, and I have this mental health condition. The triple whammy.
Then, a misunderstanding with his medical school about which cycle he was sitting exams for – ‘I showed up for the wrong cycle’ – meant he ‘was forced to interrupt’ his studies. Having fought so hard to get into medical school, this was devastating.
Without a grant, he was homeless, until he found a room in a derelict house in Moss Side. He woke up one morning to find his Azeri housemate had died of a drug overdose. He recalls scouring the streets for coins so he could buy out-of-date bread.
‘I was really unwell and felt suicidal,’ he says. ‘I was getting these traumatic flashbacks: I would scream and shout in the night. It was like this tempestuous howling storm in my head, and it just wouldn’t stop.’
It took months before Dr Hankir was well enough to return to med school; he had to repeat two years, adding to his financial difficulties. He often went to bed on an empty stomach.
But it took years to fully regain his mental health.
In his powerful presentations and lectures addressing mental health-related stigma that have won him international acclaim today, he often uses drama: theatre has played a strong role in his recovery and is an integral part of his resilience, along with cycling and running. He regularly advocates spending time in nature and keeping a gratitude diary.
His strong faith has also been central to his recovery and his resilience.
‘As a practising Muslim, I’m constantly reminded of the fragility of life. Life is so short
but it’s precious.’
He has his detractors and doubters. Some on social media have accused him of ‘toxic positivity’. Others, including fellow psychiatrists, have alleged ‘fabrication’.
But he’s also won several awards including, last year, a WHO Director-General Award for Global Health and The Sun’s Caroline Flack Mental Health Hero Award.
It’s been a journey – and he’s still on it.
‘People might only get a snapshot of me because now life is beautiful. I’m extremely blessed and I’m grateful. But this didn’t come easy: I had to work bloody hard. But as they say in The Shawshank Redemption, “I’d rather be busy living than busy dying.” Do we want to wallow in self-pity?’
Though his past is still present, he’s determined to face forward and help others do the same.
‘In Lebanon last [month], I saw a young child begging for anti-epileptic drugs for his sister.
‘Oh, my goodness. Let’s be grateful, not bitter. Let’s learn and share and grow and be positive. There are so many reasons to stay alive and to choose life.’
‘I’m constantly reminded of the fragility of life. Life is so short but it’s precious’
ALWAN: Anxiety led to illness
‘The future of general practice hangs on a precipice,’ says Gareth Oelmann, chair of the BMA Cymru Wales GPs committee.
‘Unless urgent action is taken to address workload, workforce and wellbeing, the service is at risk. This crisis should be a concern to us all.’
Warnings about the worsening state of general practice have been stark for some time, but a new campaign by BMA Cymru Wales, Save Our Surgeries, lays bare the situation with hard data and personal testimony from GPs – while offering a practical rescue package for doctors and patients.
The pressure on Suhair Alwan as a GP partner in Wrexham was so much that she ended up in hospital for 10 days with sepsis, after her 14-year-old daughter called her an ambulance.
‘The lack of sleep, the stress and anxiety and not looking after myself made me become very unwell,’ she says of the effect of an unmanageable workload, continuous interruptions, and the toll of taking sole responsibility for the surgery’s patients.
On her return to work, ‘nothing changed’ and the burden of undertaking 34 consultations a day – as well as making clinical decisions for those who had been seen by non-GP colleagues – was ‘completely exhausting’ and ‘unsustainable’.
‘I would go home and could not speak because I was so tired,’ she recalls. ‘I’d feel constantly tortured by my thoughts… had I made the right call in such a brief period? Did I have all the available information? This level of stress took a terrible toll on my mental health, I didn’t have any energy to see friends and family, and this left me feeling more anxious and lonelier. It’s no way to live.’
Dr Alwan now works as a locum GP. The anxiety returns if she works long hours – and she acknowledges
the effect on her family: ‘It upsets me to think [my daughter] also carries the burden of worry caused by my job.’
BMA Cymru Wales’ latest survey asked GPs to rate their average weekly workload on a scale of 0-100, with zero representing ‘manageable’ and 100 ‘constantly excessive’. The average response was 76/100.
Dr Alwan notes the constant interruptions she faced as a partner in a multidisciplinary team which, despite additional staff, ‘ironically ends up causing more work for GPs who are often the only ones qualified to make clinical decisions’.
Natasha Collins also moved to being a locum after nearly five years as a GP partner in South Wales. Persistent recruitment challenges amid growing demand meant: ‘We found ourselves working above our contracted hours to ensure administration work was completed so we could focus on urgent and routine patient requests.’
In March 2022, the departure of a salaried colleague left Dr Collins looking after 6,700 patients alongside one six-session GP, a nurse practitioner, prescribing pharmacist and the nursing team.
The salaried GP leaving ‘tipped us over the threshold’, she says. ‘There was no contingency left for leave or illness. I was missing events such as my fiveyear-old’s first school sports day.
‘While I felt experienced in managing a high workload, the days were incredibly long. I’d leave my practice at the end of the day, get my three children to bed then work again right up until midnight and beyond each night.
‘To live with that level of pressure day-in, day-out takes a toll, and you worry about patient safety; we know tired doctors are more likely to make mistakes. It was
‘The lack of sleep, the stress and anxiety and not looking after myself made me become very unwell’
unsafe and unsustainable.’
More than 80 per cent of GPs surveyed by BMA Cymru Wales fear they are unable to provide quality and safe care to patients owing to excessive workloads, a diminishing workforce, and rising demands.
Sue Fish, the only partner at a 2,700-patient practice in Ceredigion in rural west Wales, says: ‘I get in at 9am every day and work until 7pm, and on weekends to keep up with paperwork. We can’t provide high-quality care like this.’ Her former partner retired in May, and while she has recruited two salaried GPs to start soon, Dr Fish says she will hand her contract back by August next year, ahead of her 60th birthday, if conditions in general practice are not addressed by then.
‘GP staff worked right the way through the pandemic. We faced all the different challenges thrown at us, and we’ve gone straight from that to being excessively busy every day,’ she says. ‘Over the last 12 months I’ve had one day where I’m not committed to the surgery. I’m tired and worn out and while not completely burnt out I’m heading in that direction. Hopefully by October I’ll feel different, but there’s no long-term solution.’
Dr Fish is fearful of retaining her recruits long-term because of the practice’s rural location and a lack of appetite among GPs for becoming partners. If no new partner comes forward, the practice is likely to dissolve, forcing its patients to travel to nearby towns to see a doctor. The knock-on effect would mean: ‘Those practices wouldn’t be able to cope. There wouldn’t be enough GPs to supervise all the staff. And there wouldn’t be the space.’
The BMA report shows a deficit of 664 GPs in Wales compared with the average among OECD countries, following 84 surgery closures in the last decade. It has
left patients in Wales with 18 per cent fewer practices available, a drop from 470 to 386, as GPs take on 32 per cent more patients each (an average of 2,210 patients per full-time equivalent GP, up from 1,675) resulting in an average list size in Wales of 8,378 patients, up 23.5 per cent from 6,780.
Of the 2,324 GPs working in Wales, only 1,445 are working full-time – many have chosen to reduce their hours because of the excessive demands of the role and its effect on doctors’ wellbeing. Between them, in 2022-23, GPs in Wales have taken 27 million telephone contacts, offered 19 million appointments, issued 56 million prescription items, made 1.3 million referrals to secondary care and issued more than 500,000 fit notes.
More than a quarter (26.6 per cent) of GPs plan to leave the profession in the near future, according to the survey, while only half of partners see themselves remaining in their positions in three years’ time.
Dr Collins says closing her practice has been ‘destabilising’ for patients who now miss out on continuity of care. ‘My plan was to stay at the practice until I retired,’ she adds. ‘I was sad to leave.’
As chair of her local medical committee, she reports witnessing the pressure piling on GPs across the practices she now works at, partly driven by long waits at hospitals.
Dr Collins says at least 10 per cent of interactions are patients returning to GPs with deteriorating conditions while they wait for hospital treatment, with some of her colleagues saying this can account for up to 25 per cent per session.
Dr Fish adds: ‘Patients are just sitting on waiting
‘To live with that level of pressure day-in, day-out takes a toll, and you worry about patient safety’
‘Listen to our grave concerns and step in and save the service from collapse’
lists. Quite often we can’t do anything, for example if somebody’s got a deteriorating joint that needs replacing, or we end up managing conditions we’re not qualified to manage, like deteriorating neurological conditions, because waiting lists are so long.’
The survey found an overspend of almost £11m on managed practices by health boards, some of which overspent by 80 per cent.
Dr Fish says one of the recruitment challenges for partners has been competing with the salaries offered by managed practices. ‘We haven’t necessarily got the money to pay for all these people,’ she says. ‘And none of them want to be a partner.’
Between 2018/19 and 2022/23, 38 GP practices in Wales have handed back their general medical services contracts.
Dr Collins believes the partnership model ‘can thrive again’ if given ‘the right resources and more investment’. That would include doing more to incentivise doctors to stay in Wales and to take up partnerships.
The Save Our Surgeries campaign, launched on 28 June, offers a plan to save general practice in Wales. There are four key recommendations.
First is a commitment to funding general practice properly by restoring the proportion of the NHS Wales budget spent in general practice to the historic level of 8.7 per cent within three years, with an aspiration to increase to nearer 11 per cent in the next fi ve years.
Next is investing in the general practice workforce to allow the implementation of a national standard for a maximum number of patients that GPs can deal with to maintain a safe and high-quality service.
It urges the Welsh Government to produce a workforce strategy to ensure Wales trains, recruits, and retains enough GPs to move toward the OECD average, tackling the problems driving them away. Finally, the campaign calls for staff wellbeing to be addressed by producing a long-term strategy to improve the physical, mental, and emotional wellbeing of the workforce.
Dr Oelmann says the campaign’s launch was ‘a defining moment for general practice in Wales’ and that the campaign offers ‘a final plea to those in power to listen to our grave concerns and to step in and save the service from collapse’. It is the last chance for revival, he says, but: ‘With the correct level of support, general practice can thrive again, ensuring the family doctor’s role in the care of future generations.’
bma.org.uk/Wales-save-our-surgeries
‘With the correct level of support, general practice can thrive again’FISH: Intense pressure Images from the Save Our Surgeries campaign
One of the benefits of a long career is the ability to look back and reflect on just how far you’ve come.
Yorkshire GP Hanume Thimmegowda is able to look back further than most. Now in his 80s, Dr Thimmegowda has recently celebrated 50 years of working in the NHS, a calling that he still feels immense passion for.
‘My practice manager always asks me, “are you going to drop dead in your practice?”,’ jokes Dr Thimmegowda, who has worked as a family GP in Dewsbury for the past 43 years.
‘My health is good, so I
want to carry on. Maybe in a couple of years I’ll think it [retirement] over.’
Dr Thimmegowda’s journey towards five decades in the NHS began in the village of Maragowdanahalli in southern India, where Dr Thimmegowda was born shortly before the Second World War.
The son of farmers and the youngest of 10 children, Dr Thimmegowda did not have the easiest of starts in life, losing his father at such a young age that he has no memory of him. Despite his agricultural upbringing, Dr Thimmegowda’s family
‘At that time, as a young doctor, I had an adventurous spirit and wished to travel’
was eager he and his siblings receive an education. While his brothers found they were not academically inclined, Dr Thimmegowda thrived at his local school. Having initially wanted to pursue a career as an engineer, he was persuaded by a school friend to study medicine and, in Dr Thimmegowda’s words, ‘never looked back’.
After being accepted at Bangalore medical school and gaining his primary medical qualification,
A GP who has served the NHS for 50 years reflects on how his career progressed and how he has served the community he lives in.THIMMEGOWDA : Now and then (right)
he went on to complete postgraduate studies.
It was not long, however, before Dr Thimmegowda felt the desire to practise medicine overseas, with the UK holding a particular fascination.
‘At that time [as a young doctor] I had an adventurous spirit and wished to travel,’ explains Dr Thimmegowda.
‘All the medical books at university were written by English authors and would have place names stamped in them like Guy’s Hospital and Hammersmith Hospital. I wanted to see these places for myself.’
After applying directly to a number of health service posts, Dr Thimmegowda found himself receiving an invitation from Newcastle General Hospital offering him just a one-month placement in the NHS.
Arriving in the UK for the very first time in his life in April 1973, Dr Thimmegowda completed his stint in Newcastle before quickly landing another hospital job, this time at Castle Hill Hospital in Hull.
One thing that quickly impressed itself upon him was the NHS and principles of universal healthcare free at the point of access that it had been founded upon.
‘The NHS was something of a surprise to me,’ he recalls. ‘I didn’t realise when I was in India that the NHS was free for everybody.’
After spending the rest of the 1970s working in various hospitals across Yorkshire, Dr Thimmegowda decided he wanted to change direction in his career and become a GP.
Completing his general
bma.org.uk/thedoctor
practice training in May 1980, he was offered and took a job at a practice in Dewsbury, West Yorkshire, becoming a partner after just one year.
As the years passed, Dr Thimmegowda found himself working as a singlehanded GP but nonetheless broadened his portfolio by founding a new purposebuilt surgery for his local community.
Today Dr Thimmegowda is a senior partner at the Albion Mount Medical Practice in Dewsbury and at Mountain Road Surgery in neighbouring Thornhill, and still works five GP sessions a week.
Over his 50-year medical career, Dr Thimmegowda was also able to pursue other vocations and interests, serving for many years as a Labour councillor at his local authority and being a Rotary Club member.
He has also sought to raise funds for a range of charities including Water Aid and Macmillan Cancer Support
nurses as well as for the diabetic centre at Dewsbury and District Hospital, by partaking in events such as the Great North Run and London marathon.
Alongside his career and other commitments, Dr Thimmegowda helped to raise a family and is now the father to five sons and has nine grandchildren, with two of his sons now consultants and one of his grandsons studying medicine at Cambridge.
Dr Thimmegowda also maintained a close connection with his family and local community back in Maragowdanahalli, ultimately setting up a scholarship to help generations of children in his old village to go to school or university as well as a community centre and a temple.
In recognition of his five decades in the NHS, Dr Thimmegowda’s local community held a celebratory dinner in honour of his achievements at Dewsbury Town Hall last May.
‘I didn’t realise when I was in India that the NHS was free for everybody’Press cuttings display Dr Thimmegowda’s achievements
It was my absolute pleasure to chair this year’s BMA annual representative meeting, which took place in Liverpool last week – with my primary responsibility being to ensure your representatives were as best informed as possible on all the issues being debated and to ensure their voice was amplified and heard.
The ARM is the most significant policy-making event in the association’s calendar – and was, arguably, more important than ever as our profession and our NHS face up to times of unprecedented change and challenge.
At this year’s event many of the biggest issues of the day were discussed and confronted and, together, we formed policy that will guide doctors’ representatives and influence government decisions and societal progress.
From the workforce crisis to a demand for change from our regulator and from artificial intelligence to e-cigarettes we united to ensure we can influence debate and discourse as the incredibly powerful voice of doctors that we are.
When I stood as deputy chair of the representative body in 2019 I was elected on a manifesto of challenge, change and communication. This year’s ARM was, I hope, a demonstration of how we are addressing and achieving exactly those three things. This was our most inclusive ARM to date – with a hybrid system and fundamental changes to the in-person conference ensuring accessibility and inclusion were the foremost values at the heart of everything we did.
The 2023 ARM was the first to include 83 new seats made available to doctors via the BMA divisions focused particularly on new attendees. And, during the meeting, we made every effort to communicate as clearly as possible – including in some moments moving away
from traditional processes to ensure the representative body was as well informed as possible. One example of this was in a debate about the BMA’s resolutions process in which I empowered the representative body to vote on whether they wanted to hear the views and insight of Emma Runswick, our chief officer lead for the process.
Unfortunately, I did have to remind the body and our wider membership of our behaviour principles. I remind you again – debate is healthy, debate is welcome. But we do not single out and target those who share their opposing views at ARM. Do that and you will destroy the very democracy ARM is built on.
For me, the overwhelming message we should take away from this meeting is that, despite the huge challenge and change we all face, there is also so much for us to be optimistic about. Our profession, united, can be an unparalleled advocate for ourselves, for patients and for the NHS. We showed that over three days in Liverpool and we have shown that during the industrial action of recent months. I hope we can continue to thrive, unified, through the challenge and change ahead.
Our closing thoughts were with Anthea Mowat and her family. Anthea, who chaired the representative body from 2016 to 2019, was diagnosed with cancer earlier this year and was too unwell to join us. We thank her for the great changes she imprinted on the BMA and all that she stands for.
Dr Latifa Patel is chair of the BMA representative body
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: Jess Hurd
Read more from The Doctor online at bma.org.uk/thedoctor
The recent BMA annual representative meeting was the most inclusive we have ever held
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