The Doctor – issue 63, January 2024 by The BMA

The magazine for BMA members

thedoctor

Issue 63

January 2024

THE EXAM QUESTION Why are doctors having to stump up thousands for their own training?

Crisis and creativity

Innovation against the odds

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The pioneer

An interview with Sir Magdi Yacoub

Help them help us

Refugee doctors in need of support

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JESS HURD

In this issue 3

At a glance Junior doctors call for a ‘credible’ oﬀer

4-9 The exam question When it’s mandatory to take postgraduate exams, why do doctors bear the cost?

10-11 Language barrier A doctor from Afghanistan struggles to get the support needed to work

12-15 Innovation in the face of crisis

GPs improve care for their patients despite working under great pressure

16-17 On a mission The charity which helped some of the earliest women become doctors, 180 years on

18-21 Never miss a beat An interview with Professor Sir Magdi Yacoub

22-23 Your BMA Why diversity of views is a sign of strength

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Welcome Phil Banfield, BMA council chair This first issue of The Doctor in 2024 comes just after junior doctors in England have successfully completed the longest single industrial action in NHS history, as the UK Government once again failed to present a credible offer. I do not underestimate just how exhausting this has been. Our deepest gratitude extends to everyone, especially consultants, staff, associate specialist and specialty doctors and the many others supporting junior doctors in their pursuit of restoring the value of our profession. BMA junior doctors committee co-chair Rob Laurenson speaks for thousands of colleagues when he asks why the health secretary ‘doesn’t sit and work in collaboration with us to find a negotiated settlement?’ The Government is doing needless harm with its intransigence. Junior doctors have to spend a large chunk of their diminished salaries on postgraduate training and exams, even though passing is a vital part of career progression when demonstrating skills and qualifications. We speak to doctors facing crippling costs, underlining the BMA’s call for employers to foot the bill for mandatory exams, as other employers do in comparable professions. As a doctor, I’m not the least bit surprised our profession continues to innovate even in the most difficult circumstances. We profile a GP practice that has expanded to improve access for patients, and another which has joined forces with its neighbours to offer a wider range of services. There is so much more general practice could do with proper funding, and also a more imaginative approach from commissioners who, in the words of one GP, can be ‘fixated on what has been done before, which, to be honest, hasn’t worked terribly well’. Speaking of innovation, we have an interview with one of the most famous doctors in the world, Professor Sir Magdi Yacoub. He refers poetically to the ancient Egyptian goddess of truth, Maat: ‘If you came near her, she grew huge wings and flew away. So, you have to keep running after truth.’ His insatiable urge to discover, experiment and improve continues at the age of 88. We also have a piece on EMMS, a remarkable and longstanding charity which enabled the training of some of the first women in the UK to qualify as doctors in the 19th century and continues to improve life chances around the world. These are particularly difficult times in what will be a challenging year. I wish you all the best in your endeavours. The Doctor won a prestigious British Journalism Award last month, as it continues to represent you and champion your cause. Keep in touch with the BMA online at twitter.com/TheBMA

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AT A GLANCE SARAH TURTON PUSHING ON: Junior doctors outside St Thomas’ Hospital

Doctors call for ‘credible’ offer

unior doctors in England have vowed to strike for as long as it takes to secure a credible pay deal from the Government as they staged the longest industrial action in NHS history. Doctors walked out for 144 hours from 7am on 3 January to 7am on 9 January, adding to 28 days of action in 2023. The BMA junior doctors committee insists the Government’s stance of not negotiating unless strikes are called off is unnecessary and has repeatedly said it is willing to talk at any time. When The Doctor went to press, health secretary Victoria Atkins was yet to make the ‘final offer’ she said she had up her sleeve after the mutually agreed deadline for talks in early December passed. The Government’s failure to make an offer JDC felt was credible enough to take to members by the pre-agreed deadline led to three strike days before Christmas as well as the January action. Despite being given notice Ms Atkins did not improve on her offer of an additional 3 per cent on top of the 6 per cent uplift and one-off lump sum the Government imposed on doctors in June. JDC said this would not be worth taking to members to vote on. Speaking to The Doctor at the picket line at St Thomas’ Hospital in London, JDC co-chair Rob Laurenson said: ‘If Victoria Atkins has another offer to make, it begs the question, “why doesn’t she make it?”. bma.org.uk/thedoctor

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‘Why let more strikes go on when she has had this offer ready? Why doesn’t she sit down and work in collaboration with us to find a negotiated settlement?’ He added: ‘Strike action is the only thing that works,’ noting how nurses have been given no further pay offers despite rejecting the 5 per cent that was imposed on them and calling off their strikes. In a statement with co-chair Vivek Trivedi, Dr Laurenson added: ‘Doctors want 2024 to be the start of a renewed workforce, which can finally provide high-quality care for patients again – it is for the Government to put forward a credible offer and facilitate that journey.’ Junior doctors in Wales began a 72-hour strike, their first action in the pay restoration campaign, on 15 January after 98 per cent of members voted in favour from a 65 per cent turnout. In Northern Ireland, a six-week industrial action ballot for junior doctors began on 8 January. A 24-hour strike from 7am on 6 March is planned if members vote in favour. Meanwhile, consultants in England continue to vote until 23 January in a referendum on their pay offer, which was put to members in November. If the offer is rejected, more strikes are expected after a re-ballot that closed in December saw 89 per cent of consultants vote in favour of extending their industrial action mandate for six more months. Staff, associate specialist and specialty doctors in England are to vote from 29 January in a referendum after receiving their pay offer from the Government. In Wales, consultants and SAS doctors will be balloted on whether to take industrial action from 22 January. thedoctor | January 2024

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THE EXAM QUESTION When it’s mandatory to take postgraduate exams, why does the cost fall on doctors already suffering from years of pay erosion? Ben Ireland reports

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‘O

ne day when I got home after a 13-hour shift in an intensive care unit and my meter said I had only spent 50p on electricity I noticed I was genuinely happy about that. It was because I had to pay for my exam the next month. ‘Then I stopped myself, and I thought “this is absolutely ridiculous”.’ Hampshire internal medicine trainee 2 Lucie Olivova gives a window into the financial pressures faced by doctors in specialty training – pressures which have only intensified through years of pay erosion and the cost-of-living crisis. It has long been the case doctors have had to pay for the privilege of progressing in their careers but Dr Olivova is among a growing group asking if it must. Mandatory costs also come in the form of medical royal college membership subscriptions, GMC fees and medical indemnity, but perhaps sting the most when it comes to specialty training. Fees, typically hundreds but up to thousands of pounds per exam, have remained stubbornly high despite doctors’ real-terms pay eroding for 15 years. In the meantime, other professional perks such as accommodation and car parking now come at a cost and student-loan debt has rocketed for recent graduates. With the cost of being a doctor – of going to work – biting a large hole in already meagre pay packets, the BMA passed policy at its annual representative meeting last year calling for mandatory fees to be reimbursed by employers, as they are in comparably highskilled professions. Dr Olivova, an IMG

(international medical graduate) from Czechia, training in dermatology, says she ‘just couldn’t understand’ why mandatory exams and portfolios are expected to be the financial responsibility of employees when they are essential to training for the roles employers need. ‘It’s not up to me whether I want to do an exam or not, it is a mandatory requirement of my programme – I don’t make the rules,’ she says. ‘I’ll fail my programme if I don’t do the exam. Plus, I have to study outside work hours. I shouldn’t have to pay for the extra work I need to do.’

‘Overwhelming’ costs Exam fees vary by specialty. Dr Olivova paid the Federation of Royal Colleges of Physicians £460 each for parts one and two of the MRCP(UK) and £657 for her PACES exam. Those costs are as well as portfolio fees of £516 to £860 a year. Once she completes her MRCP(UK) exams Dr Olivova faces another £700 to take an SCE (specialty certificate examination) in dermatology. Non-fellows must also pay £35 for their diploma to be delivered. And with low pass rates for specialty exams, many doctors face costs more than once if they take resits. All that is on top of medical royal college fees (£73 per year for IMTs such as Dr Olivova or £146 for specialty trainees), and £166 a year to retain a GMC licence to practise, plus medical indemnity which typically costs hundreds a year. For three years of training, exam costs alone will surpass £2,000. Payments cannot be spread using direct debits, but doctors can reclaim tax.

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‘I’m not able to save much because I have financial commitments back home, plus rent, electricity and other bills,’ says Dr Olivova, who notes other ‘unpredictable life expenses’ also crop up, such as car maintenance, which last year cost her £1,300. ‘Because I need to drive to work, I had to just deal with it. It was quite disheartening,’ she says. ‘Going through my [first two] exams, which were three months apart, I needed to spend my savings on exams, textbooks, question banks, and all those other costs. It was quite overwhelming.’ Oba Babs-Osibodu, co-chair of the BMA Welsh junior doctors committee, says that while most aspiring doctors are aware they must pay for postgraduate exams, the ‘ridiculously expensive’ costs ‘especially compared to pay’ do not become clear for many until they embark on specialty training programmes. Radiology specialty trainee 2 Dr Babs-Osibodu has completed the anatomy and physics exams for part 1 of his FRCR which cost him £319 each (RCR now quotes £357 to £389) and has booked part 2A at £478 (it can cost up to £521). Part 2B is priced at £669 to £728. To undertake specialist radiology training, candidates must be members of the RCR, which costs £299 a year as a trainee and includes access to an ePortfolio.

‘It’s not up to me whether I want to do an exam or not, it is a mandatory requirement of my programme’

OLIVOVA: Facing intense financial pressures

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BABS-OSIBODU: ‘There are always fees’

‘They should be trying to encourage and help my progression and training. It doesn’t feel like that’

‘It almost feels like blackmail. You either pay us or you’re out’ 06

‘It’s an onslaught,’ says Dr Babs-Osibodu. ‘There are always fees. When I became an ST2 I got a bit of pay increase. Then, when I was trying to get a bit more comfortable, I was hit with this massive cost. ‘When I’m paying for exams, I’m thinking, “how much money am I going to have left?”. ‘The people employing and training me shouldn’t be making life harder, they should be trying to encourage and help my progression and training. It doesn’t feel like that.’ Dr Babs-Osibodu contrasts the situation with friends working in other sectors: ‘Their employers are paying for them to go on courses and study for exams which are not even necessarily mandatory. They want to get the best out of their potential, whereas for us it almost feels like blackmail. It’s like, you either pay us or you’re out [of specialty training].’ London GP Gerard McHale retrained as a doctor after a career in accountancy and concurs with Dr Babs-Osibodu’s assessment. During his three-year postgraduate accountancy training, Dr McHale earned a master’s degree and became a chartered accountant. All exam costs were paid by his accountancy

firm and he was given paid study leave. His firm also paid membership of his professional body, the Institute of Chartered Accountants, the equivalent of covering a doctor’s GMC and medical royal college fees. By contrast, GP trainees pay £470 for their AKT (applied knowledge test) and, from 2023, £1,180 for the new SCA (simulated consultation assessment), which replaces the £1,076 RCA (recorded consultation assessment) that was brought in during COVID to offer a remote alternative to the CSA (clinical skills assessment), which had cost £1,352. If trainees join the Royal College of GPs as an AiT (associate in training), they don’t pay portfolio costs. Subscription costs are £423 a year if training full-time, plus a £291 registration fee (reduced to £73 at certain times of year). In the accountancy sector, it is ‘taken for granted’ that firms cover exam fees and professional development, says Dr McHale. ‘The rationale is that they get the benefit. As you get more experienced, you can do more. But that’s the same in healthcare; as you get more experienced you take on more responsibility and provide a higher level of care. The employer, in both cases, gets more from you, and to do more you need the extra training.’ Dr McHale says justification in medicine for asking employees to cover costs is often that doctors get paid more after completing specialty training. That means doctors are ‘paying for the privilege’, which ‘shouldn’t be the case’, while in professional services exam costs are seen as ‘part of the package’, he says.

Nottingham psychiatry trainee Alice Ogunji paid more than £500 to take her MRCPsych Paper A. At the first attempt, she missed out on a pass by 0.8 per cent, meaning she had to pay again to resit the exam, which she passed just before Christmas. The small margin for the first attempt was made even more frustrating because her preparation was interrupted when she received an email at 7pm the night before to tell her the exam had been moved to Derby from Nottingham, meaning she had to find – and pay for – a last-minute hotel. Core trainee 2 Dr Ogunji will have to pay £496 to take her MRCPsych Paper B and £1,096 for her CASC exam. They are the reduced fees she pays as a RCPsych pre-membership psychiatry trainee, which she pays £158 a year for. The latest pass rates for the MRCPsych Paper A were 62 per cent; Paper B had pass rates of 43 per cent; and the CASC 50 per cent. The MRCP Part 1 had three sittings in 2023, with pass rates ranging from 41 to 53 per cent; Part 2 ranged from 64 to 73 per cent; and PACES between 49 and 64 per cent. Dr Ogunji says the low pass rates indicate that exams are set at the wrong level. She has run ‘irrelevant’ sample questions past clinical supervisors, who she says rarely get many right. Dr Olivova agrees: ‘A lot of questions don’t seem relevant to the way we actually practise medicine. The questions are way too theoretical and often become completely unrealistic.’ She says this is ‘especially important in the context of today’, when debate rages about the regulation and pay

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levels of medical associate professionals, who are not trained to the same level as doctors but are increasingly reported to be taking on responsibility beyond their scope. Dr Olivova asks: ‘How are we putting doctors through exams so rigorous and theoretical that we have to spend hours of our free time every day for two to three months to prepare for them, to then go back to work and see that none of this knowledge seems to be relevant?’ Evidence also shows lower pass rates among international medical graduates, who make up an increasing proportion of the NHS’s medical workforce. The MRCP(UK) 2022 equality and diversity report shows 69 per cent of UKtrained doctors passed MRCP part 1, versus 51 per cent for IMGs. This was 78 vs 62 per cent for part 2, 69 vs 43 per cent for PACES and 73 vs 44 per cent for the SCA. RCGP results also vary in data based on exams taken since 2014. For the AKT, 83 per cent of UK graduates passed compared with 46 per cent of IMGs; in the CSA 90 per cent of UK graduates passed compared with 44 per cent of IMGs, and for the RCA this was 92 per cent against 50 per cent. Doctors were also more likely to pass if they are white than BAME (Black, Asian and minority ethnic), and if they are female.

that specialty exams are discriminatory, and that doctors sitting them face the ‘psychological harm of having to withdraw from family, friends and life’ to become ‘some kind of exam hermit for a year or more’. He says pass rates are ‘evidence of a suboptimal training system, a flawed assessment model or both’ and that the length of time doctors spend studying to try and pass is a ‘sad indictment’ of the system. Mr Fleming agrees ‘most consultants’ concede they would not pass the exam, especially the written components, without intense prolonged study and ‘even openly say things like “you learn it so you can forget it”.’ While he says medical royal colleges’ income from exams ‘cannot be ignored’, he notes the ‘narrative cuts both ways’ as those who design and run the exams ‘often do so in their own time, without remuneration or recognition’ and colleges set high standards for safety reasons.

Mr Fleming backs moving to a longitudinal programmatic system of regular ‘low- to medium-stake’ tests during training using a combination of more robustly done workplace assessment and potentially outside observation to create a ‘contextual, comprehensive and relevant’ postgraduate experience. ‘It is time for us to re-examine exams,’ he says. A motion passed at the BMA’s 2023 ARM in Liverpool acknowledged the financial burden of medical training on junior doctors, calling on the BMA to demand relevant bodies reimburse fees.

McHALE: Covering training costs is normal in many professions

‘Pass rates are evidence of a suboptimal training system, a flawed assessment model, or both’

What it might cost to train

Psychological harm Orthopaedic surgeon and hand and wrist surgery fellow Simon Fleming, who has a PhD in medical education, noted the ‘increasing evidence’ bma.org.uk/thedoctor

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r training in Example is for docto specialties var y der matolog y; other

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FLEMING: Doctors become ‘exam hermits’

‘If we are to truly address differential attainment, we need to focus on much wider factors than the examination’

It says the first attempts of any mandatory exams should be covered, along with any mandatory portfolio costs. For subsequent attempts, it asks for 50 per cent of the exam cost to be reimbursed. Dr Olivova, who wrote the motion with Dr Ogunji, said the ask is ‘realistic’ but says the ideal solution would be that doctors do not pay at all. Fees, she says, should be covered out of trusts’ study budgets, which HEE (Health Education England) recently agreed to fund centrally. However, current HEE guidance states that, while study budgets can cover

courses to help prepare doctors for post-graduate exams, they cannot cover exam costs, portfolios or medical royal college membership fees. HEE says changing this would be a decision for the Government’s Department of Health and Social Care. A spokesperson says the DHSC is ‘committed to ensuring that postgraduate doctors in training have the financial support they need’ and ‘continues to keep the impact of exam costs on those doctors under review’. Drs Olivova and Ogunji reported a ‘postcode lottery’ with current study budgets. Some trusts offer to pay doctors’ travel and accommodation costs when they’re sitting exams, but not all. They believe more doctors in specialty training would value spending the money on mandatory exams than non-essential career progression courses, which they suggest can be covered if any budget remains. Doctors also argue medical royal colleges could charge less

in exam fees, especially now many have moved online since COVID. But colleges insist they are not using exam fees as an income stream, and only charge enough to cover their costs.

Justifying costs The RCGP says it runs exams on a ‘cost-neutral basis over a three-year cycle’. It also publishes a breakdown of its topline costs, which stretch into the millions, and notes for example the expense of paying for locums to cover examiners (who are practising GPs). It says doctors no longer have to cover travel and accommodation costs for its now-remote SCA exam. It also notes the ‘financial hardship’ GP trainees experience in its 2022-23 exam costs explainer, adding: ‘The college should not use the MRCGP as a source of income to fund other college activity.’ Margaret Ikpoh, vice chair of the RCGP, says: ‘The purpose of the MRCGP assessment is to ensure patient safety and that GPs meet the standards necessary to practise

A recent report by the Academy of Medical Royal Colleges’ Trainee Doctors’ Group finds ‘significant financial pressures for trainees in terms of financing study materials, training and revision courses, and examination fees’. It says: ‘Examination fees in particular have been a perennial issue for doctors in training and with the UK in the midst of a cost-of-living crisis several trainees report they are unable to undertake these exams owing to financial pressures, inhibiting their progression.’ It adds that the number of trainees affected ‘is likely to increase, even after the cost-of-living crisis is over’ and this ‘puts increasing pressure on candidates which can impact both their wellbeing and even their examination success’. The report also notes ‘increasing numbers of trainees are choosing to leave their training pathways’ with financial pressures ‘one of the contributing factors’. It recommends government, statutory education bodies or other relevant organisations consider paying for the first attempt of such ‘high-stakes’ mandatory exams in the postgraduate medical specialty training pathway across specialties and that stakeholders ‘explore the use of the trainee study budget to fund examination fees’, and the potential of paying in instalments. And there is a precedent. In Wales, GP and psychiatry trainees have their first exam attempts paid for by the Welsh Government’s ‘Train.Work.Live’ scheme.

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schemes and has frozen trainee subscription fees for 2024. Dr Dave says the RCPsych ‘would welcome further discussion on whether NHS organisations or health education bodies could use their allocated funds for training to pay for trainees’ exams’. The Federation of Royal Colleges of Physicians has held fees for its exams for seven years and says income is used to cover costs such as clinicians’ time for setting questions, quality assurance, reviewing outcomes, facilities, IT and improvements. It says it ‘would be happy to be involved in any discussions’ about how doctors can be supported with their postgraduate exam fees. The federation said all MRCP(UK) examinations are set using internationally accepted methodology, ‘with preservation of patient safety central’ and that the ‘phenomenon’ of differential attainment is present across all postgraduate medicine examinations. It makes its pass rates public and shares its equality, diversity and inclusion action plan online. The RCR says its exam fees have not even covered its own costs in recent years and it ‘regularly reviews’ pass rates and curriculum. ‘Our exams are challenging but no more challenging than they need to be,’ a spokesperson says. ‘We continue to review and improve the delivery of our exams to ensure value for members and maintain high professional standards.’ The GMC’s 2023 workforce report found a growing proportion of doctors taking an increasing amount of time away

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SARAH TURTON

independently and safely as GPs in the UK.’ A 2013 judicial review of the MRCGP exam found it was ‘lawful and fair’ and a 2017 independent review of the then-CSA and AKT said they were fit for purpose. Dr Ikpoh says the college ‘has always been transparent about differential pass rates’ and is ‘committed to identifying and addressing the underlying issues’, adding: ‘If we are to truly address differential attainment, we need to focus on much wider factors than the examination.’ The RCPsych breaks down its costs on its website, up to 2021, and says exams would be hundreds of pounds more if they had been pegged to consumer prices index inflation between 2012 and 2021. In that nine-year period, they dropped by more than £300 but have since returned to 2012 levels. It says fees ‘should not be set to generate significant surpluses’ and any surplus of more than 10 per cent will be diverted into its trainees fund. RCPsych Dean Subodh Dave says ‘rigorous quality assurance’ ensures ‘exam questions are meticulously reviewed and discussed for fairness, reliability and validity’ and that measures including accessible use of language and diversity on panels protects candidates against ‘any risk of bias’. He says the college understands ‘the economic outlook is difficult right now’ adding that exam fees are ‘regularly reviewed’ to make them ‘more manageable’ – but warned funding first attempts could create additional costs for other members. The college offers bursaries and award

from training after foundation year 2. The main reasons cited include readdressing work-life balance, preventing burnout and taking a break from exams and portfolio work.

OGUNJI: Exam location changed the night before

Social contract ‘broken’ Dr McHale believes the debate ‘comes down to how much you value your employees’ and says covering mandatory training costs has ‘been customary in many other professions for 20 to 30 years’. Dr Olivova says exam costs, in the context of pay erosion, is ‘another example of the social contract we signed up to when we went into medicine being broken’. She says when she questioned the system she received a ‘long and very well-written email’ reply from her programme director who ‘basically said, “it is what it is and it’s the same everywhere”. ‘This is one of those conversations you have in doctors’ messes over and over and everybody keeps saying “it’s stupid, it’s ridiculous” but also end with “it is what it is”. ‘I really don’t think we should accept that.’

‘The programme director basically said “it is what it is”’

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SAFE HAVEN: Dr Yousafzai found the security he needed in the UK but the learning support was limited

Language D BARRIER Refugee doctors come from around the world to the UK seeking sanctuary and, while many find safety, some struggle to access the guidance and support needed to help them return to medicine. Tim Tonkin hears one doctor’s story 10

r Yousafzai remembers why he wanted to become a doctor. Born in Afghanistan in the early 1970s and growing up amid the chaos of the Soviet-Afghan war, Dr Yousafzai recognised medicine as his calling from an early age. ‘People’s health is always the first priority of a society,’ he says. ‘For this reason, it was always my first choice when I was a child to become a doctor.’ Born and raised in Kabul, Dr Yousafzai’s family placed great value on education, with he and his siblings all pursuing careers in either engineering, law or medicine. After completing his medical qualification in 1997, Dr Yousafzai had been a doctor for just five years at the time of the US-led invasion to remove the Taliban. He went on to spend time in the USA as part of a medical fellowship programme, before returning to the country of his birth. It was in large part the scale of traumatic injuries inflicted on ordinary Afghans that led to Dr Yousafzai specialising as an orthopaedic surgeon, and to him volunteering for Sandy Gall’s Afghanistan Appeal, which seeks to help those who had been left physically or

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‘COUNTRY OF WAR’: Tanks engaged in military conflict in Afghanistan

mentally disabled by armed conflict. ‘Afghanistan is a country of war,’ he says. ‘We have many patients who have had amputations or who suffer with PTSD as well as other serious health problems like polio and TB.’

Cold weather and warm tea

in Afghanistan, Dr Yousafzai became increasingly despondent at his lack of progress. It was only after befriending a retired GP in his area that he began to gain advice on what kind of support he was entitled to and how he could access it. This included joining the BMA and receiving copies of the BMJ, something Dr Yousafzai says helped to enhance his command of English medical terms.

Dr Yousafzai was one of countless Afghans who had to flee their homes and seek refuge abroad after the Taliban once again seized power. Source of support Forced to leave everything behind, Dr Yousafzai A recognition of the need to provide greater support arrived in the UK in early 2022, where he and his fellow to doctors seeking sanctuary in the UK led the BMA in Afghans were met with bitterly cold weather but also 2019 to launch its refugee doctor initiative. warm tea and an even warmer welcome. The scheme provides a range of support including As with all international medical graduates, free access to the association’s confidential refugee doctors who wish to practise medicine counselling service, the BMA library and assistance must meet several requirements demonstrating from the BMA international department. their clinical knowledge and skills and proficiency Almost two years on from starting his life in the in English. UK, Dr Yousafzai is slowly realising his ambitions Language assessments having joined a clinical take the form of the observership role at his ‘I have 20 years of experience in war local hospital in Essex, International English surgery and orthopaedic trauma’ Language Testing System or something he says has the English Language Test for been invaluable in providing Healthcare Professionals. insights into life in the NHS. After securing refugee status, and eventually He continues, however, to advocate for relocating to the east of England, Dr Yousafzai hoped refugee doctors, having recently spoken about he would be supported in gaining the qualifications his experiences and what changes could be made necessary for him to work in the NHS. to support people such as him into returning to He found the resources, particularly for attaining the medical practice, at an event hosted by Anglia required standards in English, limited. Ruskin University. ‘When I checked the requirement for GMC ‘My aspiration and my hope are to work as an registration, the English language was the first priority orthopaedic surgeon in the NHS and share my and my level of English wasn’t enough,’ he says. experience, because I have 20 years of experience in ‘I tried to start a course but was just offered English war surgery and orthopaedic trauma,’ he says. ‘I don’t want to lose all this experience just because for Speakers of Other Languages, which isn’t suitable as of a language barrier.’ a course for a doctor needing advanced English.’ To find out more about the BMA refugee doctor Eager to work to exercise his medical vocation and initiative, go to bma.org.uk/refugee-doctors to help provide for family members who have remained bma.org.uk/thedoctor

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BMA

CREATIVE: GPs have been finding new ways of delivering care

INNOVATION IN THE FACE OF CRISIS Despite facing unprecedented pressure, there are striking examples of general practice adapting and improving patient care. Jennifer Trueland reports

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BRAMALL-STAINER: We need resources, contractual flexibility, and political will

ew would deny (governments apart) that general practice is as a sector of the NHS, and how innovative practice is in crisis. Yet despite problems with a rising GPs and their teams can be given the right workload, recruitment and retention, and resources, circumstances – evolving in different ways to deliver there are inspiring examples of innovation in general high-quality care and attract and retain staff. practice which are making a huge difference to patients, ‘There’s only so much that GPs on the ground can GPs – and the health and care service as a whole. do, which is why we desperately need the Government Some of these are showcased in a new publication to properly invest in our profession. The imagination from the BMA. Exploring Innovation in General Practice and the willingness to find solutions to the current GP highlights eight GP providers who are innovating crisis are already present in the workforce – what is with different models. It needed is the resources, the includes descriptions of contractual flexibility, and the innovations such as personal political will to make them a ‘Our strength lies in our plurality lists, working at scale, widespread reality.’ and our versatility’ employee ownership, direct Faversham Medical management, and chronic Practice in Kent has radically disease-focused care. bettered the range of health services available locally – ‘It’s so important to showcase examples of vastly improving access for patients, as well as creating innovation and creativity that exist in general practice, a more dynamic and exciting environment for doctors when GPs and their teams are given the resources and other health professionals. and autonomy to make decisions in the interests of their patients,’ says BMA GPs committee England chair Expanding services Katie Bramall-Stainer. Gaurav Gupta, a GP partner at Faversham Medical ‘Our strength lies in our plurality and versatility. Practice, and BMA GPC member for Kent, explains There isn’t a one-size-fits-all solution, just like that it’s not always been an easy process – but that he there isn’t a one-size-fits-all doctor or patient. believes the future is local. These examples might spark a thought or start a ‘We’ve been working on expanding the services in conversation. Take from them what you need; they’re our community for more than a decade now. For a long not intended to be an instruction manual. time, services were being taken away from the town. ‘What we are saying is how productive general The local hospital trust had reduced the number of

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GUPTA: Positive feedback from patients

people away from busy hospital emergency departments, for example. The approach has had a positive impact on recruitment and retention, says Dr Gupta. ‘We are very fortunate because people want to come and work with our team. We routinely get approached by specialists and staff who want to work here – it’s never a dull place.’ Although it’s a great example of innovation in general practice, it hasn’t always been easy to achieve, says Dr Gupta. ‘The regulatory and procurement processes don’t make it easy for these kinds of innovative things to be done. One thing that would help this model flourish across the whole country is if the commissioners – NHS England and the integrated care boards – were more open to innovative ideas and not so fixated on what has been done before, which, to be honest, hasn’t worked terribly well.’ The future, he says, is more community-based services closer to patients and run by local stakeholders – but it also requires perseverance. ‘You have to keep going at it. We do all these things, and they’re lovely, and they’re creating a lot of interest now, but it’s taken us 15 years to get here. It’s hard work, but when you do get to where we are, and are providing the services, it’s very rewarding, so don’t give up.’

outpatient clinics they were running, and we had a minor injuries unit which was under threat of closure. It would have been difficult for our patients to access services, so as a practice we decided to try and do something to save these services and bring more things into the town.’ The practice has a list of around 14,000, served by six GP partners and five salaried GPs. In 2014, it took over the minor injuries unit and it has now been upgraded to an urgent treatment centre. The practice also provides outpatient clinics. ‘We provide services to help ease Working at scale elective care pressures in the local hospital trusts, for Herefordshire General Practice (formerly Taurus Health) example, hand surgery clinics and we have recently is a GP federation in Herefordshire, working across started providing a full range of community eye the county to deliver patient services directly and to services, like cataract surgery and wet AMD injections. support local GP practices and networks. We also provide X-ray services This includes providing in collaboration with the local ‘When you do get to out-of-hours services for all hospital trust.’ practices in Herefordshire as where we are, and are Patients love it, he says. well as HR and BI (business providing the services, it’s ‘All of these services have intelligence) support. very rewarding’ been very, very popular and Nigel Fraser, a GP partner very well received. We get a lot of positive feedback, at Wargrave House Surgery in Hereford, is co-founder because for a lot of these things, if we didn’t do them, and chair of the federation, and explains it came about patients would have to travel quite a long distance to initially because of an idea from the LMC. get the services.’ ‘It was really to enable the practices to come GPs appreciate it too, he adds. ‘It’s great for together to tender for contracts under the Health and everybody, because patients get a local, quick service. Social Care Act, which had just come in. We thought we For us, it’s much easier to get diagnostics done quickly, collectively could work and deliver on these contracts and we can access specialist advice from those who better than if we tried to do it individually. are working around us. We’ve had instances where ‘We were also one of the prime minister’s challenge fund sites and developed a lot of the work around someone is very unwell and we’ve been able to get an enhanced access. As time has gone on, we’ve taken X-ray immediately and get them admitted to hospital, over the out-of-hours contract, so we provide 24/7 so it helps everybody.’ general practice. This is something that would be too It also helps the wider health and care system, he much for individual practices, but collectively, we’re adds, because the urgent treatment centre keeps 14

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able to deliver integrated out-of-hospital care.’ This approach is good for patients and FRASER: Able to recruit and good for GPs, he says, because essentially innovate the GPs working out-of-hours consider themselves ‘locums’ to each patient’s practice. ‘They do things like referrals, and acting on scans – things that traditional out-of-hours services wouldn’t do. There’s a proper hand-off.’ The federation, which collectively covers 190,000 patients, has developed over the last decade, says Dr Fraser. ‘The key to operating at scale is to continually reinvent yourself and make sure you’re still fit for purpose. We can do population health management at scale, collectively, and that makes great sense.’ Being able to harness the information from business intelligence tools is beneficial to individual practices as well as to the county as a whole. Creating and tracking data about what is going out. But from a contractual point of view, happening in the out-of-hospital environment is a huge the partnership model is strengthened because it resource with many practical applications. can exist, and we can provide the other functions ‘As an example, during and after COVID we had a that the system needs.’ surge of phlebotomy being pushed into practices with Recruitment and retention no extra resource. But we ‘We thought we collectively is good in Herefordshire, were able to ask the hospital although he isn’t complacent. to identify its phlebotomy could work and deliver ‘I think we probably have budget and put it into a joint on contracts better than if we tried more doctors per head of budget with us, so as the work to do it individually’ population than anywhere has come across [to general practice] our share of that budget increases. You’re able else in the country, but we know that the whole system nationally is creaking because of workload. We also have to bring the resource with the work if you’ve got the a workforce demographic that’s about to retire. data and it can be trusted.’ ‘I don’t think the picture is rosy anywhere, but there The federation has also repurposed some of the are things that we’ve done that have helped us recruit budget for health checks so that it can reach out to where traditionally, some places wouldn’t be able to.’ people who in the usual run of things wouldn’t come This includes a virtual GP service provided to patients forward for their check. across Herefordshire – but the GPs don’t necessarily ‘It’s for reducing health inequalities, really,’ he says, have to be based in the county to work for it. explaining that in the first month, several homeless ‘We’re quite a rural area people were registered with a dispersed population, with practices and had ‘There are things that we’ve but the things that can be their health checks done. done that have helped us recruit done on the phone are done ‘It’s small numbers, but it’s where traditionally, some places on the phone to reduce powerful in terms of reducing wouldn’t be able to’ people’s need to travel. And health inequalities.’ this also means we can flex resources around practices.’ Practices in Herefordshire are some of the best Herefordshire is a good place to do general performing in the country, he says, adding that he practice, he says, because it encourages innovation. believes the federation supports the independent ‘Everybody who goes into medicine wants to make contractor model. ‘A few years ago, people were a difference, and it’s really empowering if you are able thinking that the GMS contract wasn’t fit for purpose to work with colleagues to deliver things in a new way. because you couldn’t do these other “bits”. If you’ve got good people around you, and support to ‘But our model is that we are a collaborative – change and do things differently, then it’s definitely our practices are our own, but we come together empowering rather than just trying to survive.’ as Hereford General Practice, and have one voice bma.org.uk/thedoctor

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EMMS

A charity which helped some of the earliest women to qualify as doctors continues to improve life chances around the world. Jennifer Trueland reports

On a mission

hen a group of public-spirited individuals met in Edinburgh’s New Town in 1841, they could have had no idea of the far-reaching effects they would have. They founded what was to become the Edinburgh Medical Mission Society (now known as EMMS International) credited with being the first medical missionary society, and believed to be Scotland’s longest-serving healthcare charity. Today, after more than 180 years of continuous service, the charity remains dedicated not only to improving healthcare in some of the world’s hardest to reach populations, but also to supporting women in these communities to gain healthcare qualifications, improving their prospects, reducing gender inequalities – and making a real difference 16

‘The poorest people who have life-limiting conditions have access to barely any drugs’

HELP AT HAND: Healthcare workers in Nepal provide palliative care

to patients on the ground. The charity, which for more than a century has been supporting women to have careers in medicine, including some of the earliest women to qualify as doctors, began closer to home, with a dispensary in Edinburgh’s Cowgate, explains EMMS International CEO Cathy Ratcliff. ‘For many years, EMMS operated as a society that would send missionaries, but also train doctors by sponsoring people through medical education. The dispensary in Cowgate had the dual role of helping people of extremely low income during the industrial revolution, and of training doctors – including women – who went overseas to do missionary work.’

Palliative care focus Today the charity has moved away from its original ‘mission’

purpose and has programmes supporting healthcare projects among the most vulnerable and marginalised populations across the globe. It does this by working in partnership with organisations in the countries where it works, which currently includes India, Malawi, Nepal, and Rwanda. Improving access to palliative care is a particular priority, and the charity helps support local doctors and other healthcare workers by providing training and support with building capacity, for example, by creating links with governments. Helen Morrison, who until recently worked as a consultant in palliative care in Glasgow, is vice chair of EMMS International. Although palliative care was already a focus of EMMS when she joined the organisation, she is keen for it to remain a priority. ‘As someone who worked in the field, palliative care is very

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EMMS

RATCLIFF: Working with the most vulnerable

MORRISON: Keen for palliative care to remain a priority

important, and it’s something that’s still developing, even in the Western world. But in much of the world it’s in its infancy. ‘EMMS has been working in Malawi in particular for a long time in palliative care – to the extent that it’s now scoring very highly for it,’ she says. ‘But in countries like Nepal and African nations where we’re starting to work, the poorest people who have life-limiting conditions have access to barely any drugs – you can’t get morphine for patients.’ Palliative care isn’t just about dying well, she adds. ‘We’re also trying to help people with living, and that might be a period of days, weeks, months or even years. It’s about helping people with the chronic pain from conditions and all the social and psychological and emotional aspects that come with that.’

Closer to home As well as its international work, EMMS also remains loyal to its Edinburgh origins. The dispensary in Cowgate is long gone (although it was to inspire other home medical missions, including in Glasgow, Liverpool and London,

SHRESTHA: Leads on palliative care

according to its archive which is held by the Royal College of Surgeons of Edinburgh). The current project supports families living with dementia with a community lunch programme. ‘It’s for lowincome families because we only work with the most vulnerable,’ explains Dr Ratcliff. In addition to palliative care, the charity’s priorities include putting solar power into hospitals – something increasingly crucial owing to the climate crisis, and also because of the cost of fuel. But improving the prospects of women in healthcare careers remains a focus; its Healthcare Career Pathway aims to build and sustain a dedicated and highly educated healthcare workforce, improving the life chances of women, particularly in rural areas, and also building capacity. ‘There is so much migration of healthcare workers around the world, and this has huge implications for the countries where we work as they lose some of their health workforce,’ says Dr Ratcliff. ‘We hope we’re doing our bit by helping these young women, but also helping the national workforce.’

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Delivering holistic care Only 1.7 per cent of families in need of palliative care have access to it, in Nepal – and the situation is worst in rural areas. EMMS International has been working with doctors to expand rural palliative care in western Nepal, training staff and volunteers and bringing care closer to home. Amrita Shrestha is head of the Palliative Care and Chronic Disease Unit at Green Pastures Hospital in Pokhara, Nepal. As a consultant paediatrician, she first became involved in palliative care in 2018 when she began running a clinic for children with cerebral palsy. Since then, supported by EMMS International, she has completed the National Fellowship of Palliative Medicine from the Institute of Pallium in India, and now heads up an integrated palliative care service for adults and children. For her, palliative care is about meeting the needs of patients and their families in a holistic and personalised way. ‘The children who were coming to the clinic didn’t only have cerebral palsy – they had other disorders or multiple complexities,’ she explains. ‘I realised these children and their families really needed palliative care.’

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ELIZABETH ORCUTT/CHAIN OF HOPE

HAREFIELD HOSPITAL/GUY’S AND ST. THOMAS’ NHS FOUNDATION TRUST

Sir Magdi at Harefield Hospital (left) and Luxor International Hospital (above)

JULIE FISHER Sir Magdi assists a child in Addis Ababa in 2009

Never miss a beat What is it like to be one of the most famous surgeons in the world? Seren Boyd finds Professor Sir Magdi Yacoub in reflective mood, as the 88-year-old looks back on a life of astonishing innovation and frequent controversy ‘Surgeons do care, a lot more than people think’

t can be hard to discern the man behind a name linked with medical firsts, prestigious awards, celebrity and even royalty. It is easy to draw the wrong conclusions from clichés. Professor Sir Magdi Yacoub made his name as the cardiothoracic surgeon who pioneered daring procedures, took on ‘impossible’ cases, pushed past others’ disapproval. He drove fast cars, worked preposterous hours and counted

Omar Sharif and Princess Diana as friends. He also saved thousands of lives. Today, at 88 years of age, he is in reflective mode, having collaborated on a recent biography of his life. For someone who used to distrust the media, he is remarkably open now in discussing those early, controversial days of surgical firsts. He is also remarkably unassuming.

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Ruffling feathers The UK has adopted Egyptian-born Sir Magdi as its own and lauded him for his many achievements. These include the UK’s first arterial ‘switch’ operations, Europe’s first heart-lung transplant, the world’s first ‘live lobe’ transplant (of lung lobes donated by living patients) and perfecting the Ross procedure (replacing the aortic valve with the patient’s own pulmonary valve). He was knighted in 1992 and awarded the Order of Merit in 2014, the highest honour in the gift of the British monarch. He’s a Fellow of the Royal Society and of the Academy of Medical Sciences. He is a national hero in Egypt, pictured alongside footballer Mo Salah in a mural in Sharqiya where he was born. Arriving in Britain aged 25, he worked under leading heart surgeons Professor Sir Russell Brock and Sir Donald Ross: the list of his colleagues and mentors reads as a Who’s Who of cardiac surgery. Yet, he often felt like an ‘outsider’ and Harefield Hospital, in Hillingdon, where he was appointed consultant cardiac surgeon in 1969, was a small hospital, vying for position with bigger London centres. Immediately, Sir Magdi started ruffling feathers. He wanted to increase Harefield’s output from about one open-heart operation a week to 10. Colleagues were awed and baffled by his stamina: he often worked through the night, snatching only a few hours of sleep or relying on brief catnaps, often in theatre. He was also known for his calmness and dexterous, outsized hands. bma.org.uk/thedoctor

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‘During sleep, your brain continues to try and solve problems,’ he says now. ‘So, if I have a problem, for example, operations which I have not done before, I digest it so much that the following morning, I can do it very quickly, faultlessly, because I’ve thought about every tiny bit throughout the night.’ Sir Magdi quickly made his name treating complex congenital heart abnormalities, performing the first ‘switch’ operations in the UK on babies born with their pulmonary and aortic arteries the wrong way round. But he was also gaining a reputation as a maverick. He hit the headlines in 1975, when he linked one-year-old Scott Molloy’s circulatory system to that of a baboon, to provide life support. The baby and baboon died. He was certainly driven – not least to prove wrong his father, a general surgeon, who had told a young Magdi he had the ‘wrong temperament’ for surgery. But it was the presenting need that drove him, not personal ambition. ‘I believe the patient-doctor relationship is sacred,’ he says. ‘The patient leaves his life entirely in your hands; that’s a massive responsibility. ‘Some people say, “You’ve done this new procedure for your own benefit, to be famous”. Never! I would only do operations if the patient has nowhere to go and is desperate. And I think very hard: how can we save this patient or at least help them and buy time until we have something even more new to offer?’

MAGDI YACOUB HEART FOUNDATION

For all his determination to extend the boundaries of surgery and science, those cases which saw his name and his hospital splashed across the headlines took their toll, he tells The Doctor. Surgeons don’t always deserve their ‘unfeeling’ reputation. ‘Actually, they suffer massively, because they are human beings after all, and they have emotions,’ says Sir Magdi. ‘And they do care, a lot more than people think.’ He is undoubtedly an extraordinary man: he won a scholarship to medical school at 15. Yet, what has always defined and driven him, and disconcerted his critics, is an extraordinary sense of purpose. ‘My primary duty is to my patients, not to the media or even to society at large,’ he says in his biography.

Sir Magdi teaching at the Aswan Heart Centre in 2014

‘Some people say, “You’ve done this new procedure for your own benefit, to be famous”. Never!’

Ethical debate Surgeon Christiaan Barnard performed the world’s first heart transplant in South Africa in 1967; Donald Ross conducted the first in the UK the following year. Neither patient survived more than a few weeks: the operations were considered experimental. Soon afterwards, the British Government thedoctor | January 2024

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AMR ABDALLAH

declared a voluntary moratorium on further transplants because of high failure rates linked to organ rejection and infection. There were also strong moral objections to removing a heart that was still beating (which was essential for transplant) even if the patient was brain-dead and on a ventilator. It was 1979 before the Conference of Medical Royal Colleges equated brain death with the patient’s death. So, Sir Magdi’s decision to defy the moratorium and perform a heart transplant in September 1973 won him many critics, including colleagues, especially when his patient died within hours. But Sir Magdi was ambitious for Harefield and for a national transplant programme. A certain Ken Clarke, then health minister, described him as ‘mad’. As soon as new anti-rejection drugs became available, and the moratorium lifted, Sir Magdi performed three heart transplants early in 1980. Then, he insisted on removing the donor heart himself, which sometimes involved a flight and always a tense four-hour countdown before the heart had to start beating again. His first transplant patient in 1980 died within two months, the second within hours; the third, Derrick Morris, lived for a further 25 years. Debates about medical ethics raged. When Sir Magdi decided to perform a heart transplant for 10-day-old Hollie Roffey in 1984, even Christiaan Barnard said it was a mistake. She died within three weeks. Sir Magdi recalls discussions long into the night about whether he should operate, ‘niggling doubts’, disquiet over critical media coverage and distress over Hollie’s death. But it had been her only chance. Asked now about how he coped with the risk and criticism, he is deliberate in defining his priorities. ‘I put all my effort into serving that patient and forget that this is a beautiful child I have known for some time. I do have emotions. But during an operation, particularly if it is something new, I become completely automatic, and put all my energy into getting out of this procedure safely in a committed

A mural by Hany Gendy depicting Sir Magdi and the Egyptian international football player Mo Salah in Sharqiya Governorate, north of Cairo, in 2020

‘During an operation, particularly if it is something new, I become completely automatic’

‘I see people who were going to die in a week without transplantation and who have survived 35 years’

fashion. Afterwards, I can feel exhausted.’ Being lead surgeon was often lonely, he says, especially when breaking new ground. ‘As Lord Brock used to say, you don’t know whether you will meet a policeman on a bicycle, someone very kind, or a whole army which will descend on you and your patient. You are out there on your own. But you are acting totally, I mean totally, on behalf of patients who really have nowhere to go. ‘When something doesn’t go right, the concentration is entirely on: how can we prevent this happening again? If anything wrong happens, it’s got to be the chief, me, who carries the can.’

Different era Sir Magdi recognises he was the man for a time when clinical governance was less tight and ethical positions still fluid. Would his pioneering be possible today? Definitely not, he says. ‘We couldn’t have done what we did in the early days to advance the care of human beings, in the current environment, when there is so much governance, regulations. They really would stifle innovation.’ Sir Magdi subscribes to philosopher Karl Popper’s assertion that science progresses by ‘leaps of imagination’, not small steps. He points out that the ancient Egyptian goddess of truth, Maat, was beautiful and elusive. ‘If you came near her, she grew huge wings and flew away. So, you have to keep running after truth.’ To keep pushing those boundaries, his clinical work has always run alongside scientific research. He set up the Harefield Heart Science Centre where today scientists in the Magdi Yacoub Institute explore, among other things, the potential of tissue engineering to grow living heart valves and gene editing to address heart disease. He has also established research centres in Egypt, Mozambique and Qatar. He acknowledges the possibility that scientific advances may one day make transplantation obsolete. ‘Eventually, there has to be other solutions; when it’s going to happen, I don’t want to speculate. But for the time being, transplantation and heart surgery is a fantastic tool for benefiting humanity. Transplantation has done wonderful things: I see people who were going to die in a

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Sharing knowledge Sir Magdi is now considered one of the world’s most innovative surgeons and Harefield is a world-class heart and lung transplant centre. Through his charity, Chain of Hope, he has set up cardiac services around the globe, including centres in Egypt (Aswan), Ethiopia and Mozambique. Other major heart centres are being built in Cairo and Kigali (Rwanda). All these centres are free at the point of entry, like the NHS: he is passionate about addressing health inequalities. Before building the Aswan Heart Centre, he sparked a near-riot by announcing on Good Morning Egypt his intention to provide free cardiac care to children. Thousands queued to see him, and he had to escape through a hospital roof with a police escort. But Sir Magdi shrugs off the plaudits. He had to be persuaded to lend his name to projects, swayed only by friends’ assertions that they would receive more funding if they bore his name. He agreed to the biography only to ‘inspire others’ to go into medicine. His focus now is on legacy, sharing what he has learnt. When we talk, he has recently returned from Aswan Heart Centre, now a major training centre for doctors across Africa. ‘My dad used to say, “I don’t want to leave you money: I want to leave you education and knowledge”. I owe a whole lot of debt to people. My main function in life now is to pass on all that I have learnt to the next generation.’ He sleeps more than he did. His Radio 4 Desert Island Discs choice of a luxury item was a hammock. But he is still pushing, still seeking challenges. His passion for growing orchids has waned since cloning took the skill out of propagation. He developed a new operation to treat a congenital problem called truncus arteriosus as recently as 2019. ‘I firmly believe I cannot be bored,’ he says. ‘If I’m bored, I’m not doing enough. And if I stop, I will rot.’ A Surgeon and a Maverick: the Life and Pioneering Work of Magdi Yacoub is published by the American University in Cairo Press bma.org.uk/thedoctor

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HANS MURMANN

week without transplantation and who have survived 35 years of fantastic life, have seen their grandchildren.’

PRINCESS DIANA: Rapport with young patients

His friend Diana As Harefield grew, and its research developed, so did its fundraising. This was often supported by former heartsurgery patients, including comedian Eric Morecambe. It’s a measure of the man that Sir Magdi still has longstanding friendships with many of them. Another fundraiser and regular visitor to Harefield was Princess Diana, who had become romantically involved with Sir Magdi’s senior registrar, Hasnat Khan. The princess started making unscheduled visits to patients on Harefield’s paediatric ward. Sir Magdi recalls hearing her laughter, often late at night. Later, she became involved in fundraising and was guest of honour at a dinner at Harrods, then owned by Mohamed Al-Fayed, in 1996. But when she attended two of Sir Magdi’s operations and a photo emerged of her in theatre, wearing make-up and earrings, the press pounced. They accused her of posing an infection risk – and courting publicity. Sir Magdi is adamant it was a genuine love of children that drew her to Harefield. ‘She had a rapport with children that I had rarely witnessed in others.’ They became friends. It was Princess Diana who drove him to Heathrow when his brother Jimmy died after a fall in the Black Forest. ‘Diana was a great comfort to me. I still hear her voice in my head urging me to carry on.’

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Your BMA Diversity of views within the BMA is a sign of strength

thedoctor

With 2024 now upon us, I would like to wish all of you a happy new year, and sincerely hope you were able to enjoy some rest with friends and family during the holiday period. The start of a new year can seem daunting, and looking ahead I know we will face numerous challenges as a union and as a profession, the navigation of which will require effective leadership. As your BMA representative body chair I know that leadership – and an ability to listen – go hand in hand and it cannot be understated how important your feedback is to how I, and my fellow chief officers, fulfil our roles and responsibilities. I have always made clear my door remains open to all members who want to contact me on any issue, and it goes without saying that, in welcoming feedback, I accept this will sometimes include criticism. My previous column, for example, which focused on the humanitarian crisis in the Gaza Strip and the West Bank and sought to outline the BMA’s policy-based positions on this tragedy, evoked strong and sometimes personal responses from some of you. Similarly, I know there are those who have disagreed or taken issue with the association’s approach to industrial action or to call for a moratorium on physician and anaesthesia associates in the NHS, and subsequently made

@drlatifapatel these feelings clear to me. In my capacity as your representative body chair, my own personal views are not there to be platformed. My obligation and commitment have always been to represent the positions and policies of the BMA accurately and to further the accessibility and inclusivity of our association to the benefit of all our members. Our policy book can be viewed online and I would encourage all our members to have a look at what policies your fellow members have passed for BMA action. My role is to allow members such as yourself to make democratic change through proposing and developing informed policy, a process that essentially shapes the association and points it towards the direction you want us to go. If there is something you disagree with and wish to change, put yourself forward to attend our next annual representative meeting in June, via election from your BMA division, your regional council or our conferences. All BMA members are now eligible to nominate and vote in the elections in their division area, and I urge anybody who wants to participate and to make a difference to visit bma.org.uk/my-bma for more information. Alongside applying for a seat, I would also

The Doctor

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

Senior staﬀ writer: Peter Blackburn (020) 7874 7398

@TheDrMagazine @theBMA The Doctor is published by the British Medical Association. The views expressed in it are not necessarily those of the BMA. It is available on subscription at £170 (UK) or £235 (non-UK) a year from the subscriptions department. All rights reserved. Except as permitted under current legislation, no part of this work may be photocopied, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical or otherwise without the written permission of the editor. Printed by Warners Midlands. A copy may be obtained from the publishers on written request. The Doctor is a supplement of The BMJ. Vol: 384 issue no: 8413 ISSN 2631-6412

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

15/01/2024 12:05

encourage you to submit motions for debate at this year’s ARM through your divisions and regional councils. If there is something of particular relevance to you, that you believe merits consideration and debate, putting this issue forward as a motion is an excellent way of raising your voice and potentially influencing association policy. Guidance for drafting motions can be found on the BMA website, with the deadline for submissions to this year’s ARM 9am on 2 April. Attending conference and contributing to debate should serve as important reminders that it is you who decides what our priorities should be, you who decides what we debate and you who ultimately decides what your BMA does for you. Different opinions within the BMA and among our 195,000 membership should never be viewed as signs of division and weakness, but as diversity and strength. Having a plurality of thought and, crucially, a safe and mutually respectful environment in which these can be further explored, is precisely why we have been able to come so far as a trade union and professional association.

One need only look at the make-up of our executive team, which includes two junior doctors and two women, our first chief officer to be an open and proud member of the LGBTQ+ community, our first chief officer to be a woman from a minority background and to serve while pregnant and a new parent and a chief officer with a longterm health condition. We want to recognise how important our diversity is and I hope our membership appreciates that, with diversity in leadership, comes diversity of thought and the way our members are represented. It is incredibly important to us we are given feedback, whether it’s constructive criticism or positive and all of us are open to getting that feedback from our members. But again – your greatest asset in this association is your voice so do consider putting yourself forward. As ever, I am always happy to hear from you and any questions you might have. To get in touch please write to me at RBChair@bma.org.uk or @DrLatifaPatel Dr Latifa Patel is chair of the BMA representative body

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Inc lud ing

Göreme (World Heritage)

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• Cappadocia (World Heritage): enchanting landscape, with unique natural phenomena, buildings and bizarre tufa formations • Konya: visit the Monastery of the Whirling Dervishes whose dance has been declared an Intangible Heritage of Humanity (admission included) • Göreme (World Heritage): open-air museum, which includes numerous monastery complexes, wall paintings and a cave church, a highlight of any trip to Cappadocia (admission included) • Çavuşin: impressive village where you can enjoy typical green tea • Monks Valley (World Herçitage): fairytale rock formations and changing colours promise unforgettable moments, together with Göreme a World Heritage • Arts and crafts in traditional carpet factory • Sinasos: idyllic village with ancient Greek mansions • Valley of Love: romantic walk through the uniquely shaped tufa formations in the Valley of Love • Underground cities: more than 100 cities have been dug out of mountains here. You will explore the secrets of one of the many mysterious underground cities of Cappadocia (admission included) • Craftsman tradition in a jewellery and leather factory • Historic Silk Road: numerous medieval caravanserais line this world-famous route • Antalya: city tour through the capital of the Mediterranean region with Mediterranean flair • Karpuzkaldiran Waterfall: imposing waterfall which thunders into the open sea on the coast

Day 8 – 15: FREE extended holiday in an exclusive 5-star luxury hotel example hotel

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+ FREE 8 days of relaxation in an 5-star luxury hotel Flight Dates Seasonal price increase p.p.

Sept. 2023 (19 – 28.9) £200

Oct.2023 (3 – 12.10) £150

Spend the next 8 days relaxing on the Turkish Riviera in your 5-star luxury hotel! The comfortable rooms are luxurious and modern. Unwind in the hotel‘s fantastic spa with sauna or stroll along the beach.

Oct. 2023 (17 – 19.10) £100

Sensational rate for you as a reader of THE DOCTOR from only Airports Airport fees p. p. Days of Depature

Birmingham £0 Tue

Oct. 2023 (24 – 26.10) £50

Oct. 2023 (31.10) £0

£200

Nov. 2023 (2 – 7.11) £0

Febr. 2024 (21 – 28.2) £0

(Price when booking the following separately)1 Return flights with a reputable airline2 £2501 to and from Antalya, incl. hotel transfers 7-day 5-star cultural tour of £5651 Cappadocia - 7 nights in a double room in selected 4- and 5-star hotels (national category) - 7× tasty breakfast - Round trip in our modern and air-conditioned travel coach - Spectacular range of excursions + admissions (as per itinerary) OUR GIFT: FREE 8 days of relaxation £3851 in a 5-star luxury hotel - 7 nights in a double room in an exclusive 5-star luxury hotel in the Turkish Riviera (national category) - Attractive outdoor pool, heated indoor pool, private beach and wonderful spa area, including sauna Qualified, English-speaking cultural tour guide Combined price per person Price difference per person

Your rate per person from only £200* Optional services at attractive conditions: Gourmet package: The package includes a delicious buffet every evening with international specialities during the 7-day cultural tour: only £129 per person instead of £1491. Single room surcharge: £200 per person (subject to availability) March 2024 (6 – 31.3) £60

* per person 1 instead of £1,200 London Gatwick £35 Tue | Wed | Thu

£1,2001 – £1,0001

March 2024 (19 – 27.3)# £120

April 2024 (3 – 10.4)# £180

April 2024 (17 – 24.4) £240

Your saving per person

- £1,0001 Manchester £35 Tue | Wed | Thu

British citizens do not need a visa to enter Türkiye for stays of up to 90 days. Passports must be valid for a minimum period of six months from the date of entry into Türkiye and there should be a full blank page for the entry and exit stamps. Nationals of other countries are advised to Your advantage code! DOC111183 enquire at the Turkish Embassy about the entry requirements applicable to them. * The statutory bed tax is already included in the price. A deposit of 20% of the tour price is payable upon receipt of written booking confirmation. The remaining amount must be paid 80 days before departure. The price applies on 27 February 2024 for flights from Birmingham. For other travel periods, seasonal price increases apply as listed in the flight schedule. The trip only applies to the recipient and accompanying adults. The travel conditions and Call now, privacy policy of RSD Travel Limited apply. These can be requested from the travel hotline or viewed at www.rsd-travel.co.uk. The passenger can absolutely free, to secure your preferred travel dates. terminate the contract at any time before the package tour begins in exchange for payment of a commensurate withdrawal fee. For more information, please see the T&Cs of RSD Travel Limited. Note: minimum number of participants 15 people for each travel date. Cancellation no later than 20 days The hotline is open Monday – Friday from 9 a.m. to 6 p.m. before the start of the trip, if this is not achieved. Planned group size approx. 30 people. Not suitable for people with reduced mobility. Subject to misprints and changes. The photos show typical examples of what you can expect from our hotels. Gift only applies when booking the cultural tour. Tour operator: RSD Travel Ltd., 2nd Floor Suite, Cuttlemill Farmhouse, # Holiday price increase p.p.: £49. 1 Cuttlemill Business Park, Watling Street, Towcester NN12 6LF, The combined price of individual components if booked separately was calculated on 27 June 2023 the travel dates 27 February 2024 to 12 March 2024. Flight from Birmingham to Antalya and Antalya to Birmingham on www.turkishairlines.com (cheapest, cancellable available United Kingdom Registered No. 07507940 (England & Wales) flight including luggage), transfers airport – hotel – airport on www.suntransfers.com. Holiday Inn Antalya –Lara, Akra Hotel, Dervish Cave House on www.booking.com, coach tour on www.nbktouristic.com, excursions on www.viator.com. The comparative price for the gourmet package is based on the standard prices of our Turkish partner (www.nbktouristic.com). Between the date of the price comparison and the date of travel, these prices may go up as well as down. 2 e.g. SunExpress 3 Feedback provided by customers of RSD Travel Ltd and RSD Reise Service Deutschland GmbH, a European group of companies travelling in 2021/22. All the flights and flight-inclusive holidays in this brochure are financially protected by the ATOL scheme. When you pay you will be supplied with an ATOL Certificate. Please ask for it and check to ensure that everything you booked (flights, hotels and other services) is listed on it. Please see our booking conditions for further information or for more information about financial protection and the ATOL Certificate go to: www.caa.co.uk

0800 021 1267

20230893 The Doctor Magazine – Issue 63 – January 2024– p.24.indd 1

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