The Doctor – issue 64, February 2024 by The BMA

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Issue 64

February 2024

Who needs Australia? The doctors heading to Ireland in search of a better life

Race against time The fight against antimicrobial resistance

Medical ethics New guidance online

Nye and then

The birth of the NHS, a retelling

12/02/2024 11:05

JESS HURD

In this issue

At a glance Why Northern Ireland’s newly restored government must make the NHS a priority

4-9

You’re welcome Doctors who have moved to Ireland say they feel valued but warn it is no utopia

10-13

Race against time The doctors fighting antimicrobial resistance with new treatments, diagnostics, and ways of working

Welcome Phil Banﬁeld, BMA council chair

Overcoming our diﬀerences

Sara Otung, one of the actors in of the new National Theatre play Nye, cried when she realised the mammoth effort it took for Aneurin Bevan to establish the National Health Service – particularly when the dawning horror of what was at stake today and the threats to its existence became clear to her. In an interview about the new play for this February edition of The Doctor she reflected: ‘It hit home to me what it took to make the NHS … Is this also what it takes to keep it?’ The actor, who is a senior house officer in acute medicine away from the stage and has paused medical training while rehearsing and performing, is passionate about the health service she works in and is now advocating for, alongside long-time NHS supporter and campaigner Michael Sheen in the production. Dr Otung’s reflections powerfully sum up the huge concerns many of us have about the crisis in the NHS – and speak to why your BMA is campaigning so tirelessly for its doctors and its future. I hope Nye can enlighten a wider audience about the brilliance of our health service and the value of the expertise we fight to keep in this country. Our campaign for pay restoration is now in its 16th month. A comprehensive feature in this issue of the magazine explains the latest on industrial action in England, Wales and Northern Ireland for junior doctors, SAS doctors and consultants. Sooner or later, governments, providers and employers must decide collectively what is more important: having enough doctors to treat patients or making political points against trade unions? Another piece outlines proposed changes to the SAS doctor contract and the next steps in that process. Also in this issue, we look at the global rise in antibiotic resistance and the challenge this pivotal issue poses for health and the delivery of care. We also discuss the BMA’s handbook of ethics and law – Medical Ethics Today – which has been distilled into an instantly accessible online version to ensure doctors have the immediate support and guidance they need in the modern workplace. And we speak to the doctors moving their lives and careers to Ireland about the ‘respect’ they feel the NHS denies them and their working lives in the UK.

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

14-15

Nye and then What we can learn from a new play about the birth of the NHS

16-17

No backing down Doctors in Wales go on strike for the ﬁrst time

18-19 Online ally

BMA ethics guidance goes digital

20-21

SAS doctors vote on pay oﬀer Government proposal under consideration

Your BMA

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STORMONT: Restored government must address NHS crisis

AT A GLANCE

Back in business Since the suspension of devolution in Northern Ireland two years ago, around 20 general practices have collapsed or handed back their contracts to deliver GP services. This, says Alan Stout (who chairs the BMA Northern Ireland GPs committee), is a catastrophe. ‘We only have around 300 practices, so that’s a big proportion. It’s never a decision that’s taken lightly. The GPs doing this feel it badly, for themselves, their staff, and because they feel they are letting down their patients, who they’ve known and looked after for years and years. It really is very difficult.’ This month there has been a big change in Northern Ireland. Devolution has finally been restored; Stormont is sitting again. There’s a health minister, a health committee, and warm words both from the new first minister – Sinn Féin’s Michelle O’Neill – and her deputy Emma Little-Pengelly, about the need to improve health services. There is a lot of unhappiness among doctors in Northern Ireland. Juniors are balloting on strike action; consultants and SAS doctors are considering industrial action. Waiting lists are the worst in the UK and there is a workforce crisis which is only exacerbating an already parlous situation. As seen above, general practice is in crisis. So what difference will the restoration of devolution make? ‘The bottom line is that you can’t run a health service without the politics,’ says Dr Stout. ‘Northern Ireland was left without any political leadership and I think we’ve proven that you just can’t run a health service without it – it’s a massive public institution and there has to be political accountability. ‘We’re not kidding ourselves – restoration of devolution isn’t a magical panacea; it’s not going bma.org.uk/thedoctor

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to suddenly solve all of the problems. But it can start to give us a better direction, and adds in that vital piece of accountability that we really need at the moment, because we’re going to be having some really, really difficult conversations among ourselves and with the public.’ Dr Stout, who is also deputy chair of the BMA Northern Ireland council, has several clear ‘asks’ of the newly appointed health minister Robin Swann. ‘The absolute top-line is retention of staff. We have to look after and retain the healthcare staff we have, including doctors, because we are losing them quickly. The other priority is funding. It’s not only getting the total right; it’s also making sure that you can get a recurrent budget that allows for proper planning and proper change.’ Dr Stout’s practice in East Belfast is an interesting melting pot of ‘old’ and ‘new’ Belfast, of deprivation and prosperity. He points out the window of his modern premises, part of a block owned by the local health trust, housing multiple practices and services. ‘If you look that way, you can see the Titanic building, and the big Harland and Wolff cranes, Samson and Delilah. And if you walk that way, you’re basically into the old, terraced housing – a very deprived part of Belfast. But if you go in that direction you get up to Ballyhackamore, a thriving metropolitan part of Belfast, with more expensive housing and affluent people. So, we get a real mix – it just depends what direction they are coming from.’ We spend a few minutes looking out of the window trying to spot Stormont, which he says is a ‘stone’s throw’ away, but just tantalisingly out of sight. Nevertheless, the hope must be there that the politicians who inhabit it will be able to make positive change. By Jennifer Trueland

STOUT: Restored devolution ‘can start to give us a better direction’

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GALLAGHER: Doctors seem better respected by their employers in Ireland

YOU’RE WELCOME

BRIAN MORRISON

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The Republic of Ireland offers a very different experience to working in the NHS. UK doctors who have made the move say they feel welcomed and valued, but warn it is no utopia. Ben Ireland reports

ou have heard the one about doctors moving to Australia for better pay and conditions but a lesser-reported exodus is happening much closer to home. There might be more kangaroos than four-leaf clovers on picket-line placards but what appears to be a growing number of doctors are moving from the UK to work in the Republic of Ireland. Doctors who may want to remain closer to friends and family but who are equally fed up with NHS working conditions are being targeted by online adverts for jobs in Ireland, with reports of recruiters turning up at picket lines to offer information. Ireland shares a common travel area with the UK, allowing citizens of both countries the right to live and work in the other. It is third on the list of destinations doctors gave to the GMC for where they intend to move to when leaving to practise abroad. In the latest GMC Workforce Report, which uses 2022 data, 310 UK-based doctors say they intend to move to Ireland – 26 of whom were British, 129 Irish (those born in Northern Ireland could say either) and 155 of other nationalities. But this data does not confirm their intended move came to fruition – and many doctors also keep their GMC licences to practise after moving from the UK to keep their options open. IMC (Irish Medical Council) data is also unclear, as it measures where doctors went to medical school rather than where they were previously working. Of the 3,008 doctors who registered with the IMC for the first time in 2022, 56 studied in the UK, 867 in Ireland and 465 elsewhere in the EU. More than half (1,620) went to medical school in neither the UK, Ireland or the EU. All categories could include doctors who were working in the NHS before registering with the IMC, which told The Doctor: ‘We do not know how many doctors came from the NHS to Ireland.’ Separate GMC data unearthed by The Doctor

perhaps gives the best indication. Some 507 UK-based doctors requested a CGS (certificate of good standing) for Ireland in 2022, with 334 retaining their licence to practise. In 2023, 804 doctors requested a CGS for Ireland, with 632 retaining their UK licences, as of late January. Requesting a CGS is not proof that a doctor has moved, but shows they are taking active steps to do so.

Respect and remuneration Kathy Gallagher, a paediatric rheumatology consultant, and her GP husband Tom Mathias moved from London to Dublin in September 2022. Dr Gallagher originally hails from Donegal on Ireland’s Atlantic coast but worked in Nottingham, the east of England and London’s Great Ormond Street Hospital after studying in Norwich. While working in the UK was ‘a great experience’, she says it ‘wasn’t easy’, including 12 house moves in 16 years for rotations and university. Dr Gallagher was offered a position a year in advance, meaning she could finish her specialty training in London and plan the transition. ‘Respect’ is a word many UK-based doctors use when complaining about pay and conditions in the NHS, and Dr Gallagher says being offered respect in Ireland is a big reason why the 10 Irish students she trained with are ‘slowly filtering back’. She says junior doctors she has worked with in Ireland report similar such respect in relation to their working conditions and pay, particularly in terms of exception reporting and study budgets. With many junior doctors keen to complete their specialty training programmes before moving, a big sell for recruiters to Ireland’s health service is its new Sláintecare consultant contract. It offers up to €252,150 (around £215,000) for a 37-hour public sector week, extra pay for on-calls and overtime, protected time for research and teaching plus the freedom to take on private work provided

‘Junior doctors report that they feel respected’

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BRIAN MORRISON

MATHIAS: Able to work ‘more proactively’ as a GP

JESSUP: Decided to seek more professional fulfilment

public obligations are met. Dr Gallagher’s consultant role is still ‘very busy’, and waiting lists long, but she says the set-up creates a ‘camaraderie’ and ensures patients who need urgent care are seen in time. And while IT systems can be just as frustrating as in the NHS, she is confident a recent investment announcement will improve things. Moving meant Dr Gallagher left behind her ‘professional support network’ and many colleagues she had grown close to. ‘Even though I’m Irish I feel like a bit of an outsider because I trained in the UK,’ she says. ‘Dublin is also expensive,’ adds Dr Mathias, who caveats: ‘But we are getting paid more than in London.’ They find living in a smaller city gives them a ‘nice quality of life’. They had considered Australia, like many colleagues. ‘The main thing that stopped us was the distance,’ says Dr Mathias. ‘You’d be so far away from friends and family, whereas here I can see the ferry. It’s nice to know we’re 15 to 20 minutes from the airport and can fly back to London in an hour.’ It’s a trip they were used to in reverse when travelling to see Dr Gallagher’s family, who are now just a three-hour drive away which ‘has made the move easier’. The move also comes with ‘a lot of paperwork’, says Dr Gallagher. As a returning Irish citizen, she had less hassle, but Dr Mathias – despite the common travel area – had to apply for a Personal Public Service

number, the equivalent of National Insurance, on top of the family finding a home and transporting personal possessions including a car. Dr Mathias grew up, studied and worked in London. He admits he ‘would probably have stayed in London forever if I hadn’t met Kathy’, but the opportunity ‘opened my eyes’. While their move wasn’t made for money, it was when looking at jobs outside the UK that Dr Mathias ‘realised how much other people are getting paid’ elsewhere.

Manageable workload The workload is ‘a different world’, he says. A typical session involves seeing 12 patients in 15-minute appointments with more time for admin. ‘I come home from work and I’m not tired,’ he explains. ‘In the NHS, I’d often come home knackered. It takes less out of me. I have time to do the job properly, and I’m paid better for it.’ Dr Mathias feels like a ‘more proactive’ GP. ‘If I’ve got an extra five minutes, I might say “let’s talk about your smoking”,’ he says. ‘You wouldn’t do that in the NHS because you’re always firefighting.’ GP Eamonn Jessup left his partnership at a surgery in north Wales in 2015 owing to punitive pension rules. He took locum roles in the UK and Cyprus before trying the Republic of Ireland, which he has now made home as a salaried GP in County Kerry. He believes ‘GPs are well off’ in Ireland but notes

‘I come home from work and I’m not tired’

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the country’s higher tax levels affect take-home pay – something he acknowledges helps pay doctors’ salaries and fund ‘tremendous’ schools. ‘If you’re going to have decent public services, you’ve got to pay for it,’ he says. After two fellow partners retired at his busy Prestatyn practice, he concluded ‘I don’t need this’, and decided to focus on finding more professional fulfilment in the twilight of his career with a reduced list size. In his UK locums, he noticed the service becoming ‘more and more see-andrefer’, recalling: ‘There was no way you could sustain continuity of care.’ Now 68, he enjoys the pace of life in rural Ireland, typically working 9.30am to 6pm, and ‘not counting the numbers’ of patients he sees. He contrasts that with the UK, where as a partner he was typically in from 8am to 6.30pm. ‘You can’t do that into your mid-60s,’ he says. Appointments in Kerry are 15 to 20 minutes, which gives Dr Jessup the time for a hands-on approach with patients, be it taking bloods, performing ear syringes or stitching – ‘the whole job’. ‘I wanted to work somewhere I could actually do things, like take foreign bodies out of eyes, without sending patients to a specialist,’ he says. Dr Jessup is more involved in the evaluation of MRI and CT scans and X-rays now, finding ‘astronomical’ levels of incidentalomas. In Wales, he was ‘always told it’s not the protocol’ for GPs to assess scans. ‘It’s a wonderful challenge medically,’ he says. ‘This is the stuff we should be doing in 21st-century medicine. I can get on with the job here, there’s less talk.’ He expects more UK-based junior doctors, frustrated at the dispute with the Government, may be tempted by Ireland, which is expanding its GP trainee places.

70 and over. Cards are also given to some people on a means-tested basis. Costs for private access vary. Face-to-face appointments are usually about €50; telephone appointments can be cheaper. Many people in this cohort have private health insurance policies. Dealing with private patients, Dr Jessup explains, can sometimes involve awkward conversations, for example if they don’t require prescriptions. ‘It’s quite hard to pack them out the door with nothing in their hand, saying “you paid for my time”,’ he says. ‘You sometimes have to be quite assertive.’ He also reports a ‘crossfertilisation’ between public and private care: ‘Say you come in with a swollen knee; I can get you an MRI in two days because I can use a special scheme called direct access, where the Irish Government pays private hospitals to do scans.’ Dr Mathias says splitting his time between public and private, which for him is about 50:50, was a ‘culture shock’ at first: ‘It takes a bit of getting used to.’ While he strives to treat every patient equally, he notes ‘a bit of health inequality’ as a result of the system. ‘Sometimes you would like to bring patients back, but some people will struggle to pay €60,’ he says. ‘Or you might recommend a patient had some blood tests done but you know it’s going to cost €30. Sometimes you change your mindset and how you practise a little bit.’ Another subtle difference Dr Mathias has noticed is the use of brand names for drugs in Ireland, rather than their scientific names in the NHS. Dr Jessup says GP patients at his surgery can get an appointment the same day or next. ‘There’s no 8am rush,’ he says, and puts this down to the ‘unsustainable demands’ on GPs in the UK. However, he reports the ‘same issues’ with communication between primary and secondary care in Ireland, including IT systems that don’t link up, meaning medication prescribed by a hospital doctor might not be on GP notes. Dr Jessup is still registered with the GMC but recently gave up his place on the performers’ list. He waited until he was settled owing to the ‘ridiculous bureaucracy’ to get back on, which he believes puts GPs from other countries off working in the UK.

‘I wanted to work somewhere I could actually do things’

‘There’s no 8am rush in the GP surgery’

‘Culture shock’ Dr Jessup warns those who move must be willing to adapt to seeing private and public patients in Ireland’s hybrid system. Roughly 80 per cent of his patients have medical cards, allowing them free or discounted care. This applies to children under eight and adults aged

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BRIAN MORRISON HUMPHRIES: Disillusioned with the way the NHS was run

Dr Mathias is still on the GMC register, too. He also gave up his licence to practise in the UK once he knew the move was permanent. Before then, he remained on his performers’ list, working locum shifts at his former practice when visiting family.

Crossing the border It’s not just doctors from the UK mainland moving to Ireland. Doctors based in Northern Ireland, where pay has eroded as badly as anywhere in the NHS amid political crisis, are now routinely zipping across the border to work in the Republic. Consultant psychiatrist Karen Humphries, who lives one mile over the border in Northern Ireland, says she ‘became totally disillusioned with the way the health service was being run in Northern Ireland’. Living so close to where she works, despite crossing the border, was ‘more good fortune than planning’ but she took advantage of the geography. She says: ‘You bump into a lot of people with Northern Irish accents.’ For Dr Humphries, it was more about the conditions – and leaving ‘an old boys’ club’ culture – than the pay, although she appreciates she now earns at least 1.5 times the salary she would get in Northern Ireland. ‘Within the NHS I felt, to some extent, I was being forced into a position where I had no choice but to underperform, and under-care for my patients,’

she says. Part of this was ‘having to jump though 50 layers of red tape’ to sanction treatment she feels should be routine, such as assisting a colleague with their patient. In the Republic of Ireland, she says she sees more tangible progress in her patients with mental health conditions, which ‘was rare in the NHS’. ‘I don’t have a waiting list,’ she adds. ‘Any referral that is urgent I can see same day or next because I’m not constricted. Nobody can overrule my clinical decision on the urgency of the patient being seen. ‘If I wish to structure my appointments so someone is half an hour, 45 minutes or an hour, I can. I have no administrative pressure, or manager looking over my shoulder saying I have to have 20-minute appointments and see X-number of patients a session. Therefore, I can give the patients exactly the service they need, when they need it, how they need it. ‘We work in a team, we discuss things and the patient gets the intervention they require. Some patients don’t need a psychiatrist, but I still hold the clinical responsibility. I can dip back in again after the psychologist, if that’s appropriate. ‘And if I wish to see a patient every day because they’re acutely unwell and I’m trying to prevent a hospital admission, I’m not restricted by somebody else’s agenda. If the person is sick and needs seeing, they get seen. I get a huge amount of job satisfaction.’

‘If I wish to structure my appointments so someone is half an hour, 45 minutes or an hour, I can’

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She insists: ‘I am still a passionate believer in the NHS as it was designed and constructed. Unfortunately, it has become management-led as opposed to clinician-led. That’s the biggest difference. [In the Republic of Ireland] it’s clinicianled, manager support. If I have an idea, they help me get it over the line; that was always lip-service in my old job.’ While the majority of Dr Humphries’ patients qualify for free public treatment, she says not all drugs she might prescribe are covered on their medical cards, ‘which hinders me a little bit’. ‘You have to be mindful of that,’ she adds, explaining: ‘Sometimes you switch your drug to one you know will either be free or cheaper. But if it’s clinically necessary, there is a hardship scheme [where patients can be reimbursed].’ The limits on availability of drugs, she says, must be weighed up against a ‘much higher standard’ of therapeutic relationship than she felt able to give in the NHS – so ‘does not impact quality of care’. Dr Humphries has given up her licence to practise in the UK because of ‘logistics’ and cost but retains her GMC registration – which means she can continue with medico-legal work. She says moving to the Republic is ‘a bigger psychological jump for somebody from England than somebody from Northern Ireland’ because ‘we’re used to crossing the border without even thinking about it’ whereas it could be a ‘massive cultural shift ’ moving from the UK mainland. Northern Irish doctors can also ‘play the double card’, to make transitions easier, she adds, noting that Brexit has made things ‘more difficult’ for doctors moving from Great Britain. ‘For consultants in Great Britain, their qualifications are not necessarily deemed in the same way they once were,’ she explains. ‘It used to be that as long as you had your medical degree and GMC licence that was it. Now, because Ireland is still part of Europe, UK qualifications are not an automatic right.’

2022: 507 doctors asked the GMC for a ‘certiﬁcate of good standing’ for Ireland – an indication of interest to move there 2023: 804 doctors asked for the certiﬁcate

Map of the Republic of Ireland Statistical source: GMC

She was ‘never 100 per cent’ about moving back but with NHS conditions deteriorating and a job opportunity in her ‘niche specialty’ presenting itself she ‘went for it’. Now, with everything in place for their young family, they are there to stay. Dr Mathias adds: ‘We said we’ll give it a year and see how we look. And we both really enjoyed it. ‘A lot more people are asking us what it’s like in Ireland and saying “maybe we’ll move in a few years”, especially since the new [Irish consultant] contract. People are more interested than they were a year ago.’ But he warns: ‘It’s not a utopia. There’s plenty over here to frustrate you too. Neither system is perfect by any means. ‘A lot of people in the UK think the grass is greener and want to go to Ireland to get paid much better. ‘People in Ireland complain about the system as much as people complain about the NHS.’ In the week leading up to his conversation with The Doctor, Dr Jessup said he had been contacted by two UK-based doctors asking him about life in Ireland. He agrees the system in Ireland is ‘far from perfect’ but appreciates the job he has – and believes with the right changes the same lifestyle could be achieved for GPs in the UK. ‘I’ve got a good salaried contract at a fantastic practice in a beautiful part of the world. And I’m loving it.’

‘If the person is sick and needs seeing, they get seen. I get a huge amount of job satisfaction’

‘Not a utopia’ Dr Gallagher notes that Ireland is also ‘haemorrhaging’ its own doctors, who have the same temptations of moving to Australia, New Zealand (and the UK). But she says a long-standing culture of moving abroad within Ireland means many doctors tend to ‘ﬂoat home’ eventually. bma.org.uk/thedoctor

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A RACE AGAINST TIME The global rise in antimicrobial resistance is perhaps the greatest threat facing medicine. But while it may seem a losing battle, some doctors are finding cause for hope in better diagnostics and novel treatments. Tim Tonkin reports

t is no understatement to say the discovery of penicillin has revolutionised healthcare since the 1940s and has helped to usher in a golden age of medical advances and boosted life expectancy. From enabling the treatment of infectious diseases to drastically improving patient outcomes following surgery, antibiotics have helped to save countless lives throughout the world. Yet almost 100 years since their discovery, the effectiveness of antibiotics, and the once unshakable cornerstone these treatments held within medicine, seems increasingly precarious. While the number of new antibiotics being developed has slowed dramatically during the past 40 years, the number of bacterial strains resistant to existing drugs has risen. This resistance, collectively known as AMR (antimicrobial resistance), has developed in large part because of overuse and misuse of antibiotics in areas such as agriculture, farming and healthcare, with poor

stewardship of these drugs allowing bacteria to evolve resistance. The spectre of AMR has seen many warnings from the science and medical community that the world is sleepwalking towards a ‘post-antibiotic age’ in which infections will be harder and more costly to treat and medical procedures such as chemotherapy, childbirth and surgery riskier. This frightening prospect saw the UK Government in 2019 launch a five-year strategy for tackling AMR which set out a range of measures aimed at curbing its effects through greatly reducing use of and unintentional exposure to antimicrobials in people and animals. That same year, a study published in The Lancet found antibiotic-resistant bacterial infections had been directly responsible for more deaths globally in 2019 (1.2m) than either HIV/AIDS or malaria. ‘This is effectively an

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arms race between us and bacteria, and it’s an arms race that we’re not going to ultimately win,’ warns consultant microbiologist David Farren. ‘We just have to try and keep one step ahead, and that involves actually looking at different ways to prevent infection or to manage infection as we go forward.’ An infection control specialist, Dr Farren says that while AMR is often labelled as a future problem, the effects of resistant infections are already a reality today for many doctors and patients. ‘If someone comes into hospital having already had an infection with a bug that has resistance to one or more class of drugs that we use, they’re going to be staying longer in hospital, they’re going to require more intensive nursing care,’ says Dr Farren. ‘Most new treatments are not actually new antibiotics, but there are newer formulations or combinations of old drugs,

BMA

FARREN: High cost to treating healthcareassociated infections

ones that were previously avoided due to cost or side effects. Drugs like fosfomycin, which would have been very commonplace 50 years ago but then fell out of fashion, are now being trotted out [to combat AMR].’

Treatment costs New treatments are indeed rare, although there are occasional developments which could herald a breakthrough in the fight against AMR. Last month saw scientists announce a new class of antibiotics known as zosurabalpin, which has been shown to inhibit Acinetobacter baumannii bacterium, a pathogen that has proved highly resistant to multiple other treatments. ‘Zosurabalpin is indeed a very welcome development in tackling a challenging pathogen in a new manner, as there are few therapeutic options for carbapenem resistant Acinetobacter baumanii,’ says Dr Farren. ‘This is the only bacteria this drug will work against currently though, and while this means it is unlikely to generate any unwanted

resistance in other medically significant bacteria, it puts the treatment somewhat into a niche. ‘It does, however, give hope that this novel approach might be used to help target bacteria such as E coli or Pseudomonas with new agents in the future.’ As well as the clinical challenges posed by patients with resistant infections, the additional time and cost incurred by the NHS as a result of AMR are considerable. Indeed, a health and social care committee report into AMR published in 2018 estimates that the annual cost to the NHS of treating drug-resistant infections came to £180m. ‘For most healthcareassociated infections, like an MRSA infection for example, we know that the cost of treating that patient is somewhere between three and four times more than an average patient. We know that their length of stay is probably two and a half times of the average person walking through the door, and the patient outcomes are less good,’ says Dr Farren. thedoctor | February 2024

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BUTLER: The emergence of better diagnostics is a ‘transformative moment’

‘They’re getting more intravenous antibiotics, using more consumables and having to be isolated in a side room or on contact precautions. There’s additional hand hygiene and personal protective equipment steps, potentially additional cleaning in and around the patient’s area. All of that contributes to an overall increased cost, increased length of stay.’ Dr Farren says tackling AMR requires a multistranded approach incorporating better infection control within healthcare settings, greater use of vaccination and more judicious use of antimicrobials through antibiotic stewardship but acknowledges that this can prove challenging. For example, the lack of rapid and effective diagnostic tools able to determine whether a patient is suffering from a viral or bacterial illness leads to antibiotics being prescribed as a precaution. ‘The other big challenge is diagnostics, and this was highlighted during COVID,’ explains Dr Farren. ‘[During the pandemic] a lot of people who just had 12

COVID were prescribed an antibiotic to cover a bacterial pneumonia as well, because the risks of missing a bacterial pneumonia were felt to be higher than the risks of not giving the drug. ‘If we had better diagnostics then we could reduce our antibiotic usage in those patients, and that’s particularly the case in primary care where access to rapid diagnostics is very limited.’ Oxford University professor of primary care Chris Butler says AMR has undoubtedly been driven at least in part by what he describes as ‘assumptionbased medicine’. As the head of Oxford’s infections and acute care research group, Prof Butler says, however, that there is cause to be quietly optimistic, with new antibiotic and antiviral medications emerging and, crucially, access to effective diagnostics in primary care becoming more readily available. ‘I think we are on the verge of a major paradigm shift, a transformative moment in healthcare delivery in primary care with the emergence of

diagnostics that are rapid and comprehensive enough to give actionable information to guide treatment at the point of care,’ says Prof Butler. ‘We’ve already got feasible, rapid point-of-care diagnostics now that can tell you whether a patient has COVID, flu or RSV, so that in a short space of time you could get targeted antivirals, if the person is sick enough to warrant that, and rule out the need for antibiotics. The world is changing too for point-of-care diagnostics to guide care for some bacterial infections in primary care as well. I think we’re moving ‘This is an forward very fast now with point-of-care tests ... we’re arms race between us soon going to see totally and bacteria, different approaches to antibiotic prescribing in and it’s an urgent care centres in arms race emergency rooms and that we’re general practices.’ not going

to win’

Patient dialogue

Another crucial component to reducing AMR by promoting responsible use of antibiotics is communication and the approach to conversations between doctors and their patients, with Prof Butler arguing that many patients today ‘If we had are better informed about AMR and understanding the better diagnostics benefits and risks to taking antibiotics. then we ‘Most people don’t want to could reduce take antibiotics unless they antibiotic really have to,’ he says. usage’ ‘We’ve done trials whereby we have trained GPs into communicating around antibiotics, and patient satisfaction is high, with those practices prescribing fewer antibiotics over a whole year subsequent to it.

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‘I think with good explanations, with shared decision-making, sharing information, and with better trial evidence about who benefits and who doesn’t, the GP is in a much better position to say a person with your symptoms or with your comorbidities, antibiotics are unlikely to help you much.’ Improved diagnostics are not the only new weapon in the fight against AMR. Virologist Josh Jones is one of a handful of people at the forefront of an emerging form of treatment known as phage therapy, that has shown promise as a potential solution to antibioticresistant bacterial infections. Naturally occurring viruses that can target and kill bacteria but cannot infect human cells, phage treatment was widely used during the 20th century within the former Soviet Union, with the advent of antibiotics largely precluding its adoption in the West. The rise of AMR, however, has seen renewed interest in phages as a possible treatment for patients with resistant infections, with Parliament’s science and technology committee launching an inquiry into the antimicrobial potential of phages in November 2022. Josh Jones is the NHS’s first clinical phage specialist and was part of the clinical team at NHS Tayside in Scotland that in June 2023 used phages to treat a patient with a bacterial infection in their hip that had proved refractory to antibiotics. ‘AMR is sometimes talked about as a future abstract problem [whereas] many of bma.org.uk/thedoctor

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the clinicians that I speak to know it’s already here,’ says Dr Jones. ‘They have already got patients who, for example, have been put on suppressive antibiotics without resolution of infection, or patients who have chronic infections who need chemotherapy and can’t because they’re unable to clear their infections with antibiotics.’ Phage therapy is an unlicensed form of treatment in the UK. However, this in itself does not prevent it being used as a form of treatment. ‘Phages can be treated like any unlicensed medicine regulations, meaning if a clinician feels that licensed medicines aren’t meeting their patient’s clinical needs, they can look for unlicensed medicines,’ explains Dr Jones. ‘As noted in Health Improvement Scotland’s recommendation on phage therapy for difficult-to-treat infections, suitable patients might be those with antibiotic resistance or antibiotic sensitivity but clinical recalcitrance. ‘It might also be for those needing an alternative medical option to prevent high-risk surgery or cases where other factors, such as allergy, might prevent the use of appropriate antibiotics. ‘While unlicensed phage therapy might be suitable for such patients now, future licensed phage therapies could serve an even larger patient population as they could be used much earlier in infections to help prevent people getting to more serious stages in their infection. ‘I think phages are

JONES: Phage therapy may be an alternative for some patients

potentially a game changer, particularly for patients with untreatable infections,’ adds Dr Jones. ‘With greater awareness and expanded access, it is something that could start sooner rather than later.’

COVID factor

‘We’ve got to treat new antibiotics as precious resources’

While AMR is likely to remain a significant challenge to healthcare around the globe for at least the immediate future, there are signs of hope on the horizon. The COVID-19 pandemic and the subsequent rapid development of mRNA vaccines and antivirals in response, demonstrated how a medical crisis can serve as an impetus to scientific advancement. Prof Butler believes ensuring new medical advances are used wisely and proportionately will be critical to the success of the response to AMR. ‘There are new antibiotics emerging,’ he says. ‘We’ve got to treat these as precious resources as something that doesn’t belong to the Government [and] doesn’t belong to the drug company, it belongs to all of us.’ thedoctor | February 2024

12/02/2024 11:17

OTUNG: Passionate about the NHS

NYE AND THEN For junior doctor Sara Otung, the chance to act in a National Theatre retelling of the life of Nye Bevan has reminded her of the wonder and fragility of the NHS. Seren Boyd reports

hen Sara Otung was auditioning for Nye, which opens at the National Theatre in London this month, the script moved her to tears. Learning what it took for Aneurin ‘Nye’ Bevan to establish a National Health Service was stirring – but realising what is at stake today, with the current threats to the NHS, made her cry. For now, her time is taken up with rehearsals: she’s part of the ensemble and understudy for Nurse Ellie and Bevan’s sister Arianwen. But off-stage, Sara is Dr Otung, a senior house officer working in acute medicine. ‘It hit home to me what it took to make the NHS,’ says Dr Otung. ‘Is this also what it takes to keep it?’ Tim Price’s new play visits Bevan (played by Michael Sheen) in hospital in 1960, towards the end of his life, as morphine-induced dreams interweave with memories. Nye shows the fierce resistance Bevan’s National Health Service Bill faced, but it also portrays the steely determination of a man who left school at 13 to work in the local mine and who pushed through the ranks of trade unionism and politics to create a health service ‘free at the point of need’. Mr Price wants to remind today’s audience why Bevan fought so doggedly to exploit a particular moment and the wartime belief that collective action could ‘solve our big problems’. ‘Pre-1948, you had one GP covering 18,000 patients, and women’s healthcare didn’t really exist because they weren’t covered by the [workers’] insurance panels,’

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Political failings Dr Otung has paused her medical training to be part of Nye, but has enjoyed impromptu consultations with director Rufus Norris on protocols such as breaking bad news; Cardiff intensivist Matt Morgan is the official medical adviser for the play. She remains passionate about the NHS. Like Bevan and Mr Price, she grew up in the Welsh valleys and did not have a privileged upbringing. As a junior doctor in Cardiff, Dr Otung quickly learnt that political decisions affect practice on the ward, especially during COVID. She accepted the rapid rota shifts, the fact she could not see loved ones. But she struggled with the feeling that policymakers were not protecting health workers – or patients. She remembers vividly bma.org.uk/thedoctor

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the day personal protective equipment guidance changed and masks were downgraded. ‘I remember listening to a patient’s chest who I was sure had COVID and was coughing and I could feel the droplets going through my mask and thinking: This is not safe. My friend worked in a nursing home and they lost many of their clients.’

JOHAN PERSSON

he says. ‘If you were a woman or child or elderly [and you were sick], you lived in chronic pain.’ Four of Bevan’s nine siblings died in childhood; his father died of miners’ ‘black lung’ (pneumoconiosis). ‘Those with a living memory of what life was like without the NHS are increasingly no longer here,’ adds Mr Price. ‘The NHS is the reason we have this concept of British fairness. This idea that, in the eyes of health, everyone was equal was radical. It’s an argument we have to keep making: it’s permanently under attack.’ In England and Wales, deaths from infectious diseases such as tuberculosis fell sharply in the first 10 years of the NHS; infant mortality (under one year) fell by a third.

‘Us and them’ But even pre-pandemic, she realised that mounting systemic pressures threatened the workforce’s wellbeing. As a foundation year 1, she had cared for one patient for three months only to see them die of a cardiac arrest; despite performing CPR, she could not save them. Dr Otung was asked if she was OK and said ‘yes’ because the ward was understaffed and there were other patients still waiting to be seen. ‘I remember not being able to close their eyes when they passed away and how much that bothered me. I was the one who told the family that their loved one had died. It was the first time I had lost a patient in that way. I couldn’t stop washing my hands.’ It saddens Dr Otung that politics around pay have driven a wedge between healthcare workers and the public. ‘I hope we find a way back from this “us and them”. I need my nurse and my nurse needs me. If my nurse is telling me they’re drowning with their working conditions, I need to help them so they can help me.’ Working on Nye has taught her that the NHS needs champions outside its workforce, too.

‘You can’t save the NHS by staying late every shift, burning yourself out. The NHS is a political institution. We need a strong will, people like Bevan, to figure out how to make it work. Knowing how you got here has a big impact on how you move forward. The NHS is still needed, still possible. We can afford what we choose to afford.’

Nye runs at the Olivier in London 24 February to 11 May, then at the Wales Millennium Centre in Cardiff 18 May to 1 June.

REHEARSAL: Dr Otung with Michael Sheen, who plays Nye Bevan

‘It hit home to me what it took to make the NHS’

A National Theatre Live broadcast on 23 April will bring Nye to cinemas across the UK.

thedoctor | February 2024

12/02/2024 11:18

RICHARD SWINGLER

UNITED FRONT As junior doctors in Wales go on strike for the ﬁrst time, Ben Ireland hears their concerns, and speaks to other groups of doctors considering industrial action

unior doctors in Wales staged their first walkout of the BMA’s pay restoration campaign as colleagues in Northern Ireland continue to vote on whether to strike and those in England move to extend their mandate once more. Thousands of junior doctors in Wales embarked on a 72-hour strike from 15 January as they called on the Welsh Government to restore pay and prevent doctors leaving Wales. Since 2008, pay in Wales has eroded by nearly 30 per cent, leaving foundation year 1 doctors earning as little as £13.65 an hour – almost £2 an hour less than the £15.50 foundation year 1 doctors in England now get paid. In addition, junior doctors in Wales were offered just a 5 per cent uplift last year, less than the 6 per cent and one-off lump sum offered to their colleagues in England who are still striking until they receive an offer they consider ‘credible’. The Labour-led Welsh Government says it wants to restore doctors’ pay but blames a lack of funding from the Conservative Government in Westminster. Speaking to hundreds of doctors who gathered outside the Senedd in Cardiff on the second day of action, BMA Welsh junior doctors committee co-chair Oba Babs-Osibodu said: ‘No doctor today is worth less than a doctor that 16

came before. We are not going to back down, we’re not going to accept this any longer.’ Co-chair Peter Fahey added: ‘For too long we have stayed quiet. Strike action is the only way for our collective voice to be heard. Our strike is an act of self-respect.’

PROTEST: Junior doctors at the Senedd in Cardiﬀ

Passing the buck Theodora Okechukwu, a foundation year 2 working in Llanelli, attended the rally. She said the feeling among doctors in Wales was that the offer made by the Welsh Government was a ‘slap in the face’ after its previous commitment to work towards pay restoration. She said blaming the Westminster Government was unfounded, noting how the devolved Scottish Government was able to make a pay offer to junior doctors in Scotland which was accepted. ‘Even if your priority is to keep patients safe, the decision should have been taken to pay doctors appropriately, so that they don’t leave Wales to work elsewhere,’ Dr Okechukwu said. BMA deputy chair of council Emma Runswick also spoke at the Cardiff rally and stressed the importance of the Welsh Government’s previous commitment to work towards pay restoration. She said: ‘They have shown that those words

‘Strike action is the only way for our collective voice to be heard’

thedoctor | February 2024

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RICHARD SWINGLER

bma.org.uk/thedoctor

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RICHARD SWINGLER

were not worth any more than the paper they were written on.’ Junior doctors in Northern Ireland began voting on whether or not to take industrial action from 8 January. Their ballot runs until 19 February and a 24-hour walkout is planned from 7am on 6 March if doctors vote in favour. BMA Northern Ireland junior doctors committee co-chair Fiona Griffin said junior doctors in Northern Ireland are ‘the worst paid with the worst working conditions’ of any doctors of the UK nations. ‘This is why we are encouraging them to vote yes and to show the strength of their feeling both in the ballot and in subsequent strike action,’ said Dr Griffin, noting that strikes could be avoided if the recently renewed Northern Ireland Executive makes improvements to pay and conditions. Junior doctors in England, meanwhile, have moved to ballot for the third time following the conclusion of the longest walkout in NHS history they staged in the first week of January. The reballot opened on 7 February and runs until 20 March. If a ‘yes’ vote is returned the mandate for strike action in England would be extended to September. For the first time, junior doctors in England will also be asked to approve an ASOS (action short of a strike) as part of that mandate. It is intended to show how much the system has been relying on junior doctors’ goodwill. BMA junior doctors committee co-chairs Robert Laurenson and Vivek Trivedi said it was ‘disappointing’ that health secretary Victoria Atkins had not returned to negotiations at the time of the reballot announcement despite during the last action saying she could do so ‘in 20 minutes’ if no strikes were called.

‘It is clear the only way for the Government to move its position on pay restoration, and to finally start to grapple with the worsening workforce crisis, is to continue with industrial action,’ said Drs Laurenson and Trivedi. Junior doctors in England have announced their next strike dates, from 7am on 24 February to 11.59pm on 28 February. Consultants in England narrowly rejected the pay offer put to them in a referendum, with 51 per cent voting against. The BMA consultants committee chose not to call further strike action to give the Government an opportunity to improve its offer ‘to a point that may be acceptable to members’. BMA consultants committee chair Vishal Sharma said: ‘The vote has shown consultants do not feel the offer goes far enough to end the dispute and offer a long-term solution to the recruitment and retention crisis.’ Specialist, associate specialist and specialty doctors in England began voting on their pay offer from government on 29 January. The referendum is to close on 28 February. No strikes have yet been called but 94 per cent of SAS doctors voted in favour of industrial action in a recent ballot. In Wales, consultants and SAS doctors have begun voting on whether to strike over pay, which has been cut by almost a third in real terms since 2008/9. Their ballots run concurrently until 4 March. For more information on SAS doctors in England, see pages 20-21

STRONG SHOWING: Junior doctors in Cardiﬀ

‘The vote has shown that consultants do not feel the current oﬀer goes far enough’

thedoctor | February 2024

12/02/2024 11:19

GETTY

RAPID RESPONSE: The ethics guidance is easy to access and clearly presented

ONLINE ALLY Doctors can now find help online with the day-to-day dilemmas they face, as the core elements of the BMA’s ethics guidance have been digitally published. By Jennifer Trueland

t 925 pages long, weighing 1.5kg and costing more than £100 in hardback, Medical Ethics Today – the BMA’s Handbook of Ethics and Law has always been a big beast. However, now its core elements have been distilled into a new online version, which is instantly accessible and easily searchable, with content which can be constantly updated to consider the latest guidance or changes in law. According to Julian Sheather, specialist adviser (ethics and human rights) with the BMA, it was time to move the core guidance online. ‘Previously we brought out a new edition of Medical Ethics Today every five to 10 years but the books became 18

extremely large and, with things being so fast-moving in the field, it was difficult to keep them up to date. ‘We decided to replace the book with an online version of our core ethical guidance, which covers those areas where doctors most routinely encounter ethical questions and dilemmas in their practice.’ It covers real-world issues based on actual problems identified by doctors, he says, and provides a framework for making ethical decisions. ‘For example, someone might want to know how long to keep medical records, or what if the police want access to medical records – they might be asking “can I provide them?” or “what would I need to take into consideration?”. ‘There are a lot of

questions doctors ask where there is a straightforward legal answer. But there are also areas where the law is silent, or it says you can do this, but you need to make a judgement or a decision. Even if there’s a legal answer, and that can be helpful, it can still leave a lot up to professional judgement. It’s in these areas where ethical advice is necessary.’

Practical design The guidance contains a flowchart of how to approach ethical questions, he adds, including what to take into consideration when coming to a decision. It is also completely up to date with GMC guidance and policy – and will be updated when this changes. ‘This is the first time we’ve

‘It’s focused on the sorts of things doctors will confront day in, day out’

‘It’s accessible to those who might not be experts in a particular area’

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The core ethics guidance falls under six main headings: ow to approach an H ethical question WISE: ‘We want people to be able to work things out for themselves’

brought out a very navigable, searchable core set of guidance. I think it will be extremely helpful for medical students and practising doctors because it’s all in one place, it’s practically orientated, it’s designed specifically for doctors – and it’s highly practical. It’s focused on the sorts of things doctors will confront day in, day out – things such as confidentiality and data protection that we in the BMA ethics department get questions about all the time. That’s front and centre of this new guidance.’

Staying safe Jan Wise, chair of the BMA medical ethics committee, says the guidance is invaluable for all doctors, but perhaps especially for those starting out in their careers. In his experience as an educator, medical students find ethics ‘phenomenally interesting’, and already find it incredibly useful to access guidance with real examples, rooted in actual practice. Putting it online – and easily searchable – will make it even more so. ‘When you’ve been in the field for two or three or even more decades and bma.org.uk/thedoctor

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SHEATHER: Guidance covers real-world issues

you’ve dealt with problems thousands of times, it’s a well-trodden path. But to someone who’s coming to the forest for the first time, the path isn’t clear. We want people to be able to work things out for themselves, and that’s where the BMA’s ethics guidance can be invaluable. It’s not doing it for them, it’s helping them to find the way for themselves to navigate so that they can do it again, and again, and again. ‘It’s easy for people like me who have been around for a long time to pontificate and say it’s obvious – well, if it was that obvious you wouldn’t need the contents of a book that’s 1.5kg.’ Different people need parts of the guidance at different points in their careers, he adds. ‘I’m not terribly familiar with the ins and outs of the bits which apply to children because I treat adults,’ adds Dr Wise, who is a psychiatrist. ‘But it’s written in such a way that it’s accessible or understandable to those who might not be experts in a particular area, so that when they need it, the map is there – the guidance to keep them safe.’ bma.org.uk/core-ethics

The doctor-patient relationship Consent and refusal by adults with decision-making capacity Mental capacity Children and young people Confidentiality

Toolkits for doctors New and revised toolkits were published on the BMA website on 31 January covering topics which are UK-wide and specific to the devolved nations. These toolkits form the individual components of the new core guidance. All have been updated to refer to new GMC guidance that came into effect on 30 January. The toolkits are: – How to approach an ethical question – Doctor-patient relationship – Confidentiality – Consent – Children and young people. There will also be new versions of toolkits on capacity and incapacity, covering the situation in different nations of the UK. These are: – Mental Capacity Act – England and Wales – Adults with Incapacity in Scotland – Mental Capacity in Northern Ireland.

thedoctor | February 2024

12/02/2024 11:20

SAS DOCTORS VOTE ON PAY OFFER After months of negotiations with the Government, SAS doctors in England are voting on whether to accept an offer to improve pay and conditions. By Tim Tonkin

aking your voice heard can make a difference. After months of negotiations with the Government aimed at securing improvements to pay and conditions, the BMA specialist, associate specialist and specialty doctors committee voted to present a final government offer to SAS doctors in England on 18 December. The offer, which would see uplifts in pay for SAS doctors on the 2021 contracts of between 6 and 9 per cent, was announced on the same day a formal ballot for industrial action returned a mandate for change, with the majority of participants backing strike action. While SAS doctors in England are yet to follow their consultant and junior doctor colleagues on to the picket lines, the decision of what happens next remains firmly in their hands, with a referendum on whether to accept or reject the offer now under way. 20

‘This offer represents a first step towards righting some of the wrongs we have faced’

While SASC is not taking a position on how members cast their votes, it is eager for doctors to have the full facts and detail of the offer before reaching a decision. Like many of their medical colleagues across the NHS, SAS doctors have endured a significant fall in real-terms pay in the past 15 years, with rising inflation and exclusion of the new contracts from pay awards granted by the Review Body on Doctors’ and Dentists’ Remuneration – the driving force behind balloting for industrial action. Under the terms of the offer made in December, pay scales for doctors on the 2021 contracts will see a basic pay increase of 6 to 9 per cent, depending on their pay point. Should the offer be approved, the changes in pay would be implemented this spring and backdated to 1 January. These pay-scale changes are separate to, and will not affect, future awards recommended by the review body and made through the

annual pay review process. The increases would not apply to doctors employed under closed contracts, such as the 2008 specialty doctor contract, although these individuals would be given indefinite eligibility to transfer to the 2021 contracts.

Funding offer As well as increases in pay, the offer to SAS doctors in England would seek to address the issue of career progression by providing a £5m fund to create specialist roles, providing opportunities for specialty doctors to progress in their careers. Roles created with this funding would only be open to internal candidates in the first round of recruitment, to help this progression. If a doctor moved from the specialty doctor to specialist grade, the funding could be used to cover the difference in salary provided the former post was not backfilled. The terms of the offer would ensure a commitment by the Department of Health,

thedoctor | February 2024

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BMA

MOHITE: ‘We need you to tell us what you think’

NHS Employers and NHS England to work together with the BMA on several measures to support progression, from promoting job planning to creating advice and guidance on promoting the specialist role, to conducting research into why more specialist roles haven’t been created and what can be done to address this. All four groups would also work together to better understand the make-up of the LED (locally employed doctor) workforce. This would include examining their contractual terms and needs, and enabling these doctors, where suitable, to move onto permanent SAS contracts. Work would also potentially include the development of a process by which all LEDs who have been fulfilling a role comparable with the duties and responsibilities of an SAS doctor for 24 months or more, should be offered the option to move to an SAS contract. Meanwhile, doctors unable to meet these criteria who have been kept on bma.org.uk/thedoctor

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‘No SAS doctor wishes to strike, but be assured, our mandate for industrial action remains strong’

temporary contracts should be offered the option to be made permanent. There would be a further agreement to promote the statutory right of LEDs with four or more years of continuous service on successive fixedterm contracts to be made permanent. Should members vote to accept the offer, SASC would agree to a withdrawal of the BMA rate card for SAS doctors performing extracontractual work in England, with the condition that the card can be re-applied in the event of a future industrial dispute.

Negotiations As the referendum gets under way, SASC UK chair Ujjwala Anand Mohite urged her colleagues to verse themselves in the details of the offer, adding that the collective interests and wishes of SAS doctors would continue to guide the committee whatever the outcome of the vote. She said: ‘This offer, reached after painstaking negotiations with the Government, represents a

step towards righting some of the wrongs that we as SAS doctors have faced and continue to face. ‘The BMA does not have a vested interest in the result of the referendum. As an association our first and foremost duty is to represent the will of our members. ‘We need you to tell us what you think by taking part in the referendum.’ She added: ‘No SAS doctor wishes to strike, but be assured, our mandate for industrial action remains strong. I urge all of you to truly consider the terms of this offer, and to use your vote to once again make your voices heard.’ Should SAS doctors vote to accept the offer, the possibility of industrial action will end with the deal implemented by April this year. A rejection could see steps towards SAS doctor strikes in England. The referendum closes at 5pm on Wednesday 28 February. For more information go to bma.org.uk/sasoffer thedoctor | February 2024

12/02/2024 11:21

Your BMA In our workplaces, and at the BMA, we should value challenge, conversation and criticism

thedoctor

‘Latifa needs to know when it’s not her place to comment.’ I was taken aback when I read those words on my multi-source feedback form at a former, non-clinical, healthcare employer. To me, this read like I was being asked to be seen and not heard. It felt like constructive criticism wasn’t welcome if it came from someone like me. People like me should just observe and nod, it seemed. I was a senior registrar at the time. People used to call me a critical friend and sometimes I was regarded as outspoken. But I felt all of this was to the organisation’s benefit. I was confident I was using my voice to ensure more viewpoints were heard – that I was trying to help colleagues, structures and systems improve. But they didn’t want to hear it. I think that said a lot about the culture of the organisation – what sort of institution operates with leaders who think it is appropriate to say, ‘don’t be critical, because we don’t want to hear it’? I reflected on the experience later, on a podcast called Dare to Disagree with a friend who is, tragically, no longer with us. We talked about criticism and constructive criticism, and it is through conversations and reflections like this that I have come to my strong view I should actively seek the thoughts of people who don’t always – in fact often don’t – agree with me. Fundamentally, I think that is a helpful and positive approach. If we all think the same, or if we surround ourselves with ‘yes people’, I think it is hard to progress as people and organisations. Sometimes I think we all need reminding of this – of how important challenge, conversation and criticism are.

The Doctor

I thought about this experience on a few occasions recently when I had messages from members – which I always encourage and appreciate – who feel that some of our BMA policy doesn’t apply to them, that it perhaps doesn’t reflect their views or experiences. Among the areas members have raised recently are current policy on physician associates, and our policy and campaign for full pay restoration. Your BMA policy is made democratically by members who attend our conferences – whether those are branch-of-practice conferences or the BMA annual representative meeting, which I chair. But we should always keep the spirit of conversation, challenge, and criticism – and the positive effects those things can bring – close to our hearts. It’s not enough to just tell people how things work currently. I strive to be a representative body chair who encourages and embraces diversity and a plurality of views. I tell those people – and I am telling you – that we need your voices to improve what we do. We need you to be in the room when policy is debated and voted on. We need people to speak against policy that passes because it helps to hone better quality, more thoughtful policy. And we need to give a platform to speakers against policy that passes, too, because we are all better off with richer debate. I understand that people disagree. I’m acutely aware our membership is some 190,000 members and there is no way the policy we ultimately produce is going to make every single member feel advocated for and represented. The only way to do this better is to have more people speak up – people from diverse backgrounds with diverse views and diverse experiences. Democracy is good – but we can always do democracy better. If you want to influence policy – to feel represented – please put your name down for a conference, submit motions and speak for or against those being proposed. It takes everyone to make the BMA the best it can be. Watch our conferences live on the web and join the conversations on social media. Write to your representatives. Write to me. I welcome your challenge, your conversation, and your criticism. I’m listening. You can contact me directly via X @DrLatifaPatel or email me at rbchair@bma.org.uk Dr Latifa Patel is chair of the BMA representative body

Editor: Neil Hallows (020) 7383 6321

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

Chief sub-editor: Chris Patterson

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: 8417 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: Brian Morrison Read more from The Doctor online at bma.org.uk/thedoctor

12/02/2024 11:22

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