The Doctor – issue 6, February 2019

The magazine for BMA members

thedoctor

Issue 6 | February 2019

Promises, promises

Can the NHS Long Term Plan really make a difference?

How does it feel?

A junior doctor’s working life told through seven emotions

A job’s worth

Asking what managers with funny sounding titles actually do

Have confidence Fresh hopes for SAS doctors to win the recognition and opportunities they deserve

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The Doctor BMA House Tavistock Square London WC1H 9JP Tel: (020) 7387 4499

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0300 123 1233 @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 £160 (UK) or £225 (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 YM Chantry. A copy may be obtained from the publishers on written request.

The Doctor is a supplement of BMJ vol: 364 issue no: 8187

Senior staff writers Peter Blackburn (020) 7874 7398 Keith Cooper (020) 7383 6390 Staff writer Tim Tonkin (020) 7383 6753 Northern Ireland news email news@bma.org.uk Scotland correspondent Jennifer Trueland 07775 803 795 Wales correspondent Richard Gurner 07786 035 874 Senior production editor Lisa Bott-Hansson Designer Victoria Rossique

ISSN 2631-6412

02

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In this issue 4-5 Briefing

Tackling GP burnout, consultants take a stand and the future of medicine

6-9

Promises, promises

Welcome Chaand Nagpaul, BMA council chair Sometimes it is the things left unsaid that are the most revealing.

The NHS Long Term Plan contains many welcome promises.

It says it will address many areas where the BMA has long called for change: the dismantling of the costly and inefficient internal market, increased integration of services, and a much-needed focus on primary care and prevention, to name just a few.

But, as our feature in this issue suggests, this could well be a castle built on sand – and it is those things left unsaid that threaten to undermine it. Omitted from the plan is any genuine solution to the workforce crisis which grips the NHS. Our hospitals and GP surgeries are riddled with vacancies – and stretched to breaking point – and those problems are only likely to increase as the Brexit uncertainty continues.

On top of that, this long-term plan does not give any serious reference to social care. The long-awaited Government green paper is still on the way, apparently, as it has been for months.

In the meantime, a lack of social-care capacity means that patients who could be cared for in the community all too often end up being admitted to hospitals, while in turn hospitals remain unable to free up beds taken by patients fit to leave.

This issue of The Doctor also reveals the latest on negotiations to reopen the long closed associate specialist grade. This could offer staff, associate specialist and specialty doctors more options for career progress, leadership roles and improved pay.

Also, we look at a scheme which helps give guidance and support to doctors coming into the NHS from overseas.

Our workforce represents everything that’s best about multicultural society – people from across the world come together to provide high-quality care at the point of need irrelevant of their first languages or birthplaces.

However, coming into a high-pressure environment in an unfamiliar country can be a daunting experience and cultural challenges can result in a poorer experience for staff and patients. Professional and pastoral support must be available whenever needed.

Will the NHS Long Term Plan be dented by existing demands?

10-13

How does it feel?

Former Secret Doctor Aoife Abbey’s new book tells the story of her working life through seven emotions

14-17

BMA writing competition A junior doctor’s demoralising first day, and asking what weirdly titled NHS managers actually do

18-21

AS you like it SAS doctors have a renewed optimism that the associate specialist grade will reopen

22-23

The other NHS Fighting for equity of care for people with learning disabilities

24-25

Guiding light A mentor can be invaluable for overseas doctors new to the UK

26-30

Life experience Loo breaks, interviews and cancer care

31

What’s on Keep on top of events

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WANNAN: Highlighting protection available in consultants’ contracts

briefing

RAO: ‘We live in fear’

Current issues facing doctors

VAUTREY: On the road to rebuilding general practice

04

Battle against burnout ‘I’m in love with the NHS,’ Leicestershire GP Annapurna Rao told last year’s BMA annual representative meeting. ‘But if there was an award for the best employer I don’t think it would be in the running.

‘Burnout, stress, we never used to hear this – now it’s an everyday feature of our lives. We live in fear. I don’t know when my next complaint will come. I know only one thing – I will be stressed and burnt out.’

For too long this has been daily life in general practice. At the same event last year, BMA GPs committee chair Richard Vautrey said the foundations of general practice were breaking under this weight. There have been numerous reports of GPs handing back their contracts.

But for Dr Vautrey, the announcement of the new GP contract in England – which looks to address many of the ongoing issues doctors face in their daily lives – could be a turning point.

The contract covers the next five years and aims to address the workforce and workload pressures facing GPs in a bid to help general practice play an increasingly prominent role in the NHS, as outlined in the recently published NHS Long Term Plan.

Included is a much-awaited, state-backed indemnity scheme for all GPs and others working for GP providers, and funding which will allow for pay rises for all practice staff.

The contract will also see primary care networks – areas covering 30,000 to 50,000 patients – developed, with each led by a GP in a clinical director role. Each area will be given funding to employ social prescribing link workers, clinical pharmacists, physician associates, practice-based physiotherapists and paramedics, with NHS England stating it will expand the primary care workforce by more than 20,000 – aimed at improving patient experience and managing GP workloads.

The contract also supports ambitions to utilise technology as an aid against challenges of demand, promising increased digital access for patients and making more appointments bookable online.

And as part of negotiations the BMA and NHS England have agreed to make a joint representation to the Government surrounding proposals to reduce the problem created by the pension annual allowance, to address the effect this is having on GP recruitment and retention.

Dr Vautrey said: ‘This package sets us on the road to rebuilding not only general practice but also the wider primary healthcare team; delivering an expanded workforce embedded within practices and giving GPs a leadership role in bringing together the community healthcare team.’

Find out more about the new GP contract at bma.org.uk/ gpagreement

More for less Here’s a few things we know about consultants.

Their average post-tax pay rise this year was a weekly £6.10.

Many face considerable tax penalties on their pensions after decades in the NHS (HM Revenue and Customs’ reward for a hard-working life of public service).

Then there’s the day-to-day.

The regular round of ‘job planning’ meetings, where they’re supposed to reach a ‘collaborative’ agreement with managers about workload. Yet one in four feel bullied by them. More than that, if you’re female or from a black or minority ethnic background, a recent BMA poll found.

‘We are starkly aware that consultants are being asked to do more and more for less and less,’ said BMA consultants committee acting chair Gary Wannan.

Consultants are in no way defenceless in the workplace of course.

No one with an employment contract is.

This is the context of the BMA’s new campaign, Know Your Rights, which aims to help consultants know the protections available to them in their contracts.

It will focus on areas such as job planning, flexible working, pensions, pay, and annual leave. It will also highlight the help available, and what is being done to improve collective rights nationally.

‘Employers have taken advantage of consultants’ goodwill for too long,’ Dr Wannan said. ‘Enough is enough.’

Another source of help can be found in the BMA’s recently launched Dr Diary app, which is for consultants, staff, associate specialist and specialty doctors and medical academics, and helps keep track of workload to inform job planning meetings.

For more information about Know Your Rights, visit bma.org.uk/ knowyourrights

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Five steps to the future Medicine has never been able to do so much for an individual.

The big question is what it can do, sustainably, for a whole population.

How a ‘universal’ health service adapts to an ageing population, ever-greater cost pressures and rapid technological change, is a hugely important issue.

And it provokes a spectrum of responses, from the odd Silicon Valley-type who believes we just need to develop a good enough app, to those who, like Dad’s Army’s Private Frazer, look at the projections and conclude ‘we’re doomed’.

Between those poles, there are a number of humane and pragmatic initiatives.

One of them is the Changing Face of Medicine project, based at the Academy of Medical Royal Colleges. It’s a multidisciplinary venture, which aims to re-evaluate medicine and healthcare by focusing on fi ve areas central to the changes likely to affect medicine.

These are: public-patientdoctor engagement, technology, doctors’ wellbeing, leadership and rethinking medical education.

The project is led by a professor of primary care and former BMA president Pali Hungin.

As well as helping to shape and create future health policy, the project aims to facilitate discussions between doctors and patient groups, and provide

a forum for junior members of the profession whose careers will need to adapt to future changes.

In doing so, the project’s leaders hope that their work will anticipate how the role of doctor might change and what it will look like by the year 2040.

‘Imagining the future, without being caught up in the mores of today, is a formidable ask,’ said Professor Hungin.

He promised ‘unfettered thinking about how society, medicine and clinicians might look in the future and how to take up a new mindset’.

One interesting feature of the predictions we often come up with is that they’re not particularly futuristic.

In the 1960s, the future meant space suits and unimaginably powerful computers. Now that we’ve done space, and got the internet, the predictions these days appear to be more grounded.

A recent book by consultant gastroenterologist Seamus O’Mahony, Can medicine be cured? – which aims in the author’s words to provoke a debate about ‘what we’re doing, where we’re going, what we’re about and what medicine is for’ – makes the case for doing not everything, but some things well and usefully.

‘Medicine is not about curing all diseases and increasing longevity indefinitely, it’s about easing the path of people from the cradle to the grave and

Keep in touch with the BMA online at

making the conditions of human life more tolerable,’ he said.

A life ‘more tolerable’.

It sounds modest but achieving it may well require the collective wits of this and future generations. As we come to terms with the pace of change, it’s not a bad objective to keep in mind.

HUNGIN: ‘Imagining the future without being caught up in the mores of today’

Read more online ‘Inter-deanery transfer restrictions relaxed’ “‘Lead” posts for SAS grade’ ‘Sexual assault investigation bungled, finds report’ ‘RB chair wins anaesthetists’ award’ ‘Call to reduce risks to GP partners’ ‘Plan to change the face of medicine’ Read all the latest stories online at bma.org.uk/news

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Promises, promises The NHS Long Term Plan makes welcome pledges on tackling the sources of ill health and promoting integration but, with the funding likely to be swallowed by existing demands, can it really make a difference? Peter Blackburn reports

‘T

his is a historic moment. Our vision is clear. Our commitment is assured. So let’s deliver the NHS of the future.’

Cynicism may have been the overwhelming feeling for many at prime minister Theresa May’s speech last month, unveiling the future vision for the NHS in England.

After all, this is a government that has given little regard to the health service, NHS staff and patients during Brexit negotiations, that promises much and delivers little – 5,000 more GPs springs to mind – and it follows a government led by many of the same parliamentarians who claimed to have ‘fully funded’ the NHS, despite presiding over an era of record-breaking strain on frontline services and wholesale cuts to budgets.

It is also the second plan aimed at revolutionising the health service this decade.

The previous iteration, the ‘five-year forward view’, hailed as an opportunity to revitalise the way care is planned and delivered, was undermined by profound cuts to budgets, soaring demand and catastrophic failures in recruitment and retention of staff.

So what are the odds on the Government and NHS England’s latest plan delivering ‘the NHS of the future’ – one which the prime minister claims will deliver radical improvements to technology, workforce and infrastructure and will deliver a ‘more integrated’ health service focused on ‘prevention and early diagnosis’?

Unlike the five-year forward view, NHS England chief executive Simon Stevens’s latest plan is actually backed with some sort of finance; rather than requiring cuts of around £20bn, this iteration is backed by year-on-year real-terms funding rises of around 3.4 per cent.

The result of that pledge is that NHS spending will increase by £20.5bn in real terms, from £114.6bn in 2018/19 to £135bn in 2023/24. While something of a departure from the recent trend, it’s a smaller increase than the average 3.7 per cent increase which the Health Foundation calculated the NHS received between its formation in 1948 and 2016/17.

Treading water If the health service wants to do more than ‘stand still’ in keeping up with an ageing population and other cost pressures, and actually genuinely transform services, it is reckoned that it would need considerably more.

As BMA council chair Chaand Nagpaul says: ‘Ultimately, there is a need for honesty about how far the £20.5bn over five years will stretch.

‘World-class care requires world-class funding and the investment in the NHS Long Term Plan will still leave the UK falling behind comparative nations such as France and Germany.’

While evidently not a genuinely transformative amount of funding, the Government’s commitment does mean there are conversations to be had about what the health service can do and where it should change, rather than simply where the axe must fall. And this is where the plan comes in.

At the top of Mr Stevens’s agenda is prevention. For many doctors it may be galling that this intention is outlined after seemingly endless warnings from public health leaders and 17 years after the publication of Derek Wanless’s health review, which said poor levels of health in the population would see considerable

‘The investment in the NHS Long Term Plan will still leave the UK falling behind comparative nations’

STEVENS: Renewed emphasis on prevention

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Core public health grant made to local government (2018/19 prices)

£2.9 £2.3 2014/15

pressure on the NHS, swamping Government investment in services. Sir Derek’s report urged prevention to be placed at the centre of health policy.

‘This was all predicted, so it’s not a surprise that we find ourselves needing to rediscover the lessons previous generations have taught us,’ BMA public health medicine committee local authority lead Sohail Bhatti says.

With regard to prevention, the plan focuses on the top five lifestyle factors leading to premature death in England: smoking, poor diet, high blood pressure, obesity, and alcohol and drug use. It also references air pollution and lack of exercise.

In a bid to tackle these problems it suggests offering NHS-funded tobacco treatment to people admitted to hospital, doubling funding for the NHS diabetes prevention programme and establishing alcohol-care teams in hospitals where need is greatest.

For Dr Bhatti, the NHS Long Term Plan is a positive step but one which fails to address the mistakes of the past – and those mistakes could threaten its success.

He says: ‘There is lots of good stuff in there, no doubt there’s some really good ideas. People should take more responsibility for their health and if we encourage people to keep themselves healthy that’s all for the better – but it’s duplicitous to be cutting public health funding at the same time.

You can’t say one thing and do the other.’

Funds slashed Research from the Health Foundation last year found that £3.2bn a year would be required to reverse the effects of the cuts Dr Bhatti talks about – with funding falling by £700m since

2018/19

2014/15, a fall of almost a quarter per person in the country, owing to austerity measures placed on local authorities.

Dr Bhatti says: ‘The guillotine fell on the big budgets – drugs and alcohol, sexual health and zero to 18 children’s services. As they have the biggest budgets they have the most obvious cuts. My experience is people in local authorities tried really hard to get the same level of service for less money but if you suck as much out as you can, eventually you fail because fundamentally you don’t have enough money. In the long run services fall over.’

While it must be a positive step for prevention to be in vogue, these are ideas likely to be confounded by the brutal cuts that have been before – and an unwillingness to look to effective population-wide measures, such as a minimum unit price for alcohol; reducing sugar levels in food; and greater restrictions on junk-food marketing.

For Dr Bhatti, talk of prevention is cheap, and action would speak much more loudly.

‘There’s no point fiddling while Rome burns,’ he says.

One of the plan’s biggest focuses is on reforming services – particularly boosting primary and community care, personalising care, increasing digitalisation and, perhaps most prominently, local integration.

billion

The Government’s NHS Long Term Plan makes tackling the causes of ill health a priority – but in recent years it has spent less and less

‘It’s duplicitous to be cutting public health funding at the same time’

BHATTI: Counterproductive public health cuts

Integrated care More care will be expected to be provided at urgent treatment centres, rather than emergency departments, with more being unveiled across the country. Multidisciplinary teams are to be set up in primary care networks which GP practices will be asked thedoctor | February 2019 07

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Youth drug and alcohol services

Obesity in adults

-32% -29% -19% -9% -18%

Percentage falls in real-terms public health grant spending between 2014/15 and 2018/19

Sexual health services

to join, and 200,000 more people are to be given a personal health budget by 2023/24.

It also suggests every patient will have a right to access telephone and online consultations within the next five years.

Integrated arrangements, where different parts of a local health system are asked to come together to plan care for patients jointly in their area, are now expected to cover the whole country by April 2021 with integrated care systems, which are voluntary partnerships, and integrated care providers, contracted bodies responsible for an area’s services, supported by NHS England.

The BMA has consistently welcomed greater integration and reduced duplication of services, while insisting the proper investment must be available to achieve it.

Dr Bhatti says: ‘I would welcome greater integration but it shouldn’t be about saving money – it should be about better outcomes and better flow.’

But there is one main stumbling block in the path of this integrated future for the NHS: legislation. The 2012 Health and Social Care Act enshrines competition and procurement regulations – facilitating a bloated internal market and tendering bureaucracy. Until parts of this system are gone, integrated care will go nowhere fast.

And NHS England has dropped welcome hints that change could be on the way in the plan – suggesting legislative changes would enable ‘more rapid progress’.

The plan suggests impediments to ‘placebased’ commissioning – another term for integrated-care arrangements where services are planned and provided by a body or group of organisations for their local area – could be removed. And it also suggests allowing the creation of ‘integrated care trusts’, the removal of general competition rules and cuts to procurement processes.

Dr Nagpaul says: ‘At a time when the NHS

Adult drug and alcohol services

Stop smoking services /tobacco control

can least afford it, too much time and money is spent on tendering processes for contracts.

Given the long waits for treatment and the cash-strapped state of our health service, time and money should be spent on the front line, delivering better care to patients, not on costly tenders.

‘These competition rules have also resulted in a fragmented NHS driven by commercial motives rather than providing patients with seamless care.

‘When Government rhetoric is centred around integration within the health service, independent providers bidding on time-limited contracts sits entirely at odds with this philosophy. Only by removing the requirement to put services out to tender, can local systems work together to ensure cohesive patient-centred healthcare.’

In mental health, the plan renews the previously asserted commitment to grow investment in mental health services faster than the NHS budget overall for each of the next five years, including expanding access to Improving Access to Psychological Therapies services and ridding the NHS of out-of-area placements. However, the promises are vague, according to BMA consultants committee mental health lead Andrew Molodynski.

‘What they are doing is good in a way and it is sustaining some improved investment but it’s actually only really holding the position where we are now. This money is not going to be transformative, it’s just looking to keep us where we are,’ Dr Molodynski says.

‘In all branches of the service – children’s services, which get the most publicity, adult services and older adults’ services – across the country there have been very significant increases in demand in the past five or six years. My service has had an increase from 350 to 600 referrals a year in five years and that’s not unusual.

‘People don’t like to talk about it but the

‘I would welcome greater integration but it shouldn’t be about saving money’

NAGPAUL: ‘Time and money should be spent on the front line’

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Increase in spending needed is:

£3.2 billion ... to restore the public health grant in real terms and implement the spending allocation suggested by the ACRA formula, without any area experiencing a loss.

ACRA – the Advisory Committee on Resource Allocation – is an independent body which makes recommendations on the preferred geographical distribution of resources for health services.

Source: Taking Our Health for Granted: Plugging the Public Health Grant Funding Gap, The Health Foundation, October, 2018.

Figures refer to England

truth is that this has decreased quality of patient care – unless we increase investment to meet demand this will worsen further.’

Dr Molodynski adds: ‘General mental health services need to be properly supported – there has been a lot of policy and financial announcements for small services, crucially important ones, and that’s great, but general services which look after the vast majority of people get neglected.’

No direction Arguably the most significant aspect of the NHS Long Term Plan is not what it contains, but what it doesn’t contain – a genuine workforce strategy.

A document of some sort is apparently planned for later in the year, but the worry for those working in the NHS is that this workforce crisis – the NHS is short of around 100,000 frontline staff – has been a long time coming and exclusion from a grand plan for the service’s future seems ominous.

Nottingham GP Irfan Malik says: ‘The plan can’t work unless there’s adequate staffing.

Certainly, in general practice, the staffing is going lower and lower. There are more vacancies and you can even struggle to get locums in some places now.’

The plan was, however, followed this month with the announcement of a new five-year GP contract in England, which includes a promise to expand the workforce by 20,000, to include physician associates, practice-based physiotherapists and paramedics.

It also enables newly formed primary care networks to employ at least one social prescribing link worker and one clinical pharmacist.

BMA GPs committee chair Richard Vautrey said the measures, and others in the contract, would begin to address the unsustainable situation of GPs being overstretched, and in many cases choosing to leave the profession.

One significant omission, which would have given the long-term plan more credibility, is the long-promised Government green paper on social care – originally due last autumn.

Many would argue that, alongside workforce issues, the decimation of social care is actually the greatest problem facing the NHS. Community services have been hollowed out and the strain is showing in hospitals where bed occupancy is at dangerous levels – leaving the whole system blocked, at great cost.

For Ms May this plan marks a chance to deliver the ‘NHS of the future’. However, for the doctors working in the health service, another change of direction will feel like groundhog day. So can things actually be different this time?

In short, and rather contrary fashion, it seems the answer is yes, and no. This plan often has its heart in the right place – its ambitions are largely positive; they often outline an NHS with better priorities and which could have better outcomes, but without serious movement to address splintered public health and mental health, a decimated workforce and crippled social care these would be foundations built on quickly shifting sand.

If the prime minister’s commitment really is ‘assured’, then the plan will simply mark the start of a serious process and the beginning of the genuine investment. There is much more work to do.

‘The sustainability of the NHS requires a robust workforce plan that addresses the reality of the staffing crisis’

MOLODYNSKI: General mental health services need support

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EDWARD MOSS

How does it feel?

How many emotions do you get through in a working day?

Our former Secret Doctor Aoife Abbey has chosen seven, for a major new book in which she recounts her life as an intensive care trainee.

Neil Hallows reports

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T

BLOG BUSTER: Aoife Abbey was the BMA’s most successful blogger of all time

he Secret Doctor reveals everything except their name.

You know them through the situations in which they have struggled, the colleagues with whom they have battled, the patients who they have inspired or infuriated. You get a strong sense of what drives them, of what they would be like to work with – but you don’t know who they are or where they practise. That’s how it works.

So, Aoife Abbey’s decision last year to ‘out’ herself and stop writing the blog provoked mixed emotions.

There was sadness – the ‘mouthpiece of my subconscious’ as one of her doctor readers put it – was the BMA’s most successful blogger of all time (we were fortunate to find a firstrate successor). However, there was also huge pride and excitement at the very specific reason for her coming out of the shadows.

That reason was an invitation from Vintage – which publishes such classics as When Breath Becomes Air – to the Coventry specialty trainee 6 to share her writing with an even wider audience.

Her book – Seven Signs of Life: Stories from an Intensive Care Doctor – was published on 7 February.

For a doctor who had started her writing career a few years earlier by sending some blogs to the BMA website, it was a huge but daunting opportunity. She had no shortage of vivid experiences on which to draw, and was clearly a gifted storyteller but what was the best way to get these across?

She considered presenting

them in the form of a diary but then came up with something far more novel. She has written a book of seven chapters and each covers an emotion. There is fear, grief, joy, hope, anger, disgust and distraction. Under the umbrella of these chapter headings are experiences profound, exposing and often unexpected in terms of the emotions they provoke.

It’s a love letter to her specialty, or perhaps more an anniversary card between a couple who have learned each other’s failings but love nonetheless.

‘The question, “what would you have done?” is always implicit’

Chess moves Intensive care can seem a quietly mesmerising place to outsiders. There is a Monty Python sketch where doctors are in diagnostic reverence of the ‘machine that goes ping’. Screen after screen, tube after tube. Staff can feel, in the recent words of an intensive care consultant, like they are playing a long game of chess with the readings and the patient can seem slightly lost in this complexity, rarely conscious, a collection of indications.

One of Dr Abbey’s achievements in her writing is to never lose sight of the patient among the pings.

‘There is a huge amount of effort trying to “line up the numbers” in an intensivecare patient,’ she says. ‘But I think you have to balance that with the more normal things, with thinking about who your patient is.’

Sometimes patients present themselves, quite unexpectedly. She tells a story reminiscent of Oliver Sacks’s Awakenings about a woman called Rose who thedoctor | February 2019 11

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Fleeting moments of joy Finding joy in small advances, or hope in a patient’s outcome, you might think they were the two easiest chapters to write.

But they weren’t, for both have a certain baggage.

Moments of joy, as with Rose, might be fleeting. It’s a nuanced happiness, ‘for

very specific reasons, and you know what happens in the end, and the patient is still chronically ill’.

And as for hope, Shakespeare might have been right that ‘the miserable have no other medicine’ but Dr Abbey speaks of a slightly treacherous commodity where doctors might have it but fear sharing it in case they raise false expectations. It’s where Herculean effort is put into helping the 2, or however many, per cent to live, and those people then say they ‘defied’ their doctors by surviving, as if it were some kind of battle.

Anger, meanwhile, was easier to write – but raises different questions. Is it ever OK to be angry at work?

‘There is a tendency to vilify anger,’ she says. ‘If you say that you are angry, people will assume that you have an anger-management problem.’ Such moments rarely come across well in print, especially in the environment of constant monitoring which junior doctors, especially, face.

Dr Abbey smiles: ‘I can be quite fierce. For me, I think it’s for a good reason. I am trying to hold to a standard.

If you can’t get angry about certain things, how else do you know what needs changing? Maybe anger isn’t even the right word, maybe it’s just passion, or a sense of what’s right and wrong.’

If you want to make Dr Abbey angry, try being a prison guard who brings in an intubated patient and insists on remaining chained to him when the exasperated doctor explains that he might need shocking and he ‘literally

‘There is a tendency to vilify anger’

EDWARD MOSS

sometimes sang or shouted in short bursts but was completely unresponsive to questions. Then she suddenly asks for a crossword and answers every clue. The next day she has returned to her previous state.

‘I sometimes think this might be the most exhilarating, joyous and yet simultaneously sad memory that I have of medicine,’ she writes.

Rose may have briefly revealed her personality, but this being a specialty where the patients are often unconscious, doctors can need some help in contextualising them. Dr Abbey says she makes a conscious effort to find out about their lives from family members, to make a better connection with them.

Even a photograph of normal times can help.

‘One of the things I really love is when patients have their pictures in frames on their lockers. A lot of time the patients can’t see them because they’re not awake or conscious, but you can see it, and you look at it and think oh, that’s them. You can tell who they are.’

It’s a specialty where a patient may have only a 2 per cent chance of survival ‘but if we don’t have enough hope that we can see the 2 per cent, then what is intensive care for?’

LIVED AND FELT Dr Abbey focuses on fear, grief, joy, hope, anger, disgust and distraction

Find out more about the Secret Doctor blog, dip into the huge range of topics covered by Dr Abbey and the other Secret Doctor bloggers, and enter a competition to win Seven Signs of Life at bma.org.uk/secretdoctorblog

INTENSIVE READ: From the publisher who brought you When Breath Becomes Air

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between the doctor’s perspective of an experience which they might repeat many times, sometimes successfully, sometimes not, and all part of a learning curve, and the patient for whom ‘it is their D-Day’.

And while she is, from this incident, an embodiment of an open culture where doctors confront their errors, she recognises the pressures heaped on them by a highly litigious, blameridden climate.

Under scrutiny

‘Doctors are often presented as a unified mass’

can’t even breathe’.

You might remember that story from the Secret Doctor blog, and it’s good to see some old friends not just given greater context but related to the chapter headings in sometimes unexpected ways. Another, Dr Abbey’s best-read blog about her taking ownership of a clinical error, is filed under ‘grief’. It gives a sense of the weight she continues to carry, even though the error, a misreading of an X-ray, did not result in patient harm.

It seemed to resonate with doctors because of Dr Abbey’s insistence that for all the entirely correct emphasis there is on failures being systemic rather than personal, for all the fact that doctors have to learn and they will always make mistakes, she wanted to confront what she had done.

She says there is an ‘inherent discrepancy’

This was an issue on which every doctor seemed to have a view, and there is something about Dr Abbey’s style which invites them to do so. The question, ‘what would you have done?’ is always implicit. Her approach is always as much about asking and telling.

So rooted is this approach that she had a verbal exam recently and had to be gently reminded that, if those were her answers, she shouldn’t make each one sound like a question.

The book is a big deal.

Extracts have been serialised in a national newspaper, there will be interviews, promotional appearances. An actor – Irish as it happens, like Dr Abbey – has read it for an audio version.

Is she ready for its reception?

She is better prepared than most for being judged. Some of the blog comments were fairly harsh: she was too optimistic, too pessimistic. Too quick to anger, or too much of a pushover. Dr Abbey, as the Secret Doctor, would sometimes remind them firmly on Twitter that while their views were welcome, she was just a doctor like them telling a story or

expressing an opinion.

But, so far, everyone who knows her has been positive about her writing the book, and she’ll no doubt take the reviews in her stride.

Dr Abbey stresses that, if she is to be judged, it should be a judgement on her rather than the profession.

‘Doctors are often presented as a unified mass,’ she says. For Dr Abbey, ‘the intention is to reflect what is happening in my life right now’ – at a particular point in her career and perceptions.

Nothing more, nothing less.

She doesn’t doubt that if she looked back over the same experiences in 30 years’ time, some of her judgements will be different.

While Dr Abbey insists she does not want to speak for the profession, she will become a doctor who some readers feel they ‘know’ better than any other, unless they happen to have one in the family.

Whether they wish to or not, these authors, like real and fictional TV doctors, become a kind of key which people use to understand, define and measure the profession.

She’s just one doctor but there’s a parallel with the blogs at which she excels.

You don’t capture people’s imagination with generalities.

Instead you pick a single, bright example and that – rightly or wrongly – is held to illustrate a wider truth.

Dr Abbey is a single, bright example. She doesn’t mean or want to embody the profession but if, despite her protestations, her readers decide that’s what a doctor is, then – and I admit my bias as her former editor – I think they’ve chosen rather well. thedoctor | February 2019 13

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A wall of hostility Everyone remembers their first day on their wards.

Lily Snow’s was awful. Her ‘one small thing’ – an entry to the BMA writing competition – is a plea for other doctors not to be similarly belittled

MONOGRAM

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BMA writing competition 2018

I

t was her first day on the wards. She toiled and grafted for years to study and save before her entry to medical school, and for several more when she got there.

The first in her family to even make it as far as university, she struggled with feelings of not belonging from the beginning. After five years, hundreds of exams and assignments, the death of a parent and a subsequent downward spiral of her mental health followed by a long, painful recovery, there she was. Her first day as a doctor.

She arrived early in her new dress and smart shoes – ready to save lives. Her morning was exciting in the hustle and flurry of the surgical ward round, led by her educational supervisor and consultant colorectal surgeon. He was a tall, stoic man, with an authoritarian attitude and general disinterest, who she later learned took neither his supervising role nor his duty to support the wellbeing of his juniors seriously.

Instructed to get a scan for a sick patient, she made her way to radiology and asked the receptionist for help.

‘Oh… Thomas is on today,’ shooting a look that suggested she would prefer not to have to break that news.

‘Perhaps you should come back tomorrow, Mark is on, he’s lovely.’

‘I have to get a scan organised this morning, it’s really important,’ she replied.

She followed the receptionist’s directions to the consultants’ office, knocked and let herself in, remembering to be assertive and friendly.

‘“I don’t take referrals from F1s,” the radiology consultant barked’

‘She walked away from her first day feeling like a failure’

‘Hi, I’m the surgical foundation doctor 1 for – ’ ‘I don’t take referrals from F1s, get your registrar to see me,’ the radiology consultant barked without looking away from his screen as he waved her away.

‘I’m sorry, the reg is in theatre with the consultant for an emergency case, can I just tell you about a patient we would like an urgent CT on?’

‘I’ve told you I’m not speaking with you. Close the door.’ He tutted and shook his head.

Returning to the ward she was surprised at how the conversation had gone.

Why had she been sent if the radiology consultant wouldn’t accept a referral from her? Why did he feel the need to snap?

She hadn’t done anything wrong, had she? She wondered as she lifted the phone.

‘Surgical reg, you bleeped.’

‘Hi, I’m calling about the CT scan we – ’ ‘Is this urgent? I’m scrubbed and have four to see.’

‘I’m having difficulty with radiology regarding a scan, they want to speak to you.’

‘I’m busy, I can’t do my own job and yours. Figure it out.’

Repeated requests for help from senior surgical doctors were unsuccessful.

So too were the multiple calls and visits she made to the radiology consultant throughout the day, worried the entire time what could happen to this patient if she wasn’t able to secure a CT slot.

She felt her entire day had been usurped by one task.

Her F1 colleagues would understand, she hoped.

When the team arrived for the 4.30pm board round

she explained the difficulties she had had throughout the day. The consultant became irate, annoyed for the sake of his patient who had been fasting since midnight, and the potential for deterioration, and the apparent incompetence of a junior who failed to complete a simple task. Each year they became worse, arriving with so little experience, like they’ve never set foot on a ward before.

How did they not know how to get things done? What use are juniors to the team if they need hand-holding every step of the way?

Despite all of her hard work she walked away from her first day feeling like a failure, completely emotionally drained and exhausted with her self-confidence shattered thinking about how things could have gone better. She had always been told to ask for help if there was difficulty. She had done that! She reached out and no help came. She tried not to think about the callous comments her supervisor had made. Remembering she had to return tomorrow, a feeling of dread settled in the pit of her stomach.

How could she do this all over again? Why did no one tell her about this part of the job?

Did she just have a bad day or is it always like this? Is this the way it is in all departments and in all hospitals? This wouldn’t be tolerated in any other line of work. It couldn’t.

There were rules for that sort of thing.

Lily Snow was one of three runners-up in this year’s BMA writing competition.

A junior doctor, she writes under a pseudonym thedoctor | February 2019 15

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A job’s worth Are the many NHS managers with funny sounding titles as important as they think they are?

Hilary Aitken has come up with a simple test

MONOGRAM

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BMA writing competition 2018

I

t’s a fantasy really – it could never happen. But Lord, imagine if it could. The NHS could save billions.

We’ve all sat there in meetings wondering what the heck some of the fellow attendees with those esoteric job titles actually do. At the end of the meeting, we’re none the wiser. The NHS is riddled with them.

A quick perusal of the NHS Scotland jobs website revealed we are looking for a Portfolio Lead for People Led Care, a Director of Transformation and Innovation, a Hard FM Commissioning Manager and an eHealth Desktop Administrator.

The Royals must absolutely dread NHS visits. ‘And what do you do?’ They’ll be there all day.

On the website there is also an advert for a Patient Journey Facilitator – I wondered if that might actually be a porter but with a starting salary in excess of £20,000 – I fear not… There are several nasty outbreaks of acronymitis. I have no idea what any of these people do, and the worrying thing is, I fear some of them might not either. The NHS is bloated with these positions and losing a few (or a lot) would save money. Would there be any effect on service delivery? I expect you already know what I think.

‘I have no idea what any of these people do, and the worrying thing is, I fear some of them might not either’ So here’s the one thing I would change – I’ve devised a simple test. Take an averagely intelligent 12-year-old, and if you are unable to tell him or her what your job entails in one simple sentence, you’re out. Use of any of the words ‘facilitator’, ‘stakeholder’ or ‘flow coordinator’ results in immediate disqualification.

‘Journey’ is permissible only if you work in the travel or transportation office. I maintain that if you can’t summarise your job in a simple way, then what you’re doing isn’t all that useful.

Most NHS organisations have a review process to assess the need for new or replacement posts.

Forget the Department of People and Change (aka Human Resources, née Personnel) – get the 12-yearolds to review the job description. If they don’t understand what’s involved, bin it.

I was a consultant anaesthetist – I put people to sleep for their operations and looked after them while they were asleep. (OK anaesthetists, don’t all write in – I know there’s more to it than that. And one of my colleagues maintains that we got paid the big bucks to wake ’em up anyway.) But that description would give a 12-year-old a grasp of what the job entails, and a few might think, ‘gosh, that sounds interesting. How would I go about

‘They all seem to need an office to do whatever it is they do, resulting in enormous pressure on space’ becoming one of those?’ I fear that will not happen often to our new friend the Hard FM Commissioning Manager.

But these post holders have an effect in other ways, apart from their salaries. They all seem to need an office to do whatever it is they do, resulting in enormous pressure on space. How many of you are now sharing an office designed for one with three colleagues, to make way for the eHealth Desktop Administrator?

Ward day rooms have been appropriated and now contain five desks and no patients, a section of the hospital library has been partitioned off and is no longer the library, and it’s becoming increasingly difficult to find space for your trainees to relax a bit during a busy working day or night shift.

And there’s a more subtle thing – the more people you have doing all sorts of nebulous roles, the harder it is to find the person who is actually responsible for that one particular thing you need help with. It’s always somebody else.

Once, in an outbreak of charitable sensibility, I decided to undertake some regular payroll giving.

However, there seemed to be a problem – although it was being correctly debited from my salary, the recipient charity had no record of its receipt.

I started with my payroll manager, who needed to look into it. It took weeks, and the email train eventually involved 30 to 40 different people, all of whom said something along the lines of, ‘it’s not me, have you tried x?’

Nobody took responsibility and nobody knew whose responsibility it was. That didn’t happen when the finance department of a medium-sized hospital had 10 people, max.

The number of these roles will never contract unless we take action. They are mainly administrative and managerial, and who undertakes the wearyingly frequent reorganisations, all of which are supposed to make the NHS more efficient and slimline? Why, administrative and managerial staff.

It’s not going to happen – turkeys don’t vote for Christmas. So a radical rethink is needed. Bring on the 12-year-olds.

Hilary Aitken is a retired consultant anaesthetist from Renfrewshire. Her article was highly commended in the 2018 BMA writing competition thedoctor | February 2019 17

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EMMA BROWN

MEKHAEL: ‘Putting me on the associate specialist grade made me feel valued by my employer’

EMMA BROWN

ON THE UP: Dr Hewitt (above) and Dr Mekhael (left)

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AS you like it SAS doctors have a renewed sense of optimism that the associate specialist grade – effectively closed 10 years ago – will be reopened. Tim Tonkin finds out what this would mean

V

ictoria Hewitt has championed her specialty, been a clinical lead, and developed educational resources.

Hani Mekhael has introduced new procedures which have given his unit some of the best outcomes in the country.

What is interesting about these two high flyers is they say it’s their grade that has given them the freedom, status and motivation to achieve benefits for their patients.

They are associate specialists, a cherished but latterly endangered position. Effectively closed to new entrants by the Department of Health in 2008, there are now fresh hopes it will be reopened after years of BMA pressure.

‘We’ve never been so close to reopening the AS [associate specialist] grade as we are right now,’ says BMA staff, associate specialist and specialty doctors committee chair Amit Kochhar.

‘This will be a dream come true, we have fought so hard for this for so long, it will be an excellent outcome for doctors and the BMA if we are able to secure what we want.’

Dr Kochhar has been encouraged by supportive statements about SAS doctors by

the Review Body on Doctors’ and Dentists’ Remuneration (one of the very few reasons to cheer that report) and an agreement in principle from health and social care secretary Matt Hancock in September to reopen the grade to ‘extend career development for this important group of doctors’.

‘You cannot expect doctors to develop if you do not invest in them’

Innovators Negotiations on reinstating the role are due to begin next month. If they are successful, it will restore to SAS doctors a licence to lead and innovate which many feel they otherwise lack.

Associate specialists and those who aspire to the position often say the specialty doctor grade, which replaced it, does not provide the same opportunities, career progression or status that comes with being a senior hospital doctor.

‘Putting me on the AS grade made me feel valued by my employer,’ Dr Mekhael, an associate specialist in obstetrics and gynaecology says. ‘You cannot expect doctors to develop if you do not invest in them.’

Egyptian-born Dr Mekhael first came to the UK in 1994 and began working at the South West Centre for Reproductive thedoctor | February 2019 19

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EMMA BROWN

Medicine in Plymouth in 2002.

During his time there, Dr Mekhael was responsible for most of the assisted conception work, and put a huge amount of effort into developing the service. He introduced the technique of the dummy run for transferring embryos, which greatly increased rates of clinical pregnancy. His initiative saw the unit propelled into the national top 10 for clinical pregnancy rates per embryo transfer.

‘If I’d been employed as a consultant I would have had to follow a different job plan which wouldn’t have given me the chance to focus on this particular area, and excel in IVF and assisted conception,’ he says.

‘I think being an associate specialist at that unit with all my time and effort dedicated to assisted conception services facilitated all the success.’

You might think that Dr Mekhael is at least one of the doctors who ‘made it’ as an associate specialist before the drawbridge was pulled up 10 years ago. But it’s not that simple.

For when he came to move from Derriford Hospital in Plymouth to North Devon District Hospital, he could not automatically assume there would be a job of the same grade waiting for him. Instead he needed to negotiate with his new employer to draw up a local contract, the first to do so. Others have been less successful.

This is why Dr Mekhael says the current piecemeal access to the grade is discriminatory, not only because it prevents those wishing to become associate specialists from doing so, but because it limits the options of those

who already are.

By ensuring that all trusts reopen the grade, existing associate specialists would not have to fear ‘sacrificing’ their grade if they wanted or needed to change their jobs, he says.

Leadership roles With SAS doctors reporting among the highest rates of bullying and harassment in the workplace, Dr Mekhael warns that the reduced mobility resulting from the inconsistent transferability of the associate specialist grade, makes these doctors potentially more vulnerable to such issues.

For Dr Hewitt, like Dr Mekhael, holding an AS post has enabled her to bring great benefits to her patients. A palliative care doctor in Newcastle, she is a prime example of how the grade can be a springboard for service innovation and leadership.

Initially a GP, she decided she wanted to focus on palliative care. In 2006, she became clinical lead of the Northern Cancer Network, which sought to gain greater acknowledgement of the role of palliative care beyond its use within oncology.

She now has an educational role at Newcastle University, which has included developing a free online course for health professionals focusing on safe prescribing of opioid medication in cancer patients.

She says being an associate specialist was key.

‘It has definitely been an advantage because you’re allowed to bring that wealth of experience that you’ve got and to be seen as an equal.

‘If I think back to the opportunities

‘I think there is an inherent bias and assumption that if you’re a specialty doctor you’re not as experienced’

APPRECIATION: Some of the thank you cards received by Dr Mekhael’s unit

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DOUGLAS ROBERTSON

HEWITT: ‘You’re allowed to bring that wealth of experience that you’ve got’

I had, would I have had them if I had not been an associate specialist? Probably not. I think there is an inherent bias and assumption that if you’re a specialty doctor you’re not as experienced.’

One by one It’s important to stress that the efforts to reopen the associate specialist grade are not about diminishing specialty doctors – many of whom have led and innovated within their hospitals.

Gareth Clark has recently become an associate specialist in emergency medicine in Swindon. He is a beneficiary of a painstaking trust-by-trust approach taken by the BMA to reopen the grade locally – to which 29 have so far agreed in principle – while at the same time lobbying for a new national deal.

Dr Clark says reopening the AS grade would not diminish the appeal or standing of the specialty doctor role, but rather complement it.

‘People are more likely to apply for the specialty doctor or clinical fellow posts if they can see that there is career progression up to the most senior non-career grade post,’ he says.

Dr Clark believes it would give more stability to the workforce, and the opportunities that come with independent practice.

He says: ‘Specialty grade doctors have a broad set of opportunities for things they can do, particularly outside of hospital medicine, that trainees don’t. But people get put off

applying for these posts because they know they cannot reach the echelons on a par with consultancy.

‘Reopening the associate specialist grade gives them somewhere to go, as they can be on a par with the consultant team and be part of the senior management in the trust.’

The BMA is urging members who would like to become part of a future negotiations team to put themselves forward. It is not yet clear which parts of the UK the negotiations will cover.

It is also seeking the views and input of SAS doctors ahead of negotiations through a survey which will seek to gain a better insight into respondents’ working arrangements.

The survey will also be a chance for doctors to highlight the issues they would like to see prioritised across categories such as pay and entitlements, career development, job plan and role, safeguards and workload.

‘The recommendations of the DDRB and the commitment displayed by the health secretary demonstrated that the needs and concerns of SAS doctors are finally beginning to receive the recognition they have long deserved,’ says Dr Kochhar, himself an associate specialist.

‘With these negotiations we have an opportunity to make a significant and lasting difference to the career-progression opportunities of SAS doctors, and to enhance the recognition of the important work we do and contributions we make to patients and the NHS.’

‘Reopening the associate specialist grade gives them somewhere to go, as they can be on a par with the consultant team’

KOCHHAR: ‘It will be an excellent outcome for doctors’

thedoctor | February 2019 21

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The other NHS People with learning disabilities often get such a raw deal with their healthcare that it can seem like they belong to a completely different health service. Keith Cooper meets a GP passionate about achieving equity of care

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ateshead GP Dominic Slowie has been fighting for people with learning disabilities for decades, at the top table of the health service, at his practice, and as a father.

He was the NHS England lead on learning disabilities until late last year and now occupies a senior position at NHS Newcastle Gateshead Clinical Commissioning Group, as its interim medical director. However, for far longer, he has been a father and carer for his 18-yearold daughter who has a severe learning disability and a form of epilepsy, resistant to drugs since birth.

She had her first seizure at four months, a terrifying experience, he says.

‘You thought you had a healthy baby, you realised you might not. There was a gradual acceptance that there were going to be some lifelong disabilities, that we were going to have to fight her corner to ensure she got the right level of support.’

Unmet needs His family has fought the education establishment (‘There were times when she was being written off a bit’) and the health service, after a physio insisted she would never walk again (she did). Besides dancing and surprises, it’s the thing she loves the most. ‘She’ll grab your hand and drag you towards the door to go out to the park for a walk.’

He has seen similar as a GP and in his role at NHS England, although he talks about them in terms tinged with the diplomatic vernacular of an experienced bureaucrat.

Sometimes services don’t use ‘creativity’ or ‘imagination’ to achieve equity or justice, he says, before discussing a patient whose dental abscess was untreated for 18 months. ‘How can this happen?’ he asks.

At his practice, he found most overweight patients with learning disabilities weren’t checked for diabetes.

‘We recognised this as an anomaly and are doing something about it. That’s a good thing.’

Improving the lives of people with learning disabilities isn’t beyond the wit of modern medicine but it requires political will, official attention, and evidence for action. He spent five years raising it at NHS England and with Government and other partners, with some success, he says.

‘Now, I hear senior people, whether it is MPs, ministers, [NHS England chief executive] Simon Stevens, council leaders, junior doctors talking much more spontaneously about the unmet needs of people with a learning disability. The next step is doing something about it that makes a difference.’

‘There was a gradual acceptance that we were going to have to fight her corner to ensure she got the right level of support’ Will his work go on, however, now he’s left?

‘Ooh, that’s a controversial question,’ he says after a sharp intake of breath.

‘When I left I was confident that the programmes in place were the right ones to take forward.’

His biggest achievement there, the creation of the learning disabilities mortality review programme, will continue to be funded, according to the recent NHS Long Term Plan. Pinpointing themes in learning disabilities deaths and learning from them will make ‘the most difference to health outcomes for people’, he says.

It is very ambitious, he admits. Each review goes beyond the conventional. Most mortality review processes start the minute you enter hospital and stop the minute you die.

‘But learning disabilities vulnerabilities start at birth,’ Dr Slowie says. ‘They can be addressed by education, social care, participation in society, employment.’ So, investigators must talk to GPs, care homes and others involved in the community.

‘It would be reductionist to just think about the last few days in hospital,’ he adds.

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DOUGLAS ROBERTSON

SLOWIE: A campaigner for people with learning disabilities for decades

Dr Slowie’s daughter when she was younger

This extended scope adds complexity, meaning fewer probes than expected have fed into the national review.

But it’s making a difference. NHS guidance on flu jabs was recently ‘clarified’, he says, after respiratory problems were found to be a major cause of premature deaths.

He’s less optimistic about other strands of his NHS England work, especially efforts to improve care for those receiving it in specialist learning disability wards – often because of challenging behaviour or mental ill health – instead of at home or in their communities.

There are 2,500 or so people receiving this care on specialist wards. ‘The average length of stay in England?’ he asks, and he knows, of course. It’s three and a half years. Many would get better care closer to homes, if health and social care services agreed to fund it, but progress on reducing the unsuitable placements has been slow. It’s now under investigation

by Parliament’s joint committee on human rights.

He is also concerned the focus on this particular group has distracted attention from the much larger population of 1.2 million people with learning disabilities who aren’t under specialist care.

‘If there’s health inequality and premature mortality then we need to work equally hard with generic services such as GPs and acute hospitals that meet people with learning disabilities on a day-to-day basis,’ he says.

‘Initially, that argument was quite a battle, getting my colleagues to understand that the health outcomes for the majority of people with a learning disability were being ignored because everybody felt learning disability was being dealt with by specialist services.’

To address this, he explored the implementation of learning disabilities ‘GP fellows’, through extra training for qualified GPs, but just two have been appointed.

Health Education England doesn’t keep track of the numbers, a spokesperson says, but promotes the role through its training hubs and GP schools.

Above all, Dr Slowie just wants the people with learning disabilities to have the same opportunities

for health as everyone else. This can mean doing things differently, maybe making some reasonable adjustments to standard care processes and pathways.

It seems such a simple idea, yet it animates him the most in our interview, slipping him free, momentarily, from officialese.

‘If there’s health inequality then we need to work equally hard with generic services that meet people with learning disabilities’ ‘We have a cancer programme. It makes a commitment to the most vulnerable people it cares for.

But people with learning disabilities don’t get cervical screening [just 20 per cent are screened compared with 75 per cent in the general population],’ he says. ‘That’s clearly wrong. It’s similar for mammography.’

Cause for optimism He has serious concerns too about how challenging behaviour is addressed.

‘It can be because someone is in physical pain, they’re lonely or bored,’ Dr Slowie says. ‘But it takes time and money to investigate. The alternative is to call in the psychiatrists, get them sectioned and off to hospital.’ It happens often, inflaming families. Once ‘incarcerated’, they struggle to challenge and escape.

‘These are people with intellectual difficulties.’

Despite these concerns, perhaps fears for his daughter, he finds room for optimism towards the end of the interview, from a recent memory from a spa resort where the family spent her 18th birthday (she loves swimming too).

‘The staff were wonderful,’ he says. ‘They spoke to her directly. They were keen to make things easy for her. I was really heartened to see the friendliness.

‘I came away thinking maybe attitudes in our wider society are getting a bit more positive and that will impact on how and if we prioritise this work.’ thedoctor | February 2019 23

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Guiding light Coming to work in the UK as a doctor can be ‘challenging and daunting’. A new mentoring scheme helps IMGs to adapt. Tim Tonkin reports

‘I

knew so little about [this] country and the different prospects and opportunities over here,’ explains Sanhita Bhattacharya, a psychiatrist.

‘If I had had to take certain decisions on my own, I don’t know whether I would have made the right ones.’

Learning from those with greater experience than you is a central part of the medical profession. Every doctor is likely to have had at least one influential tutor or senior colleague who lent wise words or a guiding hand at some point in their careers.

For doctors trained overseas coming to the UK, going it alone while navigating the culture of the NHS can be a formidable prospect.

Cultural differences In an effort to ease the challenges faced by IMGs (international medical

graduates), the Royal College of Psychiatrists has, for the past three years operated a mentoring scheme, offering doctors coming to the UK through the MTI (Medical Training Initiative) one-toone support.

Dr Bhattacharya, now a specialty doctor in general psychiatry in Derbyshire, came to the UK from India in August 2016 as part of the MTI. Having never been to the country before, much less worked in the NHS, she admits she initially felt quite overwhelmed by her situation.

‘It is challenging and daunting for all of us who have come from another country to settle in. There are so many systems, protocols and guidelines [in the NHS] that you have to be aware of, compared to India where things are differently organised.

‘The most challenging thing for me was understanding

BHATTACHARYA: ‘The most challenging thing was understanding the structure of the NHS’

DAVE: ‘IMGs are more likely to be reported to the GMC’

the structure of the NHS. Everything is divided over here [the UK]. The community mental health team is separate from an inpatient team.

Combined with ‘the weather, the food, the accent’ she says it can be a ‘daunting experience’ to arrive in the UK.

Professional guidance

‘There are so many systems, protocols and guidelines in the NHS that you have to be aware of’

Dr Bhattacharya’s mentor, consultant psychiatrist Subodh Dave, is one of around 40 mentors involved with the RCPsych’s programme for IMGs. He says overseas medical graduates often encounter

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NEIL HODGE

cultural challenges when coming to work in the NHS, a situation which contributed to poorer professional and educational outcomes.

‘Research has shown that IMGs, when they come from countries where they may not have had the same level of training in subjects such as ethics or confidentiality, might struggle when it comes to working in the NHS. ‘What we [also] tend to see is that IMGs don’t tend to do as well in exams and other assessments and are more likely to be complained against and reported to the GMC.’ Doctors are able to select their mentors during induction days hosted by the colleges, who will then stay with them for the duration of their MTI placements, acting on an impartial, third-party basis to provide professional and personal guidance.

‘Mentoring and pastoral

support is meant to come from educational supervisors, according to the Health Education England Gold Guide,’ Dr Dave explains.

‘The problem with that is an educational supervisor is also that doctor’s line manager.

Doctors from areas such as Asia and Africa have often come from very hierarchical cultures. They do not always feel comfortable raising matters in the workplace, thinking that it would be disrespectful to do so.’

Impartial opinions The RCPsych mentoring programme does not specify the level of contact between mentors and mentees, with Dr Bhattacharya saying that she had sought assistance or advice from Dr Dave on roughly eight to 10 occasions last year.

She says her time on the MTI would have been far

more taxing had she not had recourse to a mentor.

She believes that, for IMGs wanting to gain experience in areas such as education or leadership, having a mentor who could guide and introduce them to such opportunities was invaluable.

‘You’re inundated with information once you come into the country, so it makes it easier if you can talk to somebody who is experienced and can guide you through it.

‘You do of course have a clinical or educational supervisor but I would seek Dr Dave’s advice when I needed an impartial opinion about my career progression.

‘The fact that he is not involved in my day-to-day clinical life made it easier for me to approach him.’

‘Doctors from areas such as Asia and Africa have often come from very hierarchical cultures’

Find out more at www.rcpsych.ac.uk/ training/MTI thedoctor | February 2019 25

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on the ground Highlighting practical help given to BMA members in difficulty

A probationary period that lasted a suspiciously long time, finding out your pay has not been protected and getting to grips with TUPE legislation – some of the tough situations with which the BMA has helped its members

TUPE or not TUPE? That is the question A consultant had, for a while, carried additional responsibilities as a clinical director.

When she gave up the clinical director part of her job, she was transferred, using the TUPE (Transfer of Undertakings [Protection of Employment]) legislation, back to being a full-time consultant.

She was anxious to check whether her pay was correct. She seemed to still be getting the extra allowance she had received as a clinical director. Perhaps this was correct, if it was included in her pay protection. But she wanted to be sure.

You might think her employer would be only too happy to help, if there was the possibility it was overpaying one of its doctors. You might also think it would have welcomed her open and straightforward approach in trying to clarify matters.

Our member’s overriding priority was to be paid the correct amount and not suddenly get stung for a bill if she was getting paid too much.

You can see where this is going. For

two years, she pressed her employer for an answer. Then, entirely out of the blue, came a bill for more than £30,000 because – the employer maintained – she had been overpaid by continuing to receive the clinical director allowance.

If the trust was in the right, financially speaking, this was a pretty crass way of treating an employee. But its claim didn’t stand up. The doctor, with the help of a BMA employment adviser, made the strong case that the employer had failed to tell her at the time of transfer whether the allowance would continue, and failed to answer her repeated, subsequent queries.

Also, the trust’s own policy, which gave three years’ pay protection under TUPE, could be taken to cover her previous allowance.

So, the trust dropped its claim for more than £30,000 – and paid a further six months’ allowance, in arrears, for having prematurely stopped it before the pay-protected period was up.

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Pursuit of permanence

It’s not unusual to have a probationary period when you start a new job but for one doctor it stretched on indefinitely.

Travelling from overseas to work for a private-sector employer, his probation had been extended twice already. Now eight months into the role, he desperately needed stability.

He was working hard, he felt he was doing well, and he wanted to bring his family to his new city – but that was too much of a gamble, given that he could be quickly out of a job.

Sometimes, there are legitimate reasons for extending a probationary period – for example if there are concerns about someone’s suitability for a job – but the doctor undertook a 360-degree feedback exercise and obtained additional patient-satisfaction feedback data from the company that showed he was performing at a high level, with excellent clinical and interpersonal skills.

The BMA and the member concerned suspected there was another motive at play here.

A permanent contract with this employer gave six months’ pay if the role was suddenly terminated. For probationers, it was only a week’s pay.

The BMA wrote to the doctor’s medical director in advance of his meeting about his probationary status.

The letter stressed that he had achieved, and in some cases surpassed, all that had been asked of him.

The doctor performed well at the meeting and was given a permanent contract.

On-call work went unpaid Pay protection is good for doctors but also for the continuing quality of patient care.

Here’s why: doctors who change role, perhaps to go back into training, need an element of financial security but also, the NHS needs to allow doctors who decide their passion is for a different job or specialty to be able to develop without being penalised.

The alternative is that doctors could be stuck in jobs they find demotivating, while the roles they could do better remain unfilled. It would be a waste of potential.

A specialty doctor moved to a core trainee role in 2012. Several years on, he realised that his pay had not been fully protected.

His salary was right (matching his previous one as a specialty doctor) and he received an oncall supplement, as he had previously. However, he had not been paid for the actual on-call work undertaken, as he would have been as a specialty doctor.

He alerted the BMA, which pointed out to the employer what the terms and conditions said. It should not have been a difficult case to pursue but the employer tried to resist it on the basis that it was ‘too historic’. This particular claim can be frustrating to doctors because it often comes after years of a trust making the same mistake and then, when the mistake is discovered, it argues that it has been doing it for so long that it’s impossible to rectify.

The doctor said his employer was ‘very reluctant to play ball’.

It took several months but the BMA employment adviser won the doctor his back pay – £52,000 gross. He was delighted with the outcome.

thedoctor | February 2019

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it happened to me Doctors’ experiences in their working lives

A wee bit busy Have you ever been more oliguric than your patients?

I have.

It’s not meant to be a competition and if it sounds like one, we’re in even more trouble than I thought. You’ll have to take my word for it, as I haven’t gone to the lengths of the juniors who measured their ‘output’ for a BMJ paper, but when I got home from work and realised that I hadn’t once used the bathroom during my shift, I knew there was a problem.

I was the responsible consultant on the admissions unit and there were patients literally everywhere.

Along with the relatives I needed to speak with, the calls for advice, the records to update, neither food nor fluid had slipped past my mouth since breakfast, and it was by now 3pm. It was one of those days – but I seem to have rather a lot of ‘those days’.

How had I allowed this to happen? I thought I was simply following Good Medical Practice – to make the care of the patient my ‘first concern’.

My first concern. It was drummed into me at medical school, to mould me from person to doctor. It was used

as a stick to beat me with when, as a surgical house officer, two hours after my 12-hour shift should have ended, I dared to say that I was exhausted and planned to hand a job to a colleague. I was told that I didn’t care. But I really do care.

If I didn’t care about patients or colleagues, then it would be much easier to care for myself. The trouble is that ‘those days’ of sacrificing the wellbeing of ourselves for the sake of other people can become so increasingly common that they become the norm. And while my medical education taught me a lot about clinical management, I learned very little about how to look after myself.

There’s plenty of literature – I can scarcely read an issue of the BMJ without ‘burnout’ cropping up. But the articles tend to use jargon such as – I quote – ‘human factors approaches’ or ‘recalibrating inspection regimes’.

To me, the strategies offered feel impossible to implement straight away.

While the problem is complex, the solutions need to be simple and ready to use. So here are some of mine.

Please share yours too.

–– Banish the bravado – we’re very good at bragging about the long hours and hard graft. Take a break and boast about that instead – how you managed to fit it in, or how effective you were afterwards –– Make refuelling easy – bring lunch and a big bottle of water to work, and keep them close to hand –– Patients are your ‘first concern’ but that doesn’t mean that every task has to come before your own urgent needs. There will be times when you say ‘yes, I’ll speak to the family, but I need something to eat first’ –– Don’t feel guilty about having a coffee with colleagues. Talking over a cup of coffee is better than a thousand fancy words on wellness. Call it ‘service development’ or ‘appraisal preparation’ if it makes you feel better –– Help colleagues take breaks by looking after their bleeps while they’re away, and they’ll do the same for you –– Have meetings (the useful kind) where staff can get together, share problems and discuss ideas. And remember the biscuits!

I want to look after the patient in front of me now, but I also want to be able to look after many more people in the years to come.

We look after everyone but ourselves – let’s change this.

Clare Bostock is a consultant geriatrician in Aberdeen

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the consultation The Doctor will see you now

O’RIORDAN: ‘I never stopped exercisng during my treatment’

Ipswich breast surgeon Liz O’Riordan became a blogger and patient advocate after being diagnosed with cancer, and wrote a book that combined patient and doctor experiences of fighting the disease Your pubes will fall out on day 13, a friend said. I knew you lost the hair on your head but not all of it – and me, a breast surgeon of 20 years. Doctors tell you what’s going to happen during chemo but patients tell you how to cope.

The split second it appeared on the screen, I knew it was breast cancer. I knew I would need chemotherapy, and probably a mastectomy. I was in shock. That was three years ago. I was 40.

Twitter saved my life. I announced my diagnosis on the day I found out. There was no point in hiding it. There was this flood of support. University of Oxford professor of primary care Trisha Greenhalgh direct messaged me: she was having chemotherapy too. Kate Granger became a close friend. I rang her at 3am with chemo-insomnia.

I changed the way I broke bad news to patients. So did my husband, Dermot. He’s a surgeon, too. I used to say, ‘you are lucky we caught it early’. But no one is lucky to get cancer. We used to hand patients an information leaflet and say, ‘don’t Google.

It’s scary out there’.

The first thing I did was Google. It is terrifying out there. But I found out that Macmillan and Breast Cancer Care have apps. We need to signpost patients, help them start their internet research.

Professor Greenhalgh and I wrote The Complete Guide to Breast Cancer. It brings together all we know as doctors and patients.

It was hard to write but it’s the book we both wished we had had.

I never stopped exercising during my treatment. I did a sprint triathlon halfway through treatment. I’m planning to do an Ironman triathlon in 2020. Exercise oncology is a really exciting field – there is so much research proving it can make a difference at every stage of treatment.

The cancer came back locally last year.

I’ve had more operations. I’m still adjusting.

I may not be around in five years but I just live my life. Cancer can’t take that away from you.

The Complete Guide to Breast Cancer: How to Feel Empowered and Take Control is out now thedoctor | February 2019 29

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and finally ...

Stories from the medical profession on a lighter note

ON A ROLLS: Dr Docherty’s collection of classics were, in fact, ‘jalopies’

Foot in mouth disease I’m often hard-pressed to remember the day of the week, and yet I seem to remember almost every stupid thing I have done with perfect clarity.

And so many of these stupid things seem to have taken place during interviews.

What is it that makes us say the things we neither mean nor need to say? Is it anxiety, the desire to fill a silence? The effects of the alcohol which I confess to having occasionally consumed to ‘steady the nerves’ prior to such a trial?

In the case of a senior registrar interview many years ago, it may have been an uncomfortable frankness bubbling up to the surface when it really wasn’t wanted.

The interview had gone well, so well in fact that we were on the formalities of the starting date. The date I would begin this four-year post. Four years. And what did I tell them, as the job offer was so close I could see the whites of its eyes? I said I would only be staying for a year.

It is one of the ghastly clichés of the interview process that, when a candidate is asked to describe one of their faults, they give the cringy response that they are ‘just too honest’. That was a moment when I truly was.

Here’s another lesson for the young – no interviewer likes a candidate who appears

more successful than they.

I was told at another interview that the job would involve some travelling, and I needed a car. ‘Of course,’ I said grandly. ‘I have three.’

I can only imagine what played before their minds – a feckless dilettante pursuing a career in medicine for pin money, his only challenge in life choosing between the Rolls and the Bentley. In fact, two of the cars were worthless jalopies which I had tried and failed to sell, but I neither said this nor would have profited from doing so. The damage was done.

Related to this is the universal contempt for the smart-arse. I applied for a consultant post and was somewhat overwhelmed to find 13 members on the panel. As I nodded to each in turn, I came upon one I recognised. At medical school he was termed a ‘chronic student’, because, like the characters in Doctor in the House, he had been condemned to repeat

several years because of poor exam results.

My cheery greeting, ‘so you finally got through’, probably lost me that interview before it even started. So too did my comment to a panellist whom I encountered twice, both times with his leg in plaster, and which might have implied that his skiing skills were not all that he hoped.

I finally got the consultant post, and on many occasions found myself on the opposite side of the desk.

I have tried to be kind, and to remember how I felt in the bear pits of the past. And I ask for a little indulgence for those facing the same situation now.

We may not be forgiven for a small act of madness in the operating theatre, but in interviews, I think they happen to us all.

Peter Docherty is a retired consultant ophthalmologist from Derby

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what’s on

February

March

20 Disciplinary and grievance procedures, 9.30am to 4.30pm, Glasgow

01 GP job fair, 9.30am to 1.30pm, Plymouth

25 Job planning workshop, 6pm, Belfast 26 GPC contract roadshows 7pm, High Wycombe 27 Consultants conference, 9am, London

Visit bma.org.uk/events for full details. Download the BMA events app at bma.org.uk/ events/events-app

05 Practical skills... time management and taking control, 9am, London 05 Public health medicine conference, 9.30am, London 07 GPC contract roadshows, 7.30pm, Boreham, Essex

19-20 LMC conference, Belfast 29 Conference of medical academic representatives, 9am, London

29 LNC chairs conference, 10am to 4pm, London

April

May

02 Practical skills... leadership and management for doctors, 9am, Birmingham

09 Practical skills... for human factors in healthcare, 9am to 5pm, Cardi

02 Connecting LTFT trainees, 9.30am to 4pm, London

08 Medico-legal conference 2019, 9.30am to 4.30pm, London 15 BMA retired members conference, London

25 Absence and leave management, 9.30am to 4.30pm, Kilmarnock

09 Introduction to critical appraisal workshop, 9am to 4pm, London

15 Practical skills... time management and taking control, 9am to 5pm, Bristol 17-18 Junior doctors conference 2019, 9.15am, London

Dr Diary The app that supports job planning for consultants and SAS doctors Download the app now: bma.org.uk/drdiary

Built by doctors, for doctors.

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