The Doctor – issue 10, June 2019

The magazine for BMA members

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Issue 10 | June 2019

Would you pay to work?

Doctors driven out of the NHS by punitive pension tax rules BI

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Double standards

NHS England subjects GPs to lengthy checks – but is secretive about its own performance

Streets ahead

Good care for the homeless – why is it so rare?

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thedoctor

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

Email thedoctor@bma.org.uk

Editor Neil Hallows (020) 7383 6321

Call a BMA adviser

Chief sub-editor Chris Patterson

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: 365 no: 8203

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

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In this issue 4-5

Briefing Sexually transmitted infections soar as funding is cut, and new data on GPs’ unsustainable workload

Welcome Chaand Nagpaul, BMA council chair The features in the June issue of The Doctor highlight many of the growing difficulties we face as doctors working on the front line of the NHS. Intimidating performance investigations, pensions rules which can punish going to work and rocketing demand from complex patients such as the homeless, with dwindling resource to respond: sometimes the barriers to providing the care and compassion we all trained to give seem insurmountable.

In recent weeks, pension problems have hit the headlines – with vast bills being sent to doctors hit by legislation changes. It is particularly dispiriting to hear first-hand stories of committed and talented staff decreasing their working hours, as a result. The BMA is taking effective action on this issue.

We have opened a dialogue with chancellor Philip Hammond and we are making clear the potentially devastating effect this problem could have on the medical workforce. Our advice for doctors who may be affected follows this feature.

In this issue we also hear from GPs who have been the subject of the NHS England performance investigation process. Doctors understand the need for oversight and regulation – we all appreciate the value of learning from mistakes – but this is experienced as an unsupportive and heavy-handed process, which can have a serious, negative effect on wellbeing, and it is vital it is as fair and transparent as possible.

In the January issue of The Doctor we investigated the relationship between homelessness and the NHS, finding a massive rise in demand and a huge resulting cost to the NHS – a feature recently shortlisted for the 2019 Medical Journalism Awards. In this edition, a follow-up piece finds patchy services available to homeless patients across the country, with great focus in some areas and nothing at all in others. The piece also showcases the very best of homeless healthcare from dedicated doctors and volunteers, and the lessons contained within could be used to improve the picture elsewhere. It is neither moral nor prudent to leave so many patients, with such complex needs, without due care and attention.

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All too exceptional Our research finds huge variation in the services commissioned for homeless people – but also some rare and inspiring examples of care at its best

12-17

Is it fair? Do they care?

NHS England investigations are secretive, prolonged and often highly damaging

18-21

Would you pay to work?

The punitive tax bills driving doctors away from the NHS just when they’re needed most

22-25

Let care take its course A better option for patients with chronic mental illness

26-27

On the ground SAS doctors battle for fair pay and a GP practice is hit with an unexpected bill

28-30

Life experience Practical help with treating refugees and asylum seekers, and the pitfalls of working in a foreign language

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What’s on Keep on top of events

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briefing

Uphill struggle

Current issues facing doctors

Sexual health, bins or potholes?

Sexual health has long been the Cinderella of services. But for the last six years it has been made to feel like an ugly sister – competing, unsuccessfully it seems, with bins, potholes and the thousand other calls on local authority spending.

It was not exactly lavishly resourced on the NHS but since the responsibility for public health in England was handed to councils in 2013, there have been repeated cuts to budgets. BMA research last year found a 5 per cent cut in sexual health services, £30m, between 2016/17 and 2017/18.

This has consequences. ‘Recent cuts to sexual health funding have been severe and are a false economy,’ says the Commons health and social care select committee in a report published this month.

While overall cases of STIs have fallen, there are ‘seriously concerning underlying trends’ for syphilis and gonorrhoea.

These have increased by 20 per cent and 22 per cent respectively between 2016 and 2017.

According to Public Health England data published in June, in 2018 there were 447,694 diagnoses of STIs made in England, a 5 per cent increase since 2017.

‘Inadequate sexual health services may also lead to serious personal long-term health consequences for individuals and jeopardise other public health campaigns,’ the committee’s report adds. The fight against antimicrobial resistance is flagged as ‘a major issue’ in the treatment of gonorrhoea.

Doctors have long warned of the ‘perfect storm’ or rising rates of gonorrhoea. Cases of resistant strains were recorded in England in 2015 – and in every year since, as cuts to sexual health services continue.

BMA public health medicine committee chair Peter English said: ‘The fragmented and uncoordinated way in which these services are commissioned means that across the country, people – many of whom are vulnerable and disadvantaged – are not getting access to the care they need.’

He has said previously that cuts in areas such as sexual health services often fall most severely in the parts of the country that have the greatest need.

Councils have had a tough time financially but taking on an apparently unchecked rise in serious communicable diseases is important. As important as the bins, at least.

Sisyphus may have had to roll a boulder uphill all day but some GPs might be reflecting that at least he could work in the fresh air and at his own pace.

Research from the BMA gives a striking illustration of the pressures on general practice. It shows an increase of 718,000 patients in the year to March, with GPs now responsible for an average of 2,089 patients each, the highest on record.

And this in a population whose needs are increasingly complex.

It is therefore inevitable that the research also found an increase in the number of appointments involving a wait of one week, two weeks or four – there were more than a million of the latter.

It follows research from the Nuffield Trust which found the first drop in GP numbers, relative to the size of the population, since the 1960s.

BMA GPs committee chair Richard Vautrey said: ‘With falling numbers of GPs, rising numbers of patients and

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both increased complexity and rate of consultations as more people live with more conditions that require regular care, it’s no surprise that so many GPs continue to suffer an unacceptably heavy workload burden.

‘Added to this has been the increased bureaucracy practices have had to contend with over the last decade, the problems with punitive pension tax charges, the risks relating to practice premises and, as highlighted in the Interim NHS People Plan, the difficulties many practices have in recruiting nurses.’

GP leaders have pressed hard for solutions. It is hoped that the GP contract agreed earlier this year in England will help alleviate some of the intolerable pressures on GPs. It includes additions to the workforce in primary care, state-backed indemnity, resources in IT, and a new primary care network to further integration.

Crucially, it also comes with a promise of extra funding – this promise must be honoured by this and future governments if primary care is to survive in its current state.

PERPETUAL STRAIN: Sisyphus arguably had it better than GPs

Keep in touch with the BMA online at

FINDING ANSWERS: Plans to improve NHS working conditions must include action on pensions

Plans, promises and pensions ‘More of the same will not be enough.’

While sounding a little like the protest placard in Father Ted, ‘down with this sort of thing’, it’s difficult not to agree with the sentiment of the NHS’s Interim NHS People Plan.

It aims to improve the leadership, culture and working conditions of the health service.

Attention has quite naturally focused on the reference to pensions in the document – which is brief but would have been a serious omission had it not been there at all.

The plan acknowledges the ‘concerns’ of doctors that the tax rules on the annual and lifetime allowance means that many are being forced to reduce their clinical commitments or retire early, at the time the NHS needs them most.

It mentions the so-called 50-50 plan, whereby doctors at risk of being affected by the allowance limits would halve their pension contributions in return for reduced benefits.

BMA council chair Chaand Nagpaul said: ‘We have modelled the proposed 50:50 scheme and it is clear that [it] will not remove the disincentive for doctors to reduce their working hours.’

Dr Nagpaul, however, acknowledged the health secretary’s announcement that he would also discuss other models for pensions flexibility.

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The rest of the plan is in places rather aspirational and HR-ish – new ‘leadership behaviours’ for example.

But it also confirms a commitment to re-establish a reformed associate specialist grade, flexibility in junior doctor training (but with no more detail than that) and more nurses, physios and paramedics.

Up with that sort of thing.

Perhaps the key word in the plan is ‘interim’. The full plan will have not just more detail but reveal how the Government will at last meet its pledge, made four years ago and nowhere-near achieved, of increasing GP numbers in England by 5,000. That will be an interesting read.

Read more online Gross negligence manslaughter: call to consider work pressures Consultant vacancies continue to rise Government widens job shortage list Pledge to improve record sharing Read all the latest stories online at bma.org.uk/news

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All too exceptional The provision of care for homeless people is patchy and woefully inadequate, with new research by The Doctor showing huge variation in the services commissioned.

And yet there are some rare but inspiring examples, which are responsive, compassionate and effective.

Peter Blackburn finds out how they manage it 06 thedoctor | June 2019

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PAUL HERRMANN

HELP AT HAND: Rochdale GP Zahir Mohammed and nurse Elaine Stone attend to centre client Catherine Richardson

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he greater the health and social care need, the worse the provision, states the inverse care law. It’s one of the better-known – and most regrettable – observations made about UK healthcare.

Homeless people have some of the most profound mental and physical health needs of the population. These are growing. The Doctor found visits to emergency departments had nearly tripled in seven years, in research published earlier this year. And yet provision is nowhere near matching demand. It is predicted that deficits in local authority homelessness services will increase fourfold in the next five years.

So where you do find examples of healthcare provision for homeless people that are not only effective, but achieve the things mainstream healthcare can’t always manage – integration, responsiveness, and overwhelming compassion – they’re exceptional in every way.

One such place is the Dawn Centre in Leicester. It has a day centre run by the YMCA, a large council-run hostel, a GP service run by social enterprise Inclusion Healthcare, a wide range of physical and mental health teams and specialists, local authority staff specialising in housing and homelessness, outreach teams and access to huge amounts of support, advice and guidance.

The best examples of integration are where the users can’t see the different parts that make up the service.

‘We pride ourselves on the fact that homeless people can come here and effectively not leave the building for the support and services they need,’ homelessness services manager Gary Freestone says.

‘The knowledge and relationships are our biggest strength… we have a far better opportunity with different agencies together.’

Offer of hope Meshek Munroe and Nirvana Stretton became homeless in March and spent five weeks living in a car in Leicester city centre. Mr Munroe lost his job, and the couple had become cold, hungry and hopeless.

Within minutes of arriving at the Dawn Centre, he was given a warm, fleece-lined coat.

‘I could have cried,’ he recalls, ‘it was amazing’ – and from there GP appointments were made, assistance with mental health issues offered and, most crucially of all, a place in the hostel secured. The couple is now being helped to find a new home.

‘The main thing this place does is give people hope,’ says Mr Munroe.

Darren Evans, a 40-year-old alcoholic, had been sleeping in a park, begging for money to buy his next drink.

‘I came to the Dawn Centre out of pure desperation,’ he says. ‘It wasn’t just a bed – it was like a whole team of people just surrounded me. They got me in with the GP and looked after my health, they helped me out with clothing, food and all sorts really.’

As another service user says: ‘Unless we have a service like this here we are lost.’

The services in Leicester are not replicated everywhere, however – many homeless people have nothing to turn to in their areas, finds an investigation by The Doctor, collating data around homeless health services and staffing acquired from 143 of the 191 CCGs (clinical commissioning groups) in England.

Lack of services Only 20 CCGs reported having clinical leads for homelessness – a position of responsibility for overseeing care for homeless patients recommended by some experts. And just 15 areas said they specifically hire or contract staff to work in homeless care.

Most revealing of all, the investigation SHAWN RYAN

ONE-STOP SERVICE: Gary Freestone prides himself on the varied care on offer to homeless people, including Meshek Munroe (centre) and Darren Evans (right)

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– which asked every CCG in the country to detail the health services they specifically commission for homeless patients in their area – highlights a vast disparity in care offered to rough sleepers or the vulnerably housed across the country.

In 66 CCGs, specifically commissioned homelessness services were reported. In one case this is nothing more than a £500 annual budget for flu vaccinations, in others there are comprehensive GP and outreach services costing hundreds of thousands of pounds.

But in 77 CCG areas there were no specific services detailed.

It is clear from their responses that many CCGs see the responsibility for homelessness as belonging solely to local authorities, despite its overwhelmingly strong link with poor health outcomes, and evidence that successful interventions cost society a fraction of leaving someone homeless.

While there is little central direction or investment in homeless services – an announcement of £1.9m to improve the health of rough sleepers attracted widespread derision last month – it has not stopped doctors taking the initiative in many local areas.

Rochdale GP Zahir Mohammed’s day-to-

day experience at work has taught him how arbitrary people’s fortunes can be.

‘We have been having patients who have been fine in their lives and then suddenly they are down on their luck and in a downward spiral. You just never know what is going to happen around the corner.’

His practice hosts a drop-in surgery every day for homeless patients, and stocks homeless packs containing sleeping bags, breakfast and information about overnight accommodation.

‘It’s better they come and see us than sit in A&E – it’s better for everyone. For themselves, and the cost is huge otherwise,’ Dr Mohammed says. ‘We’re pretty flat out, and, I’ll be honest, it’s getting more and more difficult because the NHS is busier and funding is tighter, but this is our philosophy.’

More homes, more homeless Dr Mohammed is one of many volunteers who also run another vitally important resource for the homeless. HART (Homeless Alliance Response Team) was inspired by a visit to a church project gathering clothes and toiletries for the homeless and now brings together GPs, nurses, therapists and mental health workers. Based around a soup kitchen,

BROTHERS IN ARMS: Wayne Taylor and Sami Benomran rely on the care centred around a soup kitchen in Rochdale

‘We have patients who have been fine in their lives and then suddenly they are down on their luck and in a downward spiral’

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PAUL HERRMANN

including case management of homeless patients who are frequent hospital attenders, support with benefits, outpatient appointments and housing options, and simplifying registration.

Perhaps most fundamentally it offers flexible access, including a drop-in every day, to a range of services including drug assessment, mental health support and dentistry.

The service is commissioned and strongly supported by local health leaders now – but initially, Dr O’Shea says, it was about individual personalities driving change, which, in part, explains such patchy care around the country.

‘If we didn’t do what we do I don’t know if there would be any service in Manchester,’ he says.

As the service develops, Dr O’Shea and homeless service manager Rachel Brennan are looking to embed a ‘hub-and-spoke’ model – partly already in place – which is based on a large homeless hub where patients are registered and the wider team of health specialists are based, with smaller GP surgeries, particularly in areas of high demand, supported to provide a more significant service for patients than is often the case.

‘It’s what we need because of the increase in population of homeless people and the increasing complexity of the people we see here,’ Ms Brennan says. ‘It’s difficult work and people have to want to do it. It’s a vocation PAUL HERRMANN

‘One of the barriers to healthcare is how people are treated by staff and other people’

it cares for around 80 people.

Volunteer Mo Jiva, a Rochdale GP and chief executive of the Rochdale and Bury local medical committee, says: ‘You see improvements really quickly and the rapport that these people have with nurses and us is amazing.’

A broad pool of volunteers helps to keep it sustainable. ‘It’s one or two hours a month for many people, which isn’t onerous, but having that rota filled makes a really serious difference and that’s a big incentive.’

Twelve miles south, in Manchester, there is a cruel paradox. The building of new flats aimed at young professionals is taking place at a spectacular rate – triple that of Birmingham, according to a recent study – but with the increase in homes, there is an increase in the homeless, often sleeping in the shadow of the flashy new apartments.

Official rough-sleeper counts in the city, bearing in mind that such figures tend to considerably underestimate true numbers, have soared from seven people in 2010 to 123 in 2018.

It is in the face of this rocketing need – an obvious concern for anyone walking through Piccadilly Gardens or St Peter’s Square – that GP Gerry O’Shea and his team work, every day.

His Urban Village Medical Practice, in the east of Manchester, has around 11,000 patients registered, including 750 who are homeless.

The scope of its work is remarkable –

SEAT AT THE TABLE: Rochdale GP Mo Jiva and centre client Stephen Dershaw

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SHAWN RYAN

within a vocation really.

‘We think we’ve got this all-singing, alldancing service, and it’s brilliant – you can have whatever needs you have met in the building, but when you ask people it’s really because they feel welcome when they are here, people remember their name, they’re asked how they are as well as getting their dressing done.

‘One of the barriers to healthcare is how they are treated by staff and other people.

That is a challenge.’

Improving access Access is also important to the approach taken by the York Street Medical Centre in Leeds. It’s run as part of Bevan Healthcare, a community-interest company with another service in Bradford, and cares for people who are homeless, in unstable accommodation or have come to the UK as a refugee or to seek asylum. It offers GP appointments, an outreach service and a substance misuse service run by an external organisation.

‘Any city needs to be responsive,’ York Street GP Rhiannon Davies says. ‘You can have services but if they are not able to respond there and then you can’t help. You need to be alongside people at the moment they

are ready for you, otherwise the barrier of days, weeks or a month means you lose that opportunity.’

Hearing Dr Davies speak, one immediately wonders how many homeless people have been ready to receive help, only to find there is little or none available in villages, towns and cities that do not have such initiatives.

York Street patients include Derek Goodwin. Released from prison a decade ago, he has lived largely on the streets between stints in hostels. Aged 43, he has severe COPD, ‘the lungs of a 72-year-old man’. About the only constant in his life has been his GP practice.

Mr Goodwin, who says he has passed out and been taken to hospital five times in recent years, explains: ‘I can get the help I need because of this place. I get treatment – alcohol support and counselling – and it’s a GP surgery for me too and I can see them about my COPD. ‘When you ask for help you want it there and then, not in a month’s time – you don’t know what you will be doing in a month.

You could be brown bread.’

These practices and projects show what is possible.

It might seem daunting to take on

TEAM PLAYERS : Homeless service manager Rachel Brennan (third from left), GP Gerry O’Shea (second from right) and the Urban Village Medical Practice team

‘I can get the help I need because of this place. I get treatment – alcohol support and counselling’

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healthcare for the homeless.

However, Dr Jiva says: ‘There are fears about a violent, druggie population, but these are myths that can be overcome – it’s nowhere near as bad as you think, and the outcomes are so much better than what you might think.

‘The first thing I thought was that I’ll need to sort my life insurance and medical indemnity, but it’s often been much more enjoyable than my own patient group.’

If it’s possible, and the financial and moral arguments have already been made, why are so few areas providing anything that could be described as comprehensive? The answer lies locally and nationally, according to those on the ground.

In a local sense money is tight and services are already strained. Few people innovate without headroom – and for many frontline staff the prospect of taking on the workload that HART in Rochdale or Dr O’Shea in Manchester have done might appear overwhelming.

And, nationally, political will is hard to find.

In any given year empty promises around homelessness and eliminating rough sleeping are dropped like confetti at a wedding but action appears much less likely.

‘There are fears about a violent, druggie population, but these are myths that can be overcome – it’s nowhere near as bad as you think’

Urgent steps needed In 2011, the Faculty for Homeless Health set a national strategy, and standards for healthcare for homeless people – including service-user involvement in commissioning and delivery of services and enhanced access to healthcare services for all homeless people in every area. Eight years on it’s hard to see that they are being met in any meaningful way.

So where should the health service, and the country, go from here? A first step would perhaps be to learn from the good work being done in pockets around the country and invest in taking those lessons elsewhere.

Among those The Doctor spoke to, those lessons were near-unanimous: research into the relationship between homelessness and health, training of and investment in NHS staff, reversal of cuts to support services and welfare and a proper housebuilding programme.

Earlier this year Ms Brennan published the results of her Winston Churchill Memorial Trust Fellowship, which saw her travel to Norway, Denmark and the USA to investigate

successful ways of delivering healthcare to the homeless.

Ms Brennan’s conclusions are clear and could hardly be considered troublingly radical in a rich country with a universal healthcare system – and which can no longer hide from the costs of doing nothing.

They include bringing healthcare to homeless people, transitioning patients to mainstream healthcare settings, and ensuring healthcare professionals have access to training in homeless health.

Zana Khan, GP clinical lead for the King’s Health Partners, part of the Pathway Homeless Team at South London and Maudsley Mental Health Trust – a service that works with patients while they are in hospital in a bid to ensure their circumstances are changed before being discharged – and an academic in homeless health, also gave her checklist for change.

For Dr Khan the steps to take are: a single budget for health, housing and social care; ‘robust’ education of frontline staff; a policy change which would mean statutory bodies have to act to avoid homelessness in a person who accesses their services; and a commitment that no person should be discharged from a hospital to the streets.

Call for resources

‘You can have services but if they are not able to respond there and then you can’t help’

BMA council chair Chaand Nagpaul said: ‘It is inspiring to see so many doctors and volunteers providing care and support to homeless patients across the country – but we need greater resources across the NHS and social care to reduce the number of people finding themselves on the street and to ensure comprehensive services are in place to help those who do fall through the cracks.

‘Given the clear cost of homelessness to the NHS it cannot be an option to have such patchy provision across the country.

‘CCGs should be encouraged to appoint homelessness leads to assess local need and coordinate care, and the resulting services must be properly funded by the Government.’

The point is, there isn’t really an alternative.

Not in this country, not in this century.

As Mr Munroe says: ‘I just don’t think we would be here without these people. We owe them our lives. We would have frozen to death in the car otherwise. You need someone to pick you up when you are down.’ thedoctor | June 2019 11

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Is it fair?

Do they care?

NHS England performance investigations can bring down a GP practice – yet data is kept secret, investigators have little training, and the process prolonged and bewildering. Tim Tonkin reports

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t’s hard to imagine much progress in medicine without the means to measure and compare. How, otherwise, can we tell if something is working or not?

If naval surgeon James Lind had worked for NHS England, it’s hard to believe it would have been all that interested in the dramatic recovery of sailors with scurvy given citrus fruit compared with those dosed with seawater.

Or that the results would have been published for anyone else’s benefit.

That certainly seems to be its attitude on performance investigations, which, as we saw in the November 2018 issue of The Doctor, can have a profoundly damaging effect on a GP’s professional life and wellbeing.

How many have taken place? How many occurred in each geographical area? How many were deemed high risk 12

and escalated to the more serious level of investigation?

Does NHS England monitor whether black and minority ethnic doctors are disproportionately affected?

The responses to these questions have varied between ‘don’t know’, it’s too much effort to find out, or the answer is held elsewhere (when it wasn’t).

So how, NHS England, do you know if the process is fair and whether it can be improved?

The thing is, if NHS England is responsible for the health service, it has a responsibility to those who work in it too.

And so, if it is taking action at a local level against GPs that will inevitably be expensive and destabilising, wouldn’t it like to know and share whether its processes and actions are fair, proportionate and consistent across the country? We continue to wait, and to press.

A reminder of why it matters so much; in the November issue, we described how a complaint brought a thriving GP practice to the brink of collapse. Misleading claims were made about the quality of care, there were procedural failings, and a consistently accusative tone. The practice had to wait a year to be cleared of any wrongdoing.

That practice’s experience is echoed by two other GPs who have spoken to The Doctor (see case studies).

One said they were likely to practise defensive medicine for ever after as a result.

Leading GPs have called for the process to be made fairer.

‘The NHS regulatory process needs to be entirely fair, reasonable and transparent,’ says Nottinghamshire local medical committee director Marcus Bicknell.

Dr Bicknell says annual data relating needs to performance

‘There seems to be huge local variation’

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investigations must be shared with LMCs, and that regional NHS bodies should publish annual figures on the numbers of investigations undertaken and their outcomes.

‘Where it identifies dangerous and inadequate practice, it must address that but generally it needs to be much more supportive.

‘I do think that NHS England has realised that general practice and GPs are so important, and that our profession is in such crisis, that it is now working towards being more supportive and less restrictive.’

Dr Bicknell says the review process in his area had improved and is now fairer and more sophisticated, but there are often too many inconsistencies in the way performance investigations are pursued.

‘There seems to be huge local variation,’ he

says. ‘Our experience in Nottinghamshire and the East Midlands was that there were loads of PAGs [performance advisory groups] against Nottinghamshire GPs and very few against Derbyshire GPs. ‘The reason for that seemed to us to be that they had different people leading the processes.’

A GP performance investigation can be triggered by a single adverse incident, or as a result of a complaint made by a patient, their relatives, or by anybody employed by or associated with a practice.

Limited training The local PAG represents the first stage in any performance investigation, with panels empowered to apply sanctions in the form of ‘voluntary undertakings’, such as referring a doctor to the National Clinical Assessment Service.

In the event of more

serious findings, the PAG can refer a doctor to the PLDP (performers list decision making panel), the next tier in the process.

Any decisions reached by a PAG panel are based on the report produced by a case investigator – an individual tasked with investigating a practice by interviewing staff, gathering evidence and establishing the facts around a complaint.

These reports therefore have an enormous professional effect on individual GPs and practices under investigation.

The power wielded by case investigators when examining a practice is considerable, yet there is concern with the limited level of training required by such investigators.

A document published

by NHS Resolution, which organises and oversees the offi cial training programme for case investigators,

‘The process needs to be much more supportive’

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states that investigators must make sure that they are ‘robust, effi cient and transparent’ in performing their duties.

It adds that: ‘A process that is straightforward and fair gives practitioners confidence that they will be treated appropriately and effectively. It is essential that case investigators are trained and supported to carry out their responsibilities.’

The person specification requires any would-be case investigator to be educated to postgraduate level or equivalent, with experience in medical management, education or appraisal.

Top of the list of required skills for the role is a ‘high level of interpersonal and communication skills’.

The document makes clear that the training is not accredited and states: ‘There are no competency-based national qualifications to qualify you as a case investigator.’

However, a GP who has completed case-investigator training reports that the course lasted just 12 and a half hours over two days.

Modules on ‘What constitutes a concern?’ took less than an hour, while training on ‘How to manage a clinical concern and determining when a local investigation might be necessary’, lasted just 75 minutes.

The GP believes this to be entirely insufficient.

‘It is extremely concerning that the training and preparation undertaken by someone who will eventually be tasked with investigating a GP or practice on a performance issue can be completed in less than two 14

days,’ he says.

‘School crossing wardens could expect more training and preparation.

‘NHS Resolution’s own pre-training reading material makes clear that performance investigations can be complex and onerous, so you would expect the training for such a role to be comprehensive and competency-based.

‘There is no summative assessment of competency following the course, and there is no calibration to ensure that individual investigators apply consistent or appropriate standards.’

GPs have been expressing concerns about performance investigations for years, but not only has there been little evidence of such concerns being addressed at national level, but some anecdotal evidence that the accusative climate has worsened.

That’s the experience of one LMC medical secretary who says, in his area, the process has become increasingly ‘hawkish’ in recent years.

‘The pressure that is being put on practitioners by the process is quite substantial,’ he says.

He says he has witnessed examples of doctors with single, relatively minor complaints against them suddenly finding themselves being investigated on a whole range of unrelated issues owing to the domino effect of the review process.

‘People will have a single clinical problem – not something that reaches the standard that the GMC will be interested in. It ends up with the PAG who will send a clinical adviser in to look at [that doctor’s] records for that

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patient. They may conclude that the notes could be better.’

He describes how a clinical adviser might then decide to look at a randomised selection of all that doctor’s records against Royal College of GPs standards and decide the notes don’t meet those standards.

The doctor might then be informed that they must complete a note-keeping course and face another review in six months.

‘We’ve had practitioners who have effectively been under review for a year for the quality of their notes, when the actual complaint had nothing to do with notes in the first place.’

Conflict of interest He adds that, in his experience, roughly 80 to 90 per cent of the complaints handled

by PAGs never went beyond this stage of review and were closed with ‘little to no action’ being taken against a doctor.

‘The [case] managers have the power to do an awful lot of harm to GPs without [the latter] having any defence.

‘A GP could have a complaint that could be investigated, and a decision made on it by a group of managers without any coalface experience.’

He says that the clinical adviser – who is themselves a GP – is appointed for and paid by the panel, which creates a potential conflict of interest.

‘There’s a danger that if he [the clinical adviser] doesn’t say what they want him to say, next month they’ll use a different clinical adviser and he won’t get paid.

‘The performance list regulations and how they’re managed is really fraught with conflicts of interest and

I personally don’t think we should have them at all.

‘Why should GPs have a double level of performance management in the form of the performance list and the GMC? No other clinical specialist has a double layer like this.’

Sanctions imposed LMC presence at PAG and PLDP reviews is at the discretion of NHS England so there is no guarantee that an LMC representative will be able to attend.

The LMC medical secretary also speaks of his frustration at how performers list decision-making panels would sometimes choose to continue to impose conditions on a doctor even when separate conditions imposed by the GMC had been lifted.

‘The GMC is our professional regulator which works to protect patient safety and it said that this [particular] doctor was fit to practise, but the local panel decided that it wanted a bit more supervision.

‘Clinical or educational supervision are imposed on you, but you as the doctor have to pay for that yourself.

‘We’re starting to get people in our area who would previously have served as clinical supervisors refusing because they, themselves are concerned about coming to the attention of NHS England.’

Following numerous requests for data on performance investigations to be released, BMA GPs committee chair Richard Vautrey wrote to NHS England’s acting director of primary care Nikita Kanani, emphasising the seriousness of many GPs’ concerns about

the impact of investigations.

Last month, GPC deputy chair Mark Sanford-Wood and GPC UK policy lead for contracts and regulations, Bob Morley, met with NHS England to discuss a way forward to obtain information, with NHS England saying it they would work towards providing the association with some regionally held data on investigations in the near future.

It was also agreed that a joint working group comprising of NHS England, the BMA and LMC representatives, would be set up to look again at aspects of the framework underpinning performance investigations, and to agree on the data that needs to be routinely collected.

Dr Vautrey said that while he welcomed the constructive outcome of the meeting, there were still many questions that needed to be answered and much work that needed to be done, to address the association’s longstanding concerns with the performance-review process.

‘All doctors accept the importance of oversight and regulation as vital safeguards to patient care, and the having the opportunity to learn from errors and, where necessary, take the necessary steps to remediate and improve,’ he says.

‘For this to happen effectively it is vital that such investigatory processes are transparent, fair to all doctors and rooted in trust.

‘Based on the accounts reported to us by many GPs, we know that this is sadly not always the experience of doctors faced with performance reviews.’

‘Decisions on complaints are made by managers with no coalface experience’

‘It is vital that investigatory processes are transparent, fair to all doctors, and rooted in trust’

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Unfair process One GP says that their experience of the performance-investigation process means that they now practise extremely defensive medicine.

The GP who wshes to remain anonymous was contacted by NHS England who advised that it had received a complaint from one of their patients.

Although not given any specifics, the doctor learned that the complaint had also been directed against professionals in other care settings.

‘When the complaint was forwarded to the practice we were asked to give a response to the complaint for it to then be considered by NHS England.’

The complaint was then passed to the NHS England clinical reviewer.

‘Even though what I’d done was thought to be OK, they decided that the patient should have been referred to the hospital anyway. Unfortunately, they upheld the complaint and that meant that the case was referred to the PAG.’ The doctor explains that during this process they had no opportunity to represent themselves at the PAG hearing or understand how decisions about their case were being made.

Their experience was made all the more stressful by being denied access to information about other parts of the complaint investigation, knowledge of which might have established that any fault might be multifactorial rather than

the result of a single individual.

‘All I knew was that they had found that my part of the interaction with the patient could have been better.

‘My case was closed where it should have closed, but I have heard so many horror stories from other doctors where people have suffered much worse experiences at the hands of the regulatory process.’

Even with the case now closed, the doctor says the experience is likely to have a lasting impact on them.

‘To be in a situation where you feel you might lose your ability to work changes things quite a lot.

‘It’s not been a conscious decision, but you start practising differently once you’ve been through this kind of experience.

‘Basically, I practise medicine much more defensively now than I did before and I am not sure that that is necessarily beneficial to my patients.

‘The whole complaints system is [currently] not designed in such a way that it supports doctors.

You’re dealing with a system that seems to presume guilt rather than the other way around as it should be in a fair system.

‘I completely understand that the NHS needs to be safe for patients and for patients to be able to get a fair hearing if something goes wrong and for us [doctors] to learn from it.

Unfortunately, the same balance has not been made when it comes to protecting doctors.’

Practices targeted A GP facing a performance review says the investigations have forced him to delay his revalidation by six months.

He says NHS England has decided to continue with its investigation despite the complaint against him having been withdrawn.

‘I’m very broad-shouldered and am physically robust enough to be able to handle this. But so many of my colleagues aren’t and often feel out of their depth.’

He knows of a number of GPs in their area who, when advised that they were being investigated, chose to resign rather than go through the ‘harrowing’ process.

‘Professionally isolated’ GPs – those working independently or in small practices, are more likely to be targeted by a performance investigation, he says.

‘It’s uncomfortable when you’re on the radar of the performance-review people at NHS England.

‘There is a sense that you’re always going to be on it and that is a little unnerving. The process is such that even when a complaint is withdrawn you still find that there is a cloud hanging over you.’ thedoctor | June 2019 17

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Would you pay to work?

Punitive tax bills are forcing doctors to reduce their hours or retire early, even though they want to work and the health service desperately needs them. Jennifer Trueland describes the anger and sense of betrayal felt by doctors, and the pressure being put on the Treasury to change its self-defeating rules

I

rfan Malik loves his job as a GP and trainer. It’s what he always wanted to be and imagined he would continue enjoying it up to retirement.

A senior partner at a practice in Sherwood, Nottingham, where he has worked since 1998, he admits he had given little thought to pension arrangements until he realised he was at risk of a heft y tax bill.

Following extensive investigations, including obtaining professional advice, he has cut his hours and left the scheme.

‘I’ve always been a headdown, full-time GP and trainer and I never really thought about the pension side of things,’ says Dr Malik. He had previously been a member 18

of the 1995 NHS pension scheme, then the 2015 one.

‘I had checked three or four years ago and was well under the lifetime [allowance] limit, so I thought I didn’t have anything to worry about. A comment from my registrar [about changes to the lifetime and annual limits] was the trigger for me to look into it. I found it was a real issue. Some colleagues – even people in their 40s – MALIK: Work hours dropped

had been stung with tax bills running into five figures.’

After seeking advice and thinking it through, Dr Malik stopped paying into the scheme and dropped his hours from full to threequarter time.

‘It means a reduction in income,’ he says. ‘It’s disappointing because I really do enjoy my job, but I’ve seen other doctors basically having to pay to do extra work, and I don’t want to take that risk.’

‘I really do enjoy my job, but I’ve seen other doctors basically having to pay to do extra work’

No warning Dr Malik is not alone. Changes to pension legislation three years ago are causing huge problems for doctors and other public sector workers by placing new limits on the amount that can be paid into

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a pension each year. A new ‘taper’ for higher earners means that the current standard annual allowance can reduce to £10,000 and that those who exceed the limits can be hit with punitive tax bills. The way that these bills are calculated is complex.

It can be done several years in arrears, meaning doctors can be hit with a huge tax bill without any warning.

Although awareness of the issue is growing – especially as vast bills hit doctors’ doormats – the BMA wants all doctors to recognise where they might be at risk, and to take advice and action accordingly.

Alan Robertson, a member and former chair of the BMA pensions committee,

says it is important to get the message out among consultants. ‘I think there’s higher financial awareness among GP partners because they run practices and have accountants, but hospital doctors don’t necessarily have that level of awareness so they won’t know anything about it until they actually have a breach. That’s why people are being surprised by bills running into tens of ROBERTSON: The NHS can’t afford to lose expertise

thousands of pounds,’ he adds.

‘I know one person who did £2,000-worth of extra work and got a £9,000 bill – nobody thinks that’s sensible.’

He warns that even if the Treasury wises up and reverses the punitive changes, the effects on the workforce could be longlasting – and devastating for the health service. ‘Some people might get used to the idea of taking a day off a week – they might find it pleasant to have a better work-life balance, spend more time with family or on hobbies.

These people will be hard to persuade to come back to the workplace full time.

‘We’re also seeing people in their mid-to-late 50s going

‘I know one person who did £2,000worth of extra work and got a £9,000 bill – nobody thinks that’s sensible’

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to Australia, New Zealand and Canada. People are leaving early and the NHS really can’t afford to lose this level of expertise.’

Betrayed and unfair The BMA is taking action on this issue, including writing to chancellor Philip Hammond, and pointing out the potentially devastating effect on the medical workforce if doctors decide to cut hours or refuse overtime or extra sessions to help in emergencies or to meet waiting-times targets, for example. They are also following closely the progress of legal challenges to the schemes for judges and firefighters.

In England, the health

and social care secretary has agreed to consult on pension reform and discuss further flexibilities. The BMA has said that the Government needs to improve on a proposal where employees would halve their contributions in return for half the pension accrual, a move insufficient to remove the incentive to reduce hours.

This isn’t only about not doing ‘extra’ work, however.

The health service relies on consultants working over and above the ‘ideal’ contract of 10 PA (programmed activities) per week, with many contracted to work 11 or 12, which is effectively up to a fifth more hours than ‘fulltime’. This would mean that if they dropped two sessions per

week, the number of ‘full-time’ consultants would not change on official workforce returns, but the number of hours available to the NHS would see a drastic reduction. Again, this would prove potentially very serious for the health service: imagine trying to fill rotas with a fifth fewer hours available, although apparently still the same number of ‘bodies’ on the ground.

When he talks about the pension crisis, Paul Youngs sounds almost emotional.

There’s a real sense that he feels betrayed – and he warns that he is not alone in reacting that way. ‘I’m 53 and have been working for the NHS for 30 years,’ says Dr Youngs.

‘When I was a junior doctor I was working 80-odd hours a

YOUNGS: People are wondering why they put in all the effort

‘We worked hard, but the NHS was a lifelong career, and we would have a good pension at the end of it’

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week, one in three weekends, and one in three nights on call.

While I was paid at the full rate for the first 40 hours, the rest of the time I was paid at a third of the hourly rate.

‘It was punishing and I was giving many hours free to the NHS, but it was part of what you could call the covenant: we worked hard, but the NHS was a lifelong career, and we would have a good pension at the end of it. It was deferred reward, if you like, and people really bought into that.

‘Now these same people are staring down at large tax bills and are really wondering what they did it for.

‘I gave my 20s, 30s and 40s, have dedicated my life to the NHS, so it’s fair to say I have an emotional response to this. People feel trapped, they feel betrayed, and they feel it simply isn’t fair.’

As well as being a consultant anaesthetist in Plymouth, Dr Youngs is chair of the BMA pensions committee. He is making it his mission to raise awareness of the pension changes so

that other doctors can look into their personal situation and take appropriate action.

This might include cutting overtime, reducing hours, or even stopping paying into the scheme, though the BMA does not advise this.

‘I’m not a technical tax expert, but our default position is that everyone should be in the NHS pension scheme – it’s part of the overall reward package for doctors. It’s a massive dilemma for each individual and doctors have to be pension aware.’

Cutting hours While some doctors have felt they have had no choice but to remortgage their houses to meet the unexpected tax bills, the other option is something called ‘scheme pays’, where the scheme settles the bill directly with HMRC and the member effectively has a loan to which interest is applied which is deducted from benefits at retirement.

This, of course, will have a detrimental effect on

their pensions when they eventually get them. ‘They call it “scheme pays” but it’s really the doctor that pays,’ says Dr Youngs grimly.

But there are doctors who feel they have no choice but to do that – and to cut their hours to ‘safeguard’ their future as far as they can. One of these is Anne Carson, deputy chair of the BMA in Northern Ireland and a consultant radiologist in the Southern Trust.

‘We’ve all been putting our shoulders to the wheel, trying to do our best for patients, and we’ve been punished with huge tax bills,’ she says. ‘I’ve had to cut down my hours – I’ve halved my work to earn the same amount of money.

I’ve decided that I’m sick of paying to go to work, and I’m not going to do it any more.

‘As I see it, it’s a raid on our pensions and it’s a raid on pay – and at the end of the day, it’s the patients who suffer. It simply doesn’t make sense unless the long-term goal is to take down the NHS and screw all doctors, but either way, it isn’t sustainable.’

CARSON: ‘I’m sick of paying to go to work’

‘We’ve all been putting our shoulders to the wheel, trying to do our best for patients, and we’ve been punished with huge tax bills’

What the BMA is doing –– R aising the issue with senior politicians, with letters already to the health secretary, chancellor, two defence secretaries and the health select committee –– Briefing parliamentarians, with MPs recently challenging the chancellor about what he intends to do to mitigate and protect against the risks created –– Encouraging members to use an online tool to contact their MPs. Around 2,000 emails have been sent –– Producing guidance for members, visit bma.org.uk/pensions-annual-allowance –– Campaigning strongly on the issue in the media, raising awareness about the unfair and counterproductive impact.

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DOUGLAS ROBERTSON

Let care take its cour A fragmented health service too often sends patients with mental illnesses far from home or for ‘treatment’ in locked wards in private facilities. It doesn’t have to be this way, as Keith Cooper finds in a close-knit, comprehensive and highly effective NHS service

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H

BETTER TOGETHER: The Hopewood Park team, with consultant psychiatrist Priya Khanna centre, left

urse

opewood Park, on Waterworks Road, Sunderland, is a rare thing in an NHS where beds for people with mental ill health are more likely axed than opened. Built to replace Cherry Knowle Hospital, the old Sunderland Borough Asylum, it opened five years ago with 120 beds.

The Doctor is on a visit to meet the mental health rehabilitation team working with patients with chronic mental illnesses, of NTW (Northumberland, Tyne and Wear) NHS Foundation Trust, led by consultant psychiatrist Priya Khanna.

It’s the sort of service badly needed elsewhere in England where ‘treatment’ is reduced to a room in a locked ward in a private hospital, far from home. Such stays last twice as long as in the NHS, the Care Quality Commission reported last year, doubling the expense and pain of separation from families and friends.

So what sets it apart, marking it out as a template for other corners of the NHS? There is the obvious advantage of the modern hospital. It’s ward blocks squat among grassy banks, gardens and covered paths, a far cry from the gothic spires of Cherry Knowle. There is a café and gym. There are the staff, the psychiatrist, psychologists, nurses, and occupational therapists, from the wards and the community. Each one plays an essential supporting role in the long road to rehabilitation for the severely ill.

At NTW, they seem close-knit. All chip in, ending and adding to each other’s anecdotes, telling us how they help people, disabled by ill health, to get their lives back.

‘We want to catch people earlier and provide the right level of support’

before being ‘stepped down’ to the ‘move-on’ ward, then into a home in the community.

‘He’s now more in contact with his family and there is still lots of ongoing rehab work with the community team,’ Dr Khanna adds.

Such is the pattern of rehab working well. ‘Our job is to try to stabilise patients, work on their life skills, start the process to move them on from hospital. Give them hope,’ is how Andy Severs, ward manager of the male HDU sums it up – mental health rehab for people with severe and complex illness. They often have more than one diagnosis. Most suffer psychosis, such as hearing voices or hallucinating. A lot of them may misuse alcohol or drugs and have difficult family relationships.

They struggle with daily life. They’re in and out of emergency care, caught in the ‘revolving doors’ of short-term admissions to acute wards, then discharged to free up a bed for the next crisis case.

Early intervention Freeing patients from the revolving doors of so-called ‘patch-up’ admissions is an important role for the team.

‘We want to identify people earlier, provide the right level of support,

Before Hopewood opened, the trust had large numbers of patients in out-of-area beds, as far away as Scotland. Now it has very few, Dr Khanna says.

‘When we opened our HDU [high dependency unit] we were able to repatriate people.’ She recalls one man was brought back to the HDU

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PHILL DAVISON

Closer to home

Cherry Knowle Hospital in 2007 and, right, Hopewood Park

10/06/2019 10:48

DOUGLAS ROBERTSON DOUGLAS ROBERTSON

rehab after 22 years. We are trying to cut that down.’ Such transfers entail longer stays than acute ones, which usually last weeks. Rehab stays range from six months to two years at NTW. These could sometimes be longer if necessary.

The prospect of longer stays in hospital isn’t always welcomed by patients, consultant nurse Lisa Strong says.

‘But if we can get the treatment right, we can build up that trust, hopefully improve insight, function and quality of life.

‘In the long term the benefits can outweigh the sense of frustration and coercion that may be there in the shorter term.’ Such decisions can be ‘angst-ridden’, she adds.

‘There’s the benefits of a rehab admission versus the costs and distress of being detained. We look at the option of rehab in the community too.’

NODIYAL: Intervention sooner rather than later gets results

Community ties

KHANNA: Time limits for treatment have been dropped

medication and psychosocial support to prevent multiple admissions,’ Dr Khanna says. ‘There may be one admission, which is longer, but their quality of life improves and they can move towards more independent accommodation.’

For what is called ‘in-reach’ work, staff go looking in the acute wards for people in need of rehab.

‘The sooner you get into it, the better the outcomes,’ consultant community psychiatrist Sunil Nodiyal says.

‘Before, people were coming to

A close working relationship between staff in the community and those on the wards seems another key to the success of mental health rehab.

Its absence is a major flaw in services elsewhere in the NHS, where patients are ‘dislocated’ through admission to unfamiliar hospitals, far from home.

NTW’s rehab community team is called the ‘step-up hub’ in the South locality and starts working with patients on wards some six months before they leave hospital.

‘Traditionally, when someone went into an HDU or equivalent ward, the community team stepped back to focus on more acute work,’ says its team leader, Michael Dingwall.

‘But we engage early on, get them used to the community, so it’s less traumatic when discharge day comes.’

It has also removed time limits for treatment in the community.

Dr Khanna says, ‘we realised it wasn’t

‘There may be one admission, which is longer, but their quality of life improves’

‘We engage early on, so it’s less traumatic when discharge day comes’

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Serenity meets safety This is a rehabilitation service with strong clinical leadership and which gives back hope to patients.

There should be many more like it

right for patients. If two years are needed, it’s two years. It’s needs-led.’

The hub runs groups in the community. They’re open to anyone on the wards, in any part of NTW’s patch, which stretches from Sunderland to Northumberland.

While some sound more social, they are designed to be therapeutic.

‘On the surface, a group might be about music, but underneath it is about tolerating other people,’ says Katrina Mason, its occupational therapist.

A camera club helped one anxious man focus on photography rather than worry about who was watching him on a bus. ‘People learn coping strategies from each other,’ Ms Mason says. ‘It makes a difference.’

The difference this rehab team makes is thanks to every bit of what’s officially known as the ‘care pathway’ for patients. The logic seems so simple. It’s the right care, in the right place, with no gaps to fall through. Yet pathways are full of holes across much of the NHS. Read next month’s issue of The Doctor, for an investigation into the financial and human costs when there’s barely a trace of a pathway of care at all.

Visiting the staff and patients at the rehabilitation service in Sunderland (Northumberland, Tyne and Wear NHS Foundation Trust) with the BMA was an uplifting and sobering experience in equal measure.

We arrived frazzled after getting lost in the middle of a busy Friday but arrived at what seemed like (and was!) an oasis of calm. We wondered if we were at the right place, as large mental health units do not normally have such tranquillity; ducks were even waddling around the car park.

The physical environment of the recently built architect-designed unit is spacious and light with good privacy for all. However, it was the staff we met that made the place and the care and support special.

Meeting staff from various disciplines talking about a whole pathway was really heartening.

This has become lost in many of our fragmented systems and commissioning arrangements but has been built and preserved here by strong, passionate and coordinated professionals backed by senior management who respect them. Patients have been able to be returned from out-of-area placements far away and there are schemes to allow even those detained under the act to take part in community activities such as gardening.

To hear Andy Severs, the manager of the HDU, talk about ‘working on skills and … giving back hope’ was amazing and an illustration of how a positive and caring approach can make such a difference.

It was sobering because of the time we spend seeing other services and hearing other stories where things don’t work, people fall through the gaps, and bad things happen. Nothing is ever perfect of course but what we saw in Sunderland – a passionate, hardworking, patient-centred group of staff with decent resources (nothing fancy) working together for patients through a whole-recovery pathway – is not that common. It could and should be.

Andrew Molodynski is the BMA consultants committee mental health policy lead thedoctor | June 2019 25

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

SAS doctors battle for fair pay in a case which highlights the importance of job-plan reviews, and a GP practice is billed for thousands by a staff member who ‘guesstimated’ overtime

Extra hours unrewarded The vast majority of doctors employed in hospitals have the right to an annual job-plan review. While this can sometimes seem like yet more paperwork, it’s vitally important. It’s the chance to agree the work you do, when and where it’s done, and the resources required.

It can help protect a doctor’s health and wellbeing and drive improvements in care.

Three staff, associate specialist and specialty doctors were not receiving such a review, and there did not actually seem to be any process to ensure it happened. In these circumstances, it is not surprising that unfairness becomes entrenched.

The doctors were working considerably in excess of the 12 PAs (professional activities) for which they were paid. An important issue was that their department had misunderstood their contractual position in relation to weekend work, and the enhancements to PAs that it brought. The employer was not receptive to the

doctors’ attempt to resolve it, so the doctors called in the BMA. Even their BMA IRO (industrial relations officer) with experience of such situations found it a tough case to resolve. The department seemed dysfunctional, the internal mechanisms of the employer ineffective. This NHS organisation was not only unhelpful but at times downright obstructive. It was presented with proof of working patterns using diary evidence but disputed it on spurious grounds.

There were face-to-face meetings, phone calls, emails and input from the BMA’s solicitors.

After more than a year, the employer agreed to reimburse the three doctors with £45,000 in recognition of several years of underpayment.

It also said it would reduce their sessions.

One of the doctor’s represented said the case could only have been won with BMA support, and that the changes had improved the quality of their lives. The IRO provided ‘immense help and support at every stage’ of the negotiations, they said.

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Manager billed GPs wrongly There are many practice staff who, like the GPs employing them, work over and above their contracted hours. While primary care has always run to an extent on goodwill, GP practices, as employers, need clear policies to recognise overtime.

The procedures at the GP surgery in this story were pretty clear. Payment for overtime had to be sanctioned by the partners and otherwise taken as time in lieu.

Unfortunately, a practice manager took a different approach. She made unauthorised overtime payments to herself (in her role, she was responsible for paying all employees) totalling thousands of pounds.

The practice manager’s justification for the payment was in what she described as ‘timesheets’ but these documents had not been shared with the GP partners who employed her. Instead, they consisted of emails she had sent to herself, listing the extra hours she asserted she had worked. Some of these hours were then claimed as overtime.

Described by the tribunal as a ‘guesstimate’, the emails described some commitments, such as attending evening partner meetings, as constituting extra hours, but she was contractually obliged to attend them without receiving overtime.

When the unauthorised payments were discovered, the practice manager was summarily dismissed. But she took the practice to an employment tribunal for breach of contract, claiming almost £6,000, based on what she said was previously unpaid overtime, and, for her notice period, the unpaid holiday and part of the pay she had not already received.

The fact that the tribunal had before it two binders with 649 pages of documents and involved the calling of three witnesses shows what a challenge GP practices, as relatively small employers, can face in answering such challenges, even if their cases appear robust. But this practice had the support of a specialist employment adviser from the BMA’s Employer Advisory Service in managing the twists and turns of the case, and was represented at tribunal by the independent legal provider Gateley’s.

The tribunal’s judgement said the claimant ‘knew very well that the overtime was not

authorised’ and it ‘did not think it was her role to pay herself what she thought was fair’.

While there had been two distinct occasions – a Care Quality Commission inspection and computer upgrade – when overtime had been specifically authorised, many of the claims were for other occasions.

Not only were all of the financial claims made by the practice manager dismissed, but she was ordered to pay back almost £4,000 given to her as an advance on her notice period. The tribunal decided she was in breach of contract at the time of her dismissal and thus not lawfully entitled to be paid notice.

The practice also claimed just over £7,000 in regard to payments the practice manager had made to another member of staff, a former colleague. The practice said some of the payments, some of which were not made through the payroll system, had been excessive. But the practice did not have enough evidence to substantiate this claim, so that was not upheld.

The case shows the importance of GP practices having clear procedures for overtime, and for tackling situations where staff act outside these procedures. Most of all, given that the practice manager was dismissed two years ago and the amount of paperwork, time and witness statements involved, it’s important for GP practices to have outside help, and that’s where the BMA Employer Advisory Service can be so vital.

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the secret doctor

More than words In an increasingly diverse society, virtually all doctors now treat patients with limited English. Google Translate is (as yet) only up to quite simple communication; using family members has serious limitations; and knowing how to say, ‘where does it hurt?’ in five languages won’t really cut it in an age of shared decision making, so inevitably we often end up relying on interpreters.

Every doctor probably has a few horror stories of mistranslations, misunderstandings and mishaps.

I remember the time I walked away from – as I fondly imagined – consenting a patient for a procedure only for the interpreter to say brightly: ‘And what is “anaesthetic”?’

Or the occasion when an interpreter fainted at the moment of delivery of a sick baby and had to be dragged out of the room to make way for the resus team.

One episode in particular made an impression on me. I was asked to go and talk to the

parents of a child who had had neurosurgery the preceding day. To be fair, the registrar who sent me didn’t know what I was being dropped into; the family has been spoken to after the operation and the outcome explained to them, not realising that the politely nodding couple were struggling to follow.

Although they spoke some English it was far from fluent, so we got a telephone interpreter. And only then did it become apparent that among the things they hadn’t understood was that the surgery had failed, and their child was permanently blind.

This is not news you want to give unprepared, as a junior, through a telephone service, but there was nothing for it.

Naturally, the parents were devastated, and the father in particular became almost hysterical. His speech grew faster and faster, with barely time for the interpreter to translate before he was shouting again. Why had we done this? Why hadn’t we taken more care? How could the baby ever have a decent life now?

In the middle of his tirade, the phone suddenly went dead. As if this encounter wasn’t enough of a disaster already, I thought.

Then a minor miracle happened. The father looked up and met my eyes for almost the first time since I had entered the room. He took a deep, shuddering breath. And he calmed down. We continued to talk.

Taken slowly, and with plenty of checks of understanding, it turned out we could cover a good deal of ground in English. The parents were still desperately sad but the tension and animosity had left the room.

Good medical interpreters are hugely valuable and we couldn’t do without them.

It’s worth remembering, however, that a third party – even a much-needed, highly professional one – can drastically alter the dynamic of a consultation.

By the Secret Doctor bma.org.uk/secretdoctor @TheSecretDr

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it happened to me

J’ai de mauvaises nouvelles...

‘Excuse me, sir, I think that’s a melanoma,’ I blurt out, pointing to the lesion on his abdomen.

‘You must see your GP,’ I gesticulate wildly, tracing the shape of an elliptical excision in the air around the offending spot, an elaborate game of dermato-charades. ‘Cut, cut.’

I’ve omitted the niceties of an introduction, there is no privacy (there are probably about 500 or so other people in the area) and I haven’t gauged how much bad news they can take before I’ve gone in with the diagnoses.

After I’ve spotted the melanoma – an ugly, irregular, brown, black and purple island on a sea of sun-damaged skin – I’ve got about a 10-second window to make my diagnosis and convey my message before I lose him in the crowds, as he walks down the swimming pool steps (and I walk up). And I’m doing it all in my 25-year-old GCSE French.

His wife’s English is no better, so I breach confidentiality by enlisting the help of the swimming-pool life guard, whose English is probably a little better than my French. I need to get my message across. His wife tells me that their grandson is also a doctor. I tell them that I am a dermatologist en Angleterre and I leave them my name, contact details and GMC number and he promises to see his médicin in a few days’ time when he gets home.

Although I have a certificate to show that I can swim five metres under water in my pyjamas and rescue a brick from the bottom

of the pool, I suspect this will be the only time I ever actually save a life in a swimming pool.

However, afterwards I am racked with doubt.

I had no time to take a history, I didn’t do a proper examination, I hadn’t even had a proper look at it and there was no dermatoscope anywhere nearby. Was my diagnosis correct?

Should I have said anything at all? Breaking every rule in the communication skills book, it could have gone so badly wrong. There was no warning shot, no assessment of how much he understood or how much he wanted to know, I mentioned the big C in my opening line, I breached confidentiality and I didn’t have a translator for a foreign-language consultation.

I often wonder what happened in the end, if he did end up going to see a French dermatologue. In the intervening months I hear nothing. And while a year is a long time to wait for a follow-up appointment, we have rebooked to go to the same resort a year later. He may well have done the same as it’s that kind of place. The odds are that I won’t recognise him, but he may spot me – an odd one out in a long-sleeved pseudo-surfer Australian SPF 50 UV protection suit. And while I can’t do a lot about many of the factors affecting my swimming-pool consultation, after a quarter of a century, I am finally getting around to doing A-level French.

The author is a consultant dermatologist thedoctor | June 2019 29

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explainer

Do you treat patients who are refugees or asylum seekers? New BMA guidance focuses on their specific health needs and how to overcome common barriers What’s there to know about asylum seeker and refugee health?

Much. They can receive free NHS care. They face unique health challenges and many have experienced violence and persecution. Your medical evidence can be crucial to their asylum claims but they may have difficulty trusting doctors. Compassion and sensitivity are required.

Caring for the patients may be emotionally affecting – you need to look after yourself, too.

What does the guidance cover?

There is background on who refugees and asylum seekers are, the often very stressful and cumbersome process of applying for asylum in the UK, and the particular health challenges and barriers to accessing care they face.

There are also links to information resources, specialist organisations and online tools that can help you support patients.

Is it my job to decide if their treatment is free?

No, but doctors can be responsible for identifying

when a patient requires care which cannot be delayed (for example, when it is urgent or immediately necessary), or which is exempt from charge.

The guidance explains how entitlement to free NHS care differs between primary and secondary care, across the nations, and if your patients’ asylum applications have been refused.

What are the particular health challenges of asylum seekers and refugees?

They’re what you might expect for people arriving after perilous journeys from countries in turmoil with poor healthcare: untreated communicable diseases, poorly controlled chronic conditions, maternity care, and mental-health needs.

Patients who have experienced violence and trauma may also need specialist support.

They’re generally banned from working. Uncertainty over their future can lead to poor mental health. They face a particularly difficult period immediately after their applications are approved, as they are no longer supported by the Home Office and have to make applications for services such as housing.

What about cultural sensitivities?

It’s good to be mindful of this.

People from different backgrounds can express mental illness differently.

They may complain of head or stomach aches instead of emotional distress, for instance. You may also want to take account of factors such as genders and political background when choosing an interpreter.

Anything else?

Anything else I should look out for?

There is far more detail in the full guidance. It’s worth checking the ‘useful resources and organisations’ section for links to support groups, too.

Experiences in the UK can also cause problems. Asylum seekers are at risk of malnutrition and other conditions linked to poverty.

The guidance can be found at bma.org.uk/ refugeehealth

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what’s on

June 19 Practical skills... leadership and management for doctors, London, 9am to 5pm 24-25 GP general update, Birmingham, 9.30am to 4.30pm 23-27 BMA annual representative meeting, ICC Belfast, 2 Lanyon Place, Belfast

July 05 Planning for retirement – delivered by the BMA, Glasgow, 9am to 4pm 26 Planning for retirement – delivered by the BMA, Cambridge, 9am to 4pm

September 19 Practical skills... for effective communication, London, 8.45 to 4.45pm 21 BMA Scottish conference, Glasgow, 9.30am to 5pm

ARM 2019 On the agenda ...

The BMA annual representative meeting will take place in Belfast, from June 23 to 27. Around 500 doctors and medical students debate issues of relevance to the profession.

Among the topics on this year’s agenda are: –– D octors’ pensions The effect of tax rules which have forced doctors to retire early or reduce their work commitments –– T he caring, supportive and collaborative project After a long campaign of engagement with members, doctors will be asked to discuss proposed solutions to create better working conditions and build a better NHS –– P rivatisation A motion calls on the BMA to lobby decision makers to protect the NHS from future trade agreements, which would threaten its status, and to resist privatisation – building on existing policy which opposes it –– NHS culture Condemning bullying and setting out how the NHS can move towards a culture of learning and support

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

–– P ay After years of below-inflation pay rises, motions condemn the role of the Review Body on Doctors’ and Dentists’ Remuneration and call for fair mechanisms to be in place to determine increases –– M ental health support A session will discuss the findings of a project launched by BMA president Dinesh Bhugra, which sought to increase the understanding of the prevalence of mental health issues among the profession.

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