The Doctor – issue 16, December, 2019 by The BMA

The magazine for BMA members

thedoctor

Issue 16 | December 2019

Calling it out

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Tackling sexism in the NHS 09/12/2019 12:11

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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.

Senior staﬀ writers Peter Blackburn (020) 7874 7398 Keith Cooper (020) 7383 6390 Staﬀ writer Tim Tonkin (020) 7383 6753 Scotland correspondent Jennifer Trueland 07775 803 795 Senior production editor Lisa Bott-Hansson Design BMA creative services Cover: David Nelson

The Doctor is a supplement of The BMJ. Vol: 367 issue no: 8226 ISSN 2631-6412

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In this issue 4-5

Briefing Brexit, NHS pressures and the pensions crisis – a year in numbers

Welcome Chaand Nagpaul, BMA council chair Welcome to the December 2019 issue of The Doctor – and may I wish all members, colleagues and friends a very happy festive season. In June, at the BMA annual representative meeting, doctors unanimously demanded action on the growing ‘public health emergency’ that is homelessness. The Doctor was named runner-up for a national journalism award last month, recognising insightful work around complex social problems, for a series of articles investigating the relationship between homelessness and health. I am pleased to say that in this issue of the magazine the work continues – with a piece revealing the deepening demand on the NHS from homeless patients and the work of hospital homelessness teams trying to break the cycle between the streets and emergency departments. This is a genuine epidemic in our society. While homelessness is a tragedy, which spans all areas of society and public services, the reality is that the NHS is under immediate pressure. In the long term the BMA will continue to demand the reversal of brutal austerity policies and urge increased investment in public services. But in the short term it is vital hospital managers and senior NHS leaders across the country take note of the mounting evidence, as outlined in our piece, of the positive opportunity of a hospital admission. We discuss the need for an NHS ‘listening-up’ culture, which is crucial as we look to tackle gender inequality in the medical profession and health service. The BMA held its first joint conference with the Medical Women’s Federation last month. We heard from female doctors who had been mistaken for nurses or who had been encouraged to flutter their eyelashes to have a patient scanned in radiology. We also look at the serious crime of female genital mutilation, and the role of doctors in breaking the generational cycle of this illegal and harmful practice. The Doctor visits a pilot psychological medicine service providing care through GP practices rather than hospitals and the newly opened ‘Medicine: The Wellcome Galleries’ exhibition at the Science Museum.

6-7

A Wellcome diversion The curious history of medicine stunningly presented at the Science Museum

8-11

Close-up care Patients who consult often and widely with ‘unexplained symptoms’, and a service that can help them

12-15

Sent back to danger A 10-year-old girl is among those under threat of deportation to countries where female genital mutilation is rife

16-21

No place to recover The NHS teams trying to give hope to homeless people, who face discharge from hospital back to the streets

22-26

Speaking up, listening up A joint BMA and Medical Women’s Federation conference explored efforts to tackle sexism

27-30

Life experience An atheist gives praise to hospital chaplains, and a junior doctor looks forward to his first NHS Christmas

What’s on? Keep on top of events

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briefing

The percentage of doctors who qualified in other EEA (European Economic Area) countries who are thinking of leaving the UK, according to a BMA survey. Doctors who qualified in other EEA countries make up almost a tenth of all those licensed to practise in the UK. Without them, the NHS would surely collapse. Brexit’s many and corrosive tentacles have reached far into the health service. They included in September, the bizarre spectacle of David

NICHOLL: Raised concerns

Nicholl, the consultant who advised the Government on no-deal Brexit planning, being told by Jacob Rees-Mogg that he was ‘irresponsible’ for raising concerns about drug shortages. Often overlooked is the effect it has had on individual doctors. Since the Brexit vote in 2016, the BMA has been

consistently lobbying for them to be given guarantees on their future statuses in the UK. While there have been some assurances, many doctors have been left feeling that they were not welcome. Greek-trained Michael Kalogirou told us in March that Brexit ‘makes it feel like you’re not accepted now’. Italian junior doctor Federica Ceroni said that after the Brexit vote, ‘I did not feel as welcome as I had before… it felt as if all that I had done while in the country had not been appreciated’.

80,092

The number of patients in England in October who waited more than four hours from the decision to admit to admission. ‘Trolley’ used to be a neutral kind of word, just a name for a mundane piece of hospital equipment. Now, in the NHS word-association game, it’s inevitably paired with ‘wait’. The number of patients waiting more than four hours for admission in October was up 63 per cent on the same month the previous year. Back in October 2010, the figure was 6,932. There are now enough people waiting each month to fill Manchester United’s football stadium (pictured top right). Nine years ago, they wouldn’t have filled Cheltenham Town’s.

PhotoLondonUK

Brexit, NHS pressures, homelessness, and the crippling pensions tax – a look back at the issues faced by the profession in 2019 and how we covered them

2019: a year in numbers

OLD TRAFFORD: People waiting more than four hours would fill up stadium

By any indication, the NHS is facing unsustainable pressures. BMA modelling of trolley waits, emergency department attendances and emergency admissions has already established that an NHS summer is now as pressured as the worst of previous winters. For this winter it predicts that even the best-case scenario in most areas will be worse than last year. One emergency medicine consultant told The Doctor: ‘I don’t think there’s an emergency medicine department in England or Wales that thinks patient care isn’t going to suffer over winter.’ The BMA, in its manifesto for the general election, set out enhanced investment by at least 4.1 per cent per year in real terms, and action on safe staffing, as key priorities.

462

The number of days a homeless patient spent in a hospital in Nottingham. Hospital attendances by patients with no fixed abode have more than tripled in three years. In our focus on homelessness we have looked at the effect on the health

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Laura McManus’s age when she became pregnant. Laura had been excluded from school at 15, was pregnant at 16, then lived in homeless hostels before doing a succession of jobs such

-£27,000

MOHAMMED: Providing excellent care for the homeless

outcomes of patients, and the work being carried out by doctors around the country. In this issue, a patient deemed medically fit for discharge faced the prospect of living rough on a housing estate. It is little wonder that hundreds of them have long stays in hospital while suitable options are found. Fortunately, that patient came to the attention of a Pathway team at his local hospital. The teams address the complex issues in a homeless patient’s life and use their expertise in areas such as clinical care, occupational therapy, social care, or substance misuse to help address their problems. Only 11 trusts operate Pathway teams at hospitals in England, when many more are needed. And that, like in so many other areas of healthcare, is a fundamental problem. Provision is patchy. Where it is there, it can be excellent – such as Rochdale GP Zahir Mohammed (pictured top), who not only hosts a drop-in surgery and stocks sleeping bags, but volunteers at a project for the homeless, too. Homeless people have many needs, but one of the most fundamental is a truly national health service.

be a doctor. Your background should not matter. ‘It should not matter if you have parents who are doctors, parents who are not, or you don’t have parents. It should not matter if you live on a council estate, live in care or live between homes.’

Consultant psychiatrist Kate Lovett’s annual pay, effectively, once she has paid a tax bill related to her pension.

MCMANUS: Discriminated against

as cleaning and serving in a chip shop. She is now a doctor, having returned to education as an adult and been well supported by the teachers there. It’s an inspiring tale but one that is all too rare. Only a minority of doctors come from working-class backgrounds, meaning there are whole sections of society barely represented by the profession. Dr McManus (pictured above) told us: ‘It wasn’t that I was academically incapable, it was discrimination and the lack of support, resources and self-belief.’ The BMA has launched a new initiative called Aspiring Doctors, which invites medical students and doctors to visit schools and colleges and talk to possible applicants. As the BMA medical students committee widening participation lead Brooke Davies said: ‘Widening participation, for me, is the concept that allows anyone to have a chance to

One of the greatest crises faced by the NHS is entirely of the Government’s own making. Changes to pensions taxation have meant thousands of consultants have been hit with huge, unexpected tax bills, forcing them to reduce their commitments at exactly the time the health service needs them most. Dr Lovett said: ‘This is terrifying – here I am at 52 having thoughts about cutting down the work I’m doing. We simply can’t afford for people even beginning to think like that.’ The BMA has been leading the campaign against the changes, lobbying successive prime ministers and other senior policy makers, surveying members to reveal the extent of the problem, and giving practical advice. LOVETT: May be forced to reduce commitments

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THE WELLCOME GALLERIES / SCIENCE MUSEUM GROUP

A LOOK BACK: (clockwise from left) A pharmacy leech jar, small phrenological heads, an anatomical model and an early MRI body scanner

A Wellcome diversion New galleries at the Science Museum show when medicine was beautiful, useful and occasionally, both. Neil Hallows takes a tour ‘Bottles of medicines which contained just a bit more arsenic than was healthy’

A Genoese medicine chest

ixty tiny heads made with grace and precision. All of them different, probably modelled on real people. In daily use by the medical profession for years. And scientifically speaking, nonsense. The overwhelming feeling you get from the Science Museum in London is one of progress. A grand procession of steam engines, flimsylooking horseless carriages and space capsules a few dizzying decades of activity apart. To infinity and beyond. The newly opened Medicine: The Wellcome Galleries tell a more nuanced tale. It’s not a simple march from darkness to the lights of a modern operating theatre. The history of medicine, and of it arriving at a point where it is not only fascinating and picturesque but actually does some genuine good, is one of innumerable rabbit holes.

The tiny heads were created for the entirely discredited discipline of phrenology, where patients’ characteristics and intelligence were judged by the size of their heads. Almost as pretty is the ceramic jar marked ‘leeches’, the coloured, stippled glass bottles of medicines which contained just a bit more arsenic than was healthy, and the gem-like amulets which may well have been patients’ best hope of recovery.

Curiosity and compassion The aesthetics are so good that when you reach a big lump of metal, four yellow rings with chipped paint, you think, ‘what’s that ugly old thing?’ but the early MRI machine has more than earned its place. There is plenty that is useful and beautiful; it doesn’t have to be either/or. A forest of rods and coloured tags could be

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EYE CATCHING: (from below, clockwise) 16th-century amputation saw, Marc Quinn’s selfconscious gene in medicine, an iron lung, carbolic spray and a model of the human eye

ON DISPLAY: (above and right) the medicine and bodies gallery

an art installation in its own right but is also a model of the myoglobin molecule made in 1960 by the Nobel laureates John Kendrew and Max Perutz. There are many such objects which are testaments to human curiosity and, by extension, compassion, such as a lancet used by Edward Jenner for the first smallpox vaccinations, an iron lung used by patients with polio, and protective clothing worn during the 2014 Ebola epidemic. In each case, the practitioners would have looked so strange, possibly even threatening, and yet all were working for a common good. In some of the other 3,000 artefacts, you see a particular strength the Wellcome collection has always had, in its emphasis on the relationship between medicine and society. There’s part of an old

‘bug van’, which within just about living memory used to put people through the humiliation of publicly transporting their few worldly goods away for fumigation during slum clearances. A strangely disturbing doll with a cigarette in her mouth and a plastic foetus in a jar below her. ‘Smokey Sue smokes for two,’ says the caption. A children’s board game from the 1980s to ‘build a better burger’ is poignant given what’s happened to the nation’s waistlines in the years since.

Grave intentions Doctors are not always the heroes in this museum. A heavy iron cage, known as a mortsafe, was for a time an essential hire when mourning the recently deceased, enough to protect the corpse from the roving attentions of anatomists until it had safely decomposed.

‘The models were treated with more respect than the corpses on which they were based’

It’s a reminder that progress tends to come at a price. The crude, black, heavy iron of the mortsafe contrasts with the outstanding craftsmanship of the delicate anatomical models nearby but they possibly have a common, grave-robbing source. In which case the models were no doubt treated with considerably more respect than the corpses on which they were based. Good or bad, life-saving or life-shortening, there is a common thread in the museum of medicine being a profession with a sense of identity, kudos and a culture all of its own. How else can you explain the amputation saw, more than 400 years old. All it needs is a strong frame and a good blade. But with its beautifully carved handle and elaborate metalwork, here was a practitioner who would cut off your leg with a dirty blade, with no anaesthetic and a filthy rag to bite on for the pain, but he’d do it with style and he’d do it with pride.

Medicine: The Wellcome Galleries, free entry, the Science Museum, London, UK sciencemuseum.org.uk/medicine

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Consultant psychiatrist Chris Schofield and specialist nurse practitioner Natasha Cain

‘The vast majority of our patients report improved symptoms and lifestyles’

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SARAH TURTON

Close-up care Patients who consult often and widely, and with ‘medically unexplained’ symptoms, can pose a particular challenge. Keith Cooper reports from a service which tries to understand their motivations and help them

auline Linton*, a 53-yearold mother of three and civil servant, was at work when matters came to a head. She shouted at colleagues, stormed out of a team meeting and burst into tears in front of her boss. She went home and visited her GP. ‘They said, “I don’t know what to do”,’ she says. ‘You’re on all the medications I can give you. I’m not sure what I can do right now.’ This was two years ago.Ms Linton had seen her GP a lot previously for her fibromyalgia, diabetes, irritable bowel syndrome, osteoarthritis, problems with her thyroid gland, insomnia, and sleep apnoea. She’s had anxiety and depression, on and off, since her 20s, taken months off work and faced disciplinary action. ‘I was struggling with friends and family. I was keeping myself to myself. Things were just really black and dark,’ she recalls. Her GP mentioned a pilot service run by Chris Schofield, a consultant liaison psychiatrist at NHNFT (Nottinghamshire Healthcare NHS Foundation Trust).

‘My GP said it took a more holistic view,’ Ms Linton adds. ‘It sounded good. I’d been back so many times, I sometimes felt like a bit of a hypochondriac.’

Community focus This new service, PCPM (primary care psychological medicine), offers liaison psychiatry through GP practices instead of hospital clinics, as is the NHS convention. ‘You get a much closer connection in the community,’ says Dr Schofield. ‘You get closer to real [life].’ It’s for people, such as Ms Linton, who have chronic physical health problems, some of whose symptoms are ‘medically unexplained’. It’s a poor phrase, Dr Schofield admits. ‘“I have no idea” is not what I call a diagnosis.’ Many see multiple doctors and take numerous medications. It’s helped hundreds so far, those cases too complex for Improving Access to Psychological Therapies, the standard NHS talking-therapy service. * name has been changed

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SARAH TURTON

Two years on from her initial referral, Ms Linton says she better understands how her physical and mental health connect. She feels more in control of her medication. Her job is no longer in jeopardy. ‘I’ve realised the fibro can be a sign that I’m about to take a dip,’ she says. ‘It’s a beginning sign before the mood drop, so I can slow down a bit,’ she adds. ‘Instead of going on a bike downhill uncontrolled, I’ve got brakes.’ But two years on, despite independently verified evidence of its benefits, the service’s future is not yet certain. It has been rolled out across south Nottinghamshire for further testing. All six CCGs are ‘supportive’ following the ‘successful pilot’ in Rushcliffe, they say. They’re helping to draft a ‘business case’ for its continuation. Its time-limited funding is, however, due to run dry next December as the NHS in Nottinghamshire seeks £78.2m of savings across its 2019/20 allotted budget. Rising demand, as in many other parts of the country, is busting its budget. All this as managers are occupied with major ‘structural’ changes in Nottinghamshire. Its six CCGs (clinical commissioning groups) are merging into one, matching the footprint of its ICS (integrated care system), which brings together NHS and local authority care managers. In addition, three integrated care providers are being set up. All will have some say on services. What stays, what goes. It’s not an easy environment in which

SMITH: ‘These patients don’t just come to emergency departments or one outpatient clinic’

novel, relatively unknown services can survive, however much good they do.

Improved symptoms So how is PCPM helping patients? How could it improve the health service in Nottinghamshire and beyond? What are its odds for survival? Liaison psychiatry, the branch of psychiatry straddling physical and mental ill health is, of course, nothing new to the NHS. What’s novel in Notts is that referrals come from GPs. ‘Many GPs say this patient group doesn’t get better. But that’s simply not true,’ says Dr Schofield. It is patient-reported symptoms, recorded at first appointments, then every three months, that show improvements in their mental and physical health symptoms and lifestyles, he adds. ‘Some see their GPs less and relationships with patients also improve. Clinicians can also feel that they have nothing left to offer this group of patients and that’s really unpleasant, too.’ The service was made possible in Rushcliffe, one of the six CCGs in 2016, thanks to time-limited funding

‘We are edging towards a system where integration has to happen, where you see the whole person and not just the physical health’

from NHS England to test ‘new models of care’. An early economic evaluation by the respected Centre for Mental Health, found it saves more, through reductions in access to health services, than its staff costs alone, an ‘extremely encouraging sign’, says its report, A New Approach to Complex Needs. Ms Linton’s first appointment was with specialist nurse practitioner Natasha Cain. ‘It was hard, wasn’t it?’ she recalls, looking to Ms Cain. ‘We went back through lots of stuff that had happened over the years. I think I only got to late teens.’ They continued to meet, weekly, then fortnightly, then monthly. They still do, though far less frequently. ‘I really like to get to know the person in front of me,’ says Ms Cain. ‘When I ask you things, you sometimes say, why are you asking me that? But I’m trying to build a picture.’ She met her family, her husband and children, early on. ‘Natasha knows me now,’ Ms Linton adds. ‘She knows my family, my circumstances. That makes an important difference. Before, I’d had CBT, EMDR [eye

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SARAH TURTON

movement desensitisation and reprocessing], lots of different counsellors. I’d be exhausted afterwards, I’d be down, build myself up, then it would be time for my next appointment. It was this constant cycle. This is so different. I’m not afraid to see Natasha.’

Empowerment

Bureaucratic hurdles Another hurdle is its awkward ‘fit’ into the NHS bureaucracy which, though shifting, still favours established services, which are already pigeonholed and ‘coded’ for the cost and savings calculations essential to budget taming. ‘These patients don’t just come to emergency departments or one outpatient clinic,’ says NHNFT programme manager for integration Helen Smith. ‘They’re in respiratory, neurology, they’re in diabetes. They’re dispersed. It makes it hard to say that we’re shifting this work to the community.’ There’s an obvious irony

NEWMAN: Financial pressures continue

‘I was spending hours in bed. My room felt like a prison. I was thinking, there’s nothing out there for me’

SARAH TURTON

Weeks after her first visit, she met Dr Schofield to discuss medication. ‘He talked about the different paths we could choose. He said, we could do this. But that could affect that, go away and think about it. That was massive. It was an empowerment. So many times we walk in and come out with a script. We don’t know the effects. When you’re taking loads of tablets you’re thinking, I’m just popping these,’ she says. Dr Schofield speaks of the service like the experienced psychiatrist he is. Its logic is simple. Its success is unsurprising. It’s what good liaison psychiatry should do and does. ‘There’s isn’t anything particularly clever about it,’ he tells The Doctor. ‘If you’ve got physical symptoms and mental health problems it’s easier to get to an appointment which is closer to you. Even the loveliest of hospitals are big. You’ve got to get through all those people, sit in a large waiting room. When patients feel better, they don’t go to their GP as often.’ But despite the positive response from doctors, patients, the encouraging signs in its evaluation, and supportive words from its commissioners, the future

of PCPM is not guaranteed. They hope it will go on and further extend across Nottinghamshire but they face several hurdles before regular, ongoing funding is agreed. ‘As responsible commissioners, we need to look at how best to spend the money available on services that local people need,’ says South Nottinghamshire CCGs deputy locality director Stewart Newman. ‘We know that the approach works really well in Rushcliffe, now we need to see whether the same outcomes are delivered at scale.’

PAGE: Integration has to happen

here with the rise of new NHS structures aimed at ‘integration’. ‘The narrative of the ICS does align with this service,’ says Rushcliffe CCG mental health lead and GP Nicholas Page. ‘We are edging towards a system where integration has to happen, where you see the whole person and not just the physical health,’ he adds. ‘It’s a race to keep the service going long enough for that to mature. It would be upsetting if it didn’t continue.’ Before her referral to PCPM, Ms Linton says she felt life was passing her by. ‘I was spending hours in bed. My room felt like a prison. I was thinking, there’s nothing out there for me.’ She still has good and bad days. ‘But because of the strategies we’ve developed and the way we look at things now, I seem to be able to deal with it.’ All services have a cost of course. Decisions are made daily about which of the many beneficial services, which make up the NHS, get funded. But as Dr Schofield points out there are other costs which should be considered. There are patients like Ms Linton across the UK, in every town, village and city. ‘Who pays for these services?’ he asks. ‘It’s the patients who pay for them when they’re not there.’ thedoctor | December 2019 11

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‘The Government is saying “no” because you’re not a British citizen, we don’t care about you’

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Sent back to danger The UK claims to be a champion of those at risk from FGM and yet deports girls and young women to countries where the practice is common. Jennifer Trueland reports on a 10-year-old girl at risk

here is a 10-year-old girl living in the UK today who has no idea what FGM (female genital mutilation) is; her mother – herself a victim – is desperately trying to ensure it doesn’t happen to her daughter. Although social services and the National FGM Centre have agreed the child is at high risk, it is likely that she and her mother (who is from Sudan but has Bahraini citizenship) will be deported. The case, says human rights barrister Charlotte Proudman, illustrates inconsistencies in the UK’s position on protecting girls and women from FGM – on the one hand, any parent in the UK who is trying to have their daughter mutilated should face the full weight of the law, while on the other, a parent who is trying to protect their child from the same thing happening to them abroad is rewarded with deportation. ‘This country is zealous when it comes to prosecutions, or tries to be,’ she says. ‘And they’re very gung-ho when it comes to trying to put parents in prison for performing FGM. But when parents say they want to protect their children from FGM, to stop deportation, the Government is saying no because you’re not a British citizen, so we don’t care about you; your life isn’t as valuable.’ FGM is a crime in the UK; it is recognised as an abuse of human rights and, in some cases, as grounds for asylum. All four nations have policies in place to try to safeguard girls and women who may be at risk of FGM. In the UK, most girls and

‘In a situation like this, there is no avenue for redress; it doesn’t really exist’

women who have been mutilated, experienced it abroad. Data-gathering processes were introduced in the NHS in England several years ago to try and find out the prevalence of girls and women who had undergone FGM but it is almost impossible to find reliable evidence of the scale of the issue. Estimates (reported in The BMJ earlier this year) suggest that around 60,000 girls in the UK are at risk on the basis that their mothers had been mutilated, which is the biggest risk factor. In 2017-18 there were 4,495 newly identified cases of FGM recorded as part of these data-gathering processes, the vast majority of whom had been mutilated before they came to the UK.

Mandatory reporting

PROUDMAN: Any parent trying to mutilate their daughter should face the full weight of the law

Doctors and other health professionals are supposed to have a role in identifying victims of FGM, and since 2015 it has been mandatory in England and Wales for them to report it to the police if there is disclosure or evidence of FGM in girls aged under 18. There are similar requirements in Northern Ireland owing to broader obligations to report certain crimes. Consultant gynaecologist Alison Scott says that the long-term eﬀect of FGM is considerable, and that breaking the generational cycle is hard. She provided evidence in a similar immigration case to that mentioned above, where a thedoctor | December 2019

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What is FGM? FGM (female genital mutilation) is a collective term used for a range of practices involving the removal or alteration of parts of healthy female genitalia for non-therapeutic reasons. Diﬀerent degrees of mutilation are practised by a variety of cultural groups in the UK. The World Health Organization classiﬁcation of FGM – Type 1 to Type 4 – is widely used to identify and record the type of FGM a girl or woman has undergone (www.who.int/reproductivehealth/topics/fgm/ overview). All forms are mutilating and carry serious physical and psychological health risks.

SCOTT: Breaking the generational cycle is hard

mother was appealing against deportation from the UK on the grounds that her daughter was at high risk of FGM in her home country. ‘The woman was possibly the most traumatised patient I have ever seen,’ says Dr Scott, who is clinical lead for socially excluded women in Lothian’s sexual health service and chairs the Faculty of Sexual and Reproductive Health (Scotland). ‘The physical and mental impact of FGM was considerable, and she was terrified that the same thing would happen to her daughter. The idea that she would have been able to protect her daughter had they been deported is risible.’ Fortunately, in that case an appeal was successful and the woman and her daughter were given leave to remain, says Dr Scott, who was instrumental in setting up Alnisa, a multiagency service for women and girls who have undergone or are at risk of FGM. For others, the story does not end so well. Dr Proudman represented the mother of the 10-year-old girl in the family division of the high court. She says the mother is suffering from PTSD as a result of her own FGM, not least because she says her sister died as a result of the practice. She and her family arrived in the UK in 2012, when the girl was three, but their asylum claim was refused. Although the family court granted an FGM protection order to prevent the girl being removed, the home secretary challenged its power to prevent deportation. ‘What you must remember as well is that most of these individuals are not entitled to legal aid and so they can’t afford to continue with immigration solicitors to help them, whereas with family courts you are entitled to legal aid,’ says Dr Proudman, who has been working on the case pro bono. She is scornful of the claim that the woman could protect her daughter. ‘There are some women who doubtless have a lot of agency and autonomy and are very vocal advocates but they haven’t suffered the same 14

traumas that she has and have not grown up in the same kind of patriarchal society. ‘She is the most vulnerable client I have ever had, and I deal with all sorts of cases including child sex abuse, paedophilia and all sorts of things but she is probably the most vulnerable I’ve come across. She can barely speak; she just sits and sobs. It’s heartbreaking.’

Raise awareness

‘The woman was possibly the most traumatised patient I have ever seen’

The 10-year-old girl’s case will be given a ﬁnal hearing next month when the family court will make ﬁndings but will be unable to stop deportation. This decision is in the hands of the home secretary. For many doctors, FGM is literally a hidden problem because patients will often not volunteer that it has happened to them, and few medics have been trained to recognise it. Dr Proudman says: ‘I’ve lectured to doctors and nurses and particularly to midwives about FGM law and policy and tried to raise awareness of mandatory reporting and so forth, and what comes out of that always is this overlap between women who have undergone FGM, girls at risk of FGM, and their insecure immigration status. ‘They’re saying, how can we protect these women and girls, and really the answer is that there’s nothing that you can do. That’s what this case says, ultimately. It shows you can make the asylum application but if they’re unsuccessful in what is a very hostile immigration environment, they’re going to be deported and you can’t prevent that, even if, like in this case, the mother is saying that her daughter will be cut, and you think there’s a high risk, but the secretary of state disagrees. No one has any other authority or power to over rule that, not even the family court.’

Medical examinations Dr Scott and Dr Proudman speak of the frustration that professionals feel, not just

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in dealing with these cases, but because of the lack of expertise and knowledge about the issue. ‘Support services for girls at risk of FGM or particularly for women who have gone through FGM are appalling,’ says Dr Proudman. ‘There’s so few medical experts that specialise in FGM so in many cases when you need a medical examination, particularly of girls, to see if they’ve undergone FGM – and sometimes it’s very difficult to ascertain if it’s type 4 [defined by the NHS as ‘other harmful procedures to the female genitals including cutting, pricking, piercing, scraping or burning’] – there’s no one really to go to, or it’s the same experts who keep coming up time and time again, who are very busy, or you have clients needing to travel really very far to have these examinations done.’ There have been recent moves to try to improve the healthcare services available. NHS England launched eight specialist clinics for adult women in September, with health secretary Matt Hancock outlining his determination ‘to do everything I can to support the survivors of this horrific act’ and noting that ‘FGM continues to devastate lives and it is vital the NHS does what it can to help. It’s absolutely crucial we reach more women so they can access support services that take care of mental, emotional, physical and clinical needs’. A sense of powerlessness is one of the most difficult elements, Dr Proudman adds. ‘That’s a horrendous feeling, but particularly when you’re an advocate, because the whole purpose is hopefully to win a case and to get some power back to your client – some legal redress and justice. And in a situation like this, there is no avenue for redress for her; it doesn’t really exist. It can be very harrowing to read the reports, but particularly to see the impact on the clients themselves – seeing her so upset, and knowing that there’s so little that you can do is extremely frustrating.’

Doctors have a vital role FGM is a serious crime no child or woman should have to suﬀer, says BMA medical ethics committee chair John Chisholm

‘The mother is saying that her daughter will be cut’

The BMA has long recognised that doctors have a vital role in breaking the generational cycle of this illegal and harmful practice – supporting and caring for those who have undergone FGM and identifying and safeguarding those who may be at risk of FGM. In the last few years there has been an unprecedented amount of governmental resources, initiatives, parliamentary and media coverage, policy developments, legislative changes, and new requirements on doctors, aimed at eradicating FGM. An outline of some of these developments can be found in Health Education England’s FGM e-learning programme – available (UK-wide) at www.e-lfh.org.uk The BMA supports the position of UN agencies, that refugee and asylum status should be granted to women and girls ﬂeeing their country to escape FGM. Despite the UN position, worldwide only a very small number are believed to have been protected on these grounds. No data are available for FGM asylum claims in the UK. Guidance for doctors on the entitlements and health needs of refugee and asylum seekers, including in relation to FGM, is available from the BMA. Visit bma.org.uk/refugeehealthoverview

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No place to recover Homeless people are attending hospital in ever greater numbers but are discharged back to the streets where they can enter a spiral of decline, readmission and premature death. Peter Blackburn meets those trying to restore hope

A&E

he closest Lee Snowball came to home comforts for 17 years were a makeshift bed in a lift shaft, bottles of milk pinched from estate doorways, and a stolen sofa in an abandoned garage. Life was ‘tough and lonely’ – sometimes he had to fight, literally, to survive those long nights. In 2016, those thousands of nights sleeping rough, or staying with friends, had taken their toll on his body and significant surgery was required to correct a bowed knee and some other, resulting, issues. After successful surgery Mr Snowball faced a return to sleeping in the park near his godmother’s house or taking shelter in the cubbyholes and rabbit warrens of a North London housing estate – on crutches, with a large, healing wound. However, medically fit for discharge is surely not equivalent to fit to be discharged to the streets? As a Department of Health study published in 2010 said: ‘Clearly, living conditions on the streets are not conducive to recovery from poor health; neither do hostels provide all elements of a good environment for recovery.’ Readmission and complications would have been almost inevitable in Mr Snowball’s case. He faced 16

becoming a victim of a vicious cycle, a spiralling relationship between ill health and homelessness. His is just one story behind a growing avalanche of statistics captured by The Doctor – with the interaction between homeless patients and the NHS rocketing as the cuts to services and stored up trauma of austerity policies bite hard across the country.

The walking wounded New research gathered through a series of FoI (Freedom of Information) requests responded to by the majority of trusts in England, reveal hospital attendances by patients with no fixed abode soared to at least 36,469 during 2018-19. Those figures represent a massive rise from 11,305 in 2010-11 and a significant jump from figures for the year prior, 2017-18, which totalled 31,924, according to statistics previously collated by The Doctor. Last year alone those emergency department attendances cost the NHS at least £5.8m, at £160 each. It is a trend echoed in hospital admissions, too. In 2018-19, 11,986 admissions for patients of no fixed abode were recorded. In 2010-11 that total number was 3,378 and in 2017-18 it was 9,282, again according to figures

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SNOWBALL: The Pathway team has started my life rolling again

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‘Living conditions on the streets are not conducive to recovery from poor health’

previously collated by The Doctor. With the cheapest hospital admission averaging £1,603, according to NHS Improvement, this year’s bill sits at £18.7m, at the very least. For most of these thousands of patients hospital appointments represent more crises, but for Mr Snowball things were very different. When he was admitted in 2016 a member of the Pathway team at University College London Hospitals became aware of his case. The team identifies the complex issues in a homeless patient’s life on admission and uses their expertise – whether in clinical care, occupational therapy, social care, substance misuse or a wide range of other areas – to address the problems, looking to wrap care around them while they are in a place where they can be helped. It is a simple idea which allows hospital trusts to do more than just discharge homeless patients to the streets, more than just count the days until their next admissions. In Mr Snowball’s case the Pathway team allowed him to access a solicitor, found temporary hostel accommodation, helped to address his health and addiction issues and eventually assisted with finding a flat. Mr Snowball’s daughter has moved in with him and he’s able to volunteer with local projects. ‘I wouldn’t have anything that I have now, without having been to hospital, without them helping me,’ Mr Snowball reflects. ‘Things have all fallen into place quite nicely. They’ve started my life rolling again and have helped me all along the way. It has just gone onwards and upwards.’ Further research illustrates just how complicated hospital discharge for homeless patients can be – and highlights a significant breakdown in the services available for clinicians to access in the community.

Long stays For the first time FoIs were used to reveal the number of patients of no fixed abode stuck on hospital wards for ‘long stays’ – defined by the NHS as 21 days or longer. In total 49 trusts said that at least 314 patients of no fixed abode had stayed in hospital for 21 days or more in 2018-19 – costing at least £5.4m, a deeply conservative figure based on NHS Improvement costings of an ‘excess bed day’ at £346, as the types of treatment received cannot be estimated, and many trusts would not reveal patient numbers. In one case, in Nottingham, a patient was stuck on a hospital ward for 462 days. And 28 other patients were on hospital wards across the country for

Research by The Doctor has found that ...

A&E

Hospital attendances by patients of no fixed abode 2018-19 2017-18

31,924

36,469

2010-11

11,305

CLEAVER: Homeless figures tip of the iceberg

100 days or more. At King’s College Hospital, London, 78 patients spent long stays in hospital, totalling 4,383 days. The reality is likely to be even bleaker than all the statistics gathered for attendances, admissions and long stays – with NHS recording mechanisms notably poor, hidden homelessness a growing issue and a number of trusts not recording data or not responding to requests for information. Faced with this sort of demand – and without the tools to cope – frontline staff are left in an increasingly difficult position, making decisions that will have a huge impact on the health and life outcomes of their patients.

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Long stays At least 314 patients of no fixed abode spent 21 days or longer on hospital wards in 49 trusts

314

patients

462 DAYS And one patient spent 462 days in hospital.

Forty nine trusts gave details of long stays in their hospitals. The overall figure is likely to be higher. Hospital attendance and admissions data for 2018/19 is based on responses from 98 trusts and is being compared with a similar exercise last January when 79 trusts responded.

After all, homeless patients die, on average, in their 40s. Barbara Cleaver, emergency medicine consultant at Imperial College Healthcare NHS Trust, says the demand and complexity of patients, combined with lack of ability to make a difference to their homelessness, is obvious on the front line. ‘There is an under-the-iceberg figure of people,’ she says. ‘We have had 20 people sleeping rough in the waiting room and around the hospital grounds – there is a sense that this is a place that is open 24 hours a day and is warm, well-lit and safe.’ Dr Cleaver adds: ‘It’s pretty difficult to feel good about doing your job when you are put in those positions or if you are making people homeless. These sorts of things are happening much more than people think.’

Stigmatised, marginalised These are patients of great complexity. Research by St Mungo’s found that most homeless people demonstrate

a tri-morbidity of physical ‘In any other illness, mental health condition there problems and substance would be horror misuse. The charity found that the average half its residents have mental age of death in health problems, 32 per cent these patients is had an alcohol dependency in their 40s’ and 63 per cent had a drugs problem. A report, recently published by the Centre for Health and Development at Staffordshire University, also found that homeless patients were a complex and marginalised group, were often stigmatised or mistreated in healthcare and also, possibly as a result, had difficulties engaging with healthcare. Most striking of all is that these patients are old and frail 20 or 30 years before their time – and the system is just not equipped to deal with that, or, often, even willing to face up to those extreme vulnerabilities. ‘In any other condition there would be horror that the average age of death in these patients is in their 40s,’ says GP Peter Buchman, a member of the Pathway team in London. ‘And sometimes in a busy hospital nobody really takes the time to clock some of these issues. They might only be 40 years old and there is a sense that they should be able to cope but they are frail young – these patients have the needs of 65- or 70-year-olds, they need support living and have complex needs.’ He adds: ‘The hospital admission is a real opportunity to assess these things and really investigate but it takes a lot of real pushing and often we find we need the involvement of us as clinicians to advocate for these patients. It is sometimes about winning hearts and minds.’ And not only are the patients complex but the wider environment is increasingly complex too, particularly thanks to swingeing austerity cuts and an increasingly fragmented health, social care and wider system.

Cuts to services The Staffordshire University report says funding cuts have led to a decrease in capacity. BBC analysis last year found that £162m had been cut from treatment budgets in England since 2013-14, while drug poisoning deaths had risen from 2,734 to 3,450 in 2016. Cuts have also been seen in mental health provision and social services. Housing is clearly a growing issue, too. In many parts of the country it is near impossible to gain access to housing. In Manchester the Pathway team reports there being ‘nowhere for patients to go’. In that city local authority staff have even seen fit to remove the ability of clinicians and managers to refer patients directly into services. All patients now must be matched through a thedoctor | December 2019 19

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MATTHEW SAYWELL

centralised system which takes hours to apply to and removes all utility of relationship-building between sectors. Even where accommodation can be found it is very often sub-standard. As the Staffordshire University report says: ‘Discharging to hostels and similar temporary accommodation was questioned due to the potential for an unstable environment that again did not meet the needs or expectations of individuals.’ The result – particularly without a service like a Pathway team in place – is clear. As the Staffordshire report, and so many other sources, show – patients are being discharged to the streets totally unfit for that sort of lifestyle, if indeed anyone can be fit to sleep rough. One local authority worker reflects on patients being discharged and given sole responsibility for their care – even ‘released with drains and all sorts of things that need aftercare’. The alternative is patients stuck in hospital beds, as the long-stay figures show. Neither outcome is successful, or, indeed, ethical. Clearly there is a massive need for investment: hospital beds, proper preventive public health, social care, mental health resourcing and, hugely importantly, a genuine house building programme. It is crucial the NHS, and indeed other related services, are put back on a ‘sustainable footing with the capacity to meet the demands’ on services, as BMA council chair Chaand Nagpaul said last month. The integration agenda could also be crucial. Pathway teams are, ultimately, multi‘We have had 20 people disciplinary, cross-service teams that bring the best skills sleeping rough in the together to wrap around the waiting room and around patient’s need. They display the hospital grounds’

UNITED FRONT: Dr Buchman (third from right) and the Pathway team at the Royal London Hospital

the sort of integration much of the health service only dreams about. And it appears to be effective. But integration talk is cheap – and has been on the lips of NHS leaders for years. File that one in the ‘wait-and-see’ pile. But, until all this change is realised, it is in this environment that doctors work and homeless patients live: an environment of ever-growing demand. Here, Pathway teams come into their own, with the skills, experience and single-mindedness to try to make a difference. Developed by the Pathway charity, the teams are generally based on a GP-led model where a small team of health professionals is integrated into a hospital trust, in a bid to help find accommodation and support for patients and avoid discharge back on to the streets. The phone seems to ring endlessly in the office of the Pathway team at the Royal London Hospital in Whitechapel. This cramped, corridor-like room may lack the grandeur of hospital boardrooms or the military-style urgency of bed management meetings, but, here, the daily battle of the NHS in 2019 is fully displayed, albeit in microcosm, through the struggles of one cohort of patients. When that phone rings and signifies the presence of a new homeless patient in hospital, a team of just five staff – a GP, nurse, occupational therapist, social worker and care navigator – spring into action. ‘A hospital admission is an amazing opportunity,’ Dr Buchman says. ‘Someone is in a place where you can help them and where they may want help also. It can be an opportunity to break the cycle.’ But across the country a freed-up hospital bed is worth more than its weight in gold. As such, time is of the essence, and constant communication – and more than a hint of gentle persuasion – is often required to find a successful outcome. Where possible, and the complex illnesses of homeless patients often mean time in hospital is lengthy, patients are assessed and their history and issues discussed, GP registration arranged, housing departments called, care packages considered and even shoes, clothing and a mobile phone found. A plan is put in place.

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‘The hospitals might think it is a result because they are out of the hospital but they will come back’

Further support It is not just about people, either. The Pathway homeless team at the Royal London have access to a six-bed facility that makes a huge difference to the whole process – a step-down facility, where homeless patients well enough to leave hospital, but still needing support or time to put further plans in place, can recover. The Stoke Newington-based facility, which comes with access to a large shared kitchen and is manned 24 hours a day, makes a huge difference. Dr Buchman says: ‘We’re very lucky to have it – there are a lot of people who there may be a solution for but with all of the frustrations of the system – navigating benefits, lost identification, the housing system and accessing services – sometimes you need a bit more time in a supported environment.’ The effects of Pathway teams and these sorts of facilities can be monumental in a patient’s life – and can have a serious, positive, impact on costs for the health service. Smiling, Dr Buchman cites the example of a patient treated for a fractured leg, who would have been discharged on to the streets. Room was found for him at the step-down facility and it later emerged that he was the unwitting victim of modern slavery. ‘He’s heading for legal status here – he’s somewhere safe and he has the chance to move on to a more normal life. It’s an amazing transformation and just shows the opportunity you have.’ The evidence base for the wider rollout of similar services to Pathway teams is as strong as the evidence of growing need. A Pathway team operating in Brighton (which will be featured in the next issue) has had a major effect. In 2018/19 compared with the previous financial year, measuring patients registered at the homeless GP surgery, the team demonstrated a 6.1 per cent reduction in emergency care attendance, a 26.1 per cent reduction in unplanned admissions and a 35.4 per cent reduction in readmissions within 30 days. And a study looking at 410 patients, which included the Royal London, found that the proportion of people sleeping on the streets after hospital discharge was 3.8 per cent in a cohort of

BUCHMAN: A hospital admission can be an opportunity to break the cycle

patients exposed to a Pathway team, compared to 14.6 per cent receiving standard care. It seems to echo what doctors called for at this year’s BMA annual representative meeting – the roll out of integrated inpatient homeless healthcare and wide-ranging action across the health system. Yet there are only 11 trusts operating Pathway teams at hospitals in England. Pathway clinical director and GP Nigel Hewett says: ‘We think there are about 50 hospitals that might benefit from the approach. At the current rate (of introducing the system to hospitals) that means we will have to wait another 40 years.’ Steve Wynne, senior Sister in the Royal London homeless team, says: ‘How on earth do people (without a specialist team) manage? They must be sending so many people out on to the streets. The hospitals might think it is a result because they are out of the hospital but they will come back.’ Even in a society increasingly hamstrung by growing demand – as demonstrated by the research for this piece – and contracting services, the opportunity of a hospital admission remains, according to those who know best. And the case for putting the people in place who can make the most of that opportunity is pragmatic – the NHS needs the respite and, crucially, so do patients. As Mr Snowball says: ‘It’s about giving people a chance – but it’s also forcing them to take the chance. Putting people around them, giving them the help they need. There are ways to get people off the streets and get their health going again, but you need to give people a push when they need that help.’ thedoctor | December 2019 21

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DAVID NELSON

‘I had to do something’

SARAH TURTON

JEWITT: Launched the Everyday Sexism in the NHS campaign SARAH TURTON

NAGPAUL: ‘It matters because it is morally right’

BOWDEN-JONES: Called for ‘zero tolerance’ to gender bias

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Speaking up, listening up Women doctors can be overlooked and underpaid, patronised or judged on their appearance. A joint conference between the BMA and the Medical Women’s Federation explored efforts to tackle sexism

ave you ever been mistaken for a nurse? Encouraged to flutter your eyelashes to get a patient scanned in radiology? Or waited for a colleague to realise you are the consultant, not your male registrar? All the above are experiences shared by female doctors for Everyday Sexism in the NHS, a campaign launched by north-west clinical research fellow Chelcie Jewitt. Dr Jewitt was one of several doctors who spoke of her own experience of sexist behaviour at the first joint MWF (Medical Women’s Federation) and BMA conference last month. At the conference, MWF president Henrietta Bowden-Jones called for ‘zero tolerance’ to gender bias. ‘Gender inequalities are prevalent across many parts of medicine and it is vital we understand what all of those challenges are,’ she said. The conference marked ‘an important day for women in medicine’, she added, ‘a day to speak up and be heard’. BMA council chair Chaand Nagpaul said the association was committed to being a ‘learning organisation’. ‘Who better to learn from than the MWF,’ he added. ‘We need a gender-equality vision

of hope and to embed equality as a positive, attractive attribute. It matters because it is morally right.’

No place for discrimination The conference came weeks after Dr Nagpaul made a series of pledges to tackle sex discrimination in the BMA itself. They follow the findings of an independent investigation into allegations of sexism and sexual harassment by Daphne Romney QC. This found that some female doctors and staff felt ‘undervalued, ignored and patronised because they are women’ and pointed to a lingering ‘old boys’ club’ culture. He said there was ‘no place for sexist behaviour and misogyny’ in the BMA and pledged to take ‘any necessary action’ to end it. BMA representative body chair Helena McKeown apologised for the way women had been treated by the association. She told The Doctor she supported Dr Jewitt’s Everyday Sexism in the NHS campaign, following her own experiences of sexist behaviour. ‘I’ve been told I was too ambitious for a woman,’ she says. ‘I’ve been asked, why wasn’t I at home with my children? The children one is worse. All parents have feelings of guilt about parenting.’ thedoctor | December 2019 23

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SARAH TURTON

MCKEOWN: ‘I’ve been told I was too ambitious for a woman’

BARHAMBROWN: Doctors must call out bad behaviour SARAH TURTON

‘Dr Jewitt’s campaign is very relevant for doctors and the BMA itself,’ Dr McKeown adds. ‘For some people, the Romney review was a surprise. We’ve had to take a good look at ourselves to see if we have just been passers-by. We have to put ourselves in other people’s shoes.’

Tackling unacceptable behaviour The conference heard that a ‘listening-up’ culture in the NHS and the medical profession was important to tackling gender inequality. ‘We spend a vast amount of resources to get women to speak up when more work needs to be done in the listening and inviting,’ Hult International Business School professor of leadership and dialogue Megan Reitz told the conference. ‘Listening up is a bit of a deaf spot. We need to look at ourselves in the mirror: how do we perpetuate the cultural habits here?’ BMA council member Hannah BarhamBrown said doctors had an important role in ‘calling out’ bad behaviour. ‘We have a way to go in making this mainstream.’ 24 thedoctor | December 2019

She pointed to the need for an ‘intersectionality’ approach to tackling gender bias which accounts for the multiple categories of protected characteristics into which women fall. ‘If we don’t, we can miss out the most vulnerable,’ she said.

ATEWOLOGUN: ‘It was when I moved to the UK that I realised I was black’

Different identities Cranfield School of Management director of gender, leadership and inclusion Doyin Atewologun said doctors’ different identities could interplay in different ways during the course of their careers. ‘Historical, cultural contexts influence experience,’ she added. ‘It was when I moved to the UK [from Nigeria] that I realised I was black,’ Dr Atewologun told the conference. ‘Through a series of experiences I learned how privileged I was socio-economically in Nigeria.’ The BMA is acting to address the issues raised by the Romney review by committing to take forward all 31 recommendations. Read about what has been actioned already and the next steps at bma.org.uk/ independentreview Turn to page 26 for BMA consultants committee deputy chair Helen Fidler’s blog about tackling insensitive colleagues

‘We have a way to go in making this mainstream’

Taking on the trolls I couldn’t have been happier about my presentation at the international AIDS conference, in Boston, Massachusetts. My research on a breakthrough medical treatment, a monthly injection for people with HIV, was widely picked up in the media, broadcast on ITV News. When I started working in HIV Medicine, I was prescribing a handful of tablets three times a day. For most now I prescribe one pill a day. However, even this single tablet is still a daily unwelcome reminder that they are living with HIV. While waiting in the departure lounge I got the call from my wife. She said, ‘don’t look at the interview on social media. You’ve been trolled. It’s personal , it’s about your appearance and sexuality’. It was really shocking. Not a single negative comment referred to the content. Ironically it was International Women’s Day the next day. I knew I needed to call it out however exposed I felt. So I posted on Twitter: ‘Happy #IWD. Today an @ITV interview re my talk on a new #HIV injectable drug was trolled with misogynist, transphobic words about my appearance. #MedicalWomen are far more than how we look.’ Wanting a platform from which to tackle this genderbased prejudice, I successfully applied to become the vicepresident of the Medical Women’s Federation. Chloe Orkin is a professor of HIV medicine at Queen Mary University of London and a consultant physician at Barts Health NHS Trust

Everyday sexism in the NHS The registrars had a great set of nights during my last weekend on ITU. All the patients decided they wanted to break but I set about fixing one after the other. It was tough, but I finally felt that I had come into my own. By Monday, I’d got to the point where I felt completely exhausted, but proud of myself for keeping everyone alive. I felt great. I led the handover. Then the male consultant to whom I was handing over turned to the male registrar and said, ‘thank you for all the hard work you have done. You have worked really hard’. Credit where credit is due, he said, ‘I really didn’t do that much. Chelcie bossed it’. Or something like that. ‘Well, make sure to say well done to her because I don’t want her getting emotional,’ came the reply. I was so upset and angry, to the point of almost crying. Realising I was tired, I went away and

SARAH TURTON

RELATING TO THEIR EXPERIENCES: Drs Orkin, Jewitt and Bajwah spoke at the conference

slept on it, determined to highlight this with my supervisor. When I told her, she mentioned that this wasn’t the first time something had been raised about this consultant’s behaviour. A friend who had previously worked with him mentioned a similar incident to me. I had to do something. I had recently read Laura Bates’ book, Everyday Sexism, which mirrored a lot of the issues I had faced working in the NHS. So I’m setting up a survey and campaign to find out more about #EverydaySexism in the NHS. What’s your experience? Chelcie Jewitt is a clinical fellow at St Helens and Knowsley Hospitals NHS Trust. The incident described occurred at a previous employer. twitter: @nhs_sexism

A fair deal for parents I’d been a consultant for three years, one on maternity leave, when I applied for a local CEA (clinical excellence award). I was told I narrowly missed, so asked how my maternity leave was considered. I got inconsistent responses. With support from my head of department, I submitted an FoI (Freedom of Information) request. It found that male doctors had a roughly equal chance of receiving awards as female ones who had not taken maternity leave in the past five years. None of the nine who had taken maternity leave in the same period had been awarded. Markers were not told about maternity leave. The trust acknowledged that while the FoI raised concerns, it did not mean that consideration of maternity leave did not occur. So I submitted a subject-access request for my personal CEA data. I was told that this had not been kept ‘as there was no requirement to do so’. After lodging a formal grievance, faults in the process were found, and I was awarded retrospectively. For the following application, I listed my achievements in the context of my part-time working and received two CEAs. Subsequently, the trust has fully engaged with suggestions to improve processes for its hundreds of female consultants. This included inviting me to redraft the guidance for markers to highlight part-time working/maternity leave and to conduct drop-in CEA clinics to help female consultants. This year all 13 of the those applying who had taken maternity leave, were awarded. Sabrina Bajwah is a consultant in palliative medicine thedoctor | December 2019 25

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When good people say bad things Simply being firm with a colleague about remarks they may not be aware others find offensive can steer behaviour in the right direction, says BMA consultants committee deputy chair Helen Fidler

Sometimes life’s questions are easy. Is the dog hungry? Clearly yes, he’s half Labrador. Is the clinic overbooked? Obviously. And some sexist behaviour is so blatantly dreadful that most people would recognise it as such. Many of us have stories of eye-wateringly unacceptable behaviour. I’ve been asked, in a job interview, whether being female would make it more difficult for me to get on with my nursing colleagues. Friends have been ‘groomed’ by senior colleagues and asked on dates, and I’m aware of one part-time consultant post that wasn’t advertised for fear it would attract someone ‘who might get pregnant’. All pretty easy to recognise as wrong, and although none of these were reported we are working to make it easier to do so. What about when FIDLER: your friends at work make Don’t miss an opportunity unacceptable comments to lead as part of banter – with the group laughing and you feeling that you are the only one who feels uncomfortable? What if they are joking about a female colleague’s sex life or clothes? Or implying she is emotionally unstable, or a ‘princess’? You may not even immediately recognise this as sexist or undermining behaviour and it is very hard to call it out – you immediately appear to be ‘not one of the gang’ and part of the fun police. And that person might be someone you think

of as a friend, so you fear jeopardising a good and supportive personal relationship. Perhaps it’s better just to pretend you didn’t hear – to move on – to hope it doesn’t happen again? I’ve done that, on and off, for 25 years now and it simply isn’t the best option. First, they won’t realise you found it offensive and will therefore probably repeat it in front of others who will learn that it is OK. Second, it damages you – you will feel uneasy that you didn’t act, disempowered and you will have missed an opportunity to ‘lead’. So how can you preserve your relationship with that person and keep the atmosphere at work convivial and inclusive? I’ve found the best way is to address it with that person afterwards, in private and in a relaxed manner. Simply telling them that, bma.org.uk/equalitymatters when they said ‘it’s probably the menopause’, it made you feel very uncomfortable and wasn’t OK, will probably be met by surprise – and nine times out of 10 by an apology. Stick to your guns and repeat it if the message hasn’t got through, and accept the apology and move on. You will have made one of the most incredible interventions possible in the war against sexism, and it will be much easier next time. I’m going to put it in my personal development plan next year.

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

An employer stubbornly insists on the (wrong) notice period, and a junior’s training placement is moved to an inconvenient location – all issues the BMA has helped to resolve Working out your notice can inspire mixed emotions – a sense of liberation or disappointment, or perhaps just a feeling of how much work is left to do. For one doctor, it was a reminder of what happens when employers are wrong and pedantic at the same time. He had found a new job and agreed a start date, then gave his employer two months’ notice. No, they said, it should be three months. The doctor raised it with HR but HR said it was up to his department, and his department ‘couldn’t accommodate’ him going sooner. Employment law has its share of ambiguities but this wasn’t one. His contract said that, having served between six and 12 months on his fixed-term contract, he was required to give two months’ notice. It would only have been three months had he been working for more than a year at the time he gave his notice. It was clear. This should have been easy but his employer, having misread the contract, was unwilling to change its mind. Others might have been tempted to leave after two months but the doctor didn’t want to part on a bad note or let down his colleagues. Doctors leaving jobs ‘early’ might even be at risk of getting reported to the GMC on the arguable grounds that they are compromising continuity of care. However, he was in difficulty, having not only agreed a start date but having found accommodation and needing to give notice on where he was living. So, he turned to the BMA, who contacted HR immediately and asked, politely but firmly, where it said in the contract that he should give three months’ notice instead of two? Success. The doctor could start his new job when he needed to, thanking the BMA adviser for her ‘kind help and support’.

You’re on holiday, trying to get away from it all. And then you spot a most unwelcome email. It’s from the organisation responsible for your training as a junior doctor: ‘We are experiencing an unprecedented demand for training placements this year and as such I must inform you of some necessary changes to your original programme allocation.’ The doctor said it was ‘a shock and a huge disappointment’. It was hard to even respond straight away because the wi-fi and phone signals were shaky. As with many trainees, this doctor – banking on some work-life balance – had planned life around training placements. The new ones were far away from home and meant long commutes. The programme covered some different specialties, and the doctor believed it missed some elements of training vital to being a GP. The doctor contacted the BMA. The employment adviser was able to secure some changes, including a promise that those missing elements would be addressed by the educational supervisor. After two months of worry, another junior doctor dropped out of training allowing the doctor to pick up a place in the original location. The doctor believes it was because of the BMA’s intervention the outcome was achieved, saying, ‘this was the first time I’ve had to use the BMA and I couldn’t speak any higher of it’.

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the secret doctor

PRAISE BE: Hospital chaplains provide a divine service

A doctor’s blessing The Secret Doctor’s current incarnation is a lifelong atheist, from a family where the parents read their children the shorter essays of Bertrand Russell while others were telling Bible stories. As a medical student, your correspondent was therefore inclined to bracket chaplains in the same category as homeopaths – they might make a few people feel better, but we’d get along just fine without them. Years of medical practice have done nothing to alter my lack of religious conviction, and the compatibility of a benevolent deity with appalling human suffering is not an issue to address in a 500-word column. But on the matter of chaplains I am happy to acknowledge I was completely, 100 per cent wrong. I still have no idea what their official duties comprise of but time and again I have watched them step in and provide a service which no one else could offer. In my foundation year 2, I called the Catholic priest at 4am for an older woman who was bleeding to death from her upper GI cancer. The medical team, myself included, were fussing ineffectually about, wondering if there was any point giving a transfusion and whether it was too late to try cryoprecipitate. The chaplain stayed discreetly in the background while there was any chance that our efforts might succeed but as the futility of our interventions became apparent, he stepped quietly forward and began to recite the prayers for the dying, the patient joining him in a whisper whenever she felt strong enough.

The contrast between our frantic bustle and the calm of those extraordinary words (‘Go forth, Christian soul, from this world…’) has stayed with me ever since. In some hospitals a number of different chaplains, each representing different faiths, can be found. That was far from the only time I saw chaplains prove their worth. From keeping a lonely old man company during a long admission to reassuring a nervous teenager before surgery, to that most poignant of all sacraments, the emergency baptism, I have been impressed by their ability to help where all our efforts are useless. The most unusual service I ever saw a chaplain provide was on an intensive care unit where a particular consultant tended to get more and more agitated and sharp-tongued whenever we were especially busy, to the considerable discomfort of his team. On the very worst days, when we’d all missed lunch and stress levels were approaching critical, the chaplain would appear as if by magic and discreetly slip him a bar of chocolate. It never failed to improve matters and everyone on the unit breathed a sigh of relief. We never discovered how the chaplain knew there was a problem or worked out how to fix it. Perhaps that’s what they mean by God working in a mysterious way. By the Secret Doctor bma.org.uk/secretdoctor @TheSecretDr

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explainer

Doctors and medical students hold a wide range of views on physicianassisted dying. The BMA will soon be asking for them What’s happening? The BMA plans to gather members’ opinions around physician-assisted dying. It wants as many members as possible to respond to a survey. Why now? At the 2019 BMA annual representative meeting, the association’s representative body voted for a poll to survey its members’ views on whether the BMA should adopt a neutral position with respect to a change in the law on assisted dying. What will you do with the results? They will be published ahead of the ARM 2020, and made available to members of the RB when they meet at the ARM in June. These representatives are drawn from BMA divisions and branches of practice. The results will help inform a

discussion, and a vote by the representatives on the BMA’s position. So the results themselves won’t set or change policy? No. BMA policy is made democratically at ARMs, where members debate and vote on motions. Any new policy or change in policy would happen at the 2020 ARM in June. Its policy of opposition to assisted dying will stand unless and until a decision is made there which may alter it. What is the association’s policy? It is to oppose assisted dying in all its forms, a policy we’ve held since 2006. This same policy, which was reaffirmed in 2016, supports the UK’s legal framework, which allows for ‘compassionate and ethical care’ for patients who are dying.

How can I take part in the survey? We will update all members in the usual way, through a dedicated webpage, via email, via social media and through the pages of this magazine. Is there anything I should do now? Yes. Do check your contact details are up to date, including your email address. You can do this via the ‘my account’ section on our website. Check that you’ve opted in to receive electronic communications and keep an eye on your emails. You could also encourage your colleagues to do the same. For help with your membership details, email membership@bma.org.uk For any other queries, email pad@bma.org.uk thedoctor | December 2019 29

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and finally...

Christmas with the family – the NHS one I qualified as a doctor this year and will be working my very first Christmas in the NHS at the Royal Surrey Hospital in Guildford. Being part of the medical profession is something I have long dreamed of, and I am massively proud to have come from Romania to work in the NHS. I was born in Novaci a village in the countryside of Romania. I became attracted to medicine because, when I was growing up, I was surrounded by doctors for the unfortunate reason that a number of my family members were unwell. As I got older I began to aspire towards studying and working in the UK because of seeing and hearing about the NHS. What fascinated me from an early age was that it was free at the point of use and for anyone regardless of their background and helps reduce social inequality. When my mother had cancer, as a family we didn’t really know how to speak to her about the disease. When I went to medical school

therefore, one of the things I was keen to learn more about was how we interact on these topics and how we can normalise these sorts of discussions between people Life has a habit of moving forward in a profession that tends to progress quite gradually it is important to strike a balance between your home life and your work life. I met my fiancée, who is a geneticist, by pure chance while sat next to her on a flight four years ago. We were working in the area of cancer research but it was only once we got chatting I realised she was from my home town, that her parents knew mine through friends of friends. We now live in London and are planning to get married. This year, I’ll be working this New Year’s Eve and finishing my shift at 9am in the morning after which I will be able to spend time with my family who will be coming over from Romania. Long hours are one of the less positive aspects of medicine but in the end it

is all worth it when you look at patient satisfaction and the overall benefit you give to society. The people that you work with you get to know very well over the months and years; whether they are doctors, nurses, occupational therapists or pharmacists. My job as a doctor would not be possible without them, and it means that all of us who will spend the festive period working in the NHS know that there is a chance to celebrate with your ‘work family’. It also reminds us and others that healthcare workers are human beings, and remembering to look after our needs is just as important as it is for our patients. Having celebrations at work, taking five minutes out of your day to share a few moments of gratitude with your team can make a big difference on a busy Christmas-time night. Bogdan Chiva Giurca is a foundation year 1 doctor in Surrey

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S RRY…

thebma writing competition 2020

‘Sorry’ has been called the most over-used word in the English language. It can seem like a verbal tic. We say it for the smallest reason, or for no reason at all.

#writeBMA

For this year’s writing competition, we’d like you to reflect on this word. When do you most remember saying it, hearing it or needing it? It might have been when you made or witnessed a mistake. Or when you had a disagreement with a patient or colleague. It might be something that happened last week or many years ago. This is inherently sensitive, and you might find it necessary to

change some identifiable details. As with our previous competitions, what matters most is that the piece is vivid and engaging. Our webpage bma.org.uk/writingcompetition has last year’s winner and runnersup to give you some inspiration. We need 700 words, and the deadline is 25 January 2020. Email your entry to thedoctor@bma.org.uk with ‘Writing competition’ in the subject line.

what’s on

Terms and conditions online

January

February

14 PCN masterclass, London, 9am to 5pm

1-2 BMA junior members forum 2020, London, 9am to 7pm

21 PCN masterclass, Bristol, 9am to 5pm 24 Planning for retirement – delivered by the BMA, York, 9am to 5pm 30 PCN masterclass, Leeds, 9am to 4pm

07 Planning for retirement – delivered by the BMA, Edinburgh, 9am to 4pm 08 Primary care networks... what’s next? Birmingham, 10am to 5pm 10 Medico-legal expert courtroom skills, London, 9.30am to 4.30pm

Visit bma.org.uk/events for full details Download the BMA events app at bma.org.uk/eventsapp thedoctor | December 2019 31

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There is always someone you can talk to...

Wellbeing support services COUNSELLING | PEER SUPPORT 0330 123 1245 Our wellbeing support services are open 24/7 to all doctors and medical students. They’re confidential and FREE of charge.

Call us and you will have the choice of speaking to a counsellor, or taking the details of a doctor who you can contact for peer support.

There is always someone you can talk to... 0330 123 1245 | bma.org.uk/yourwellbeing

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