The Doctor – issue 4, December, 2018

The magazine for BMA members

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Issue 4 | December 2018

Taking the biscuit Revealed: The consultancy companies chewing up NHS resources

Told to go home

The overseas doctor who overcame early setbacks to become a leading consultant

If you could change one thing ...

The winning entries in this year’s BMA writing competition

A spectre calls

Your NHS ghost stories

07/12/2018 09:27

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: 363 no: 8180

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 Alex Gay

ISSN 2631-6412

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In this issue 4-5

Briefing Capita’s failings continue, a call for beds and covering mental health

6-11

The wrong kind of consultants

Welcome Chaand Nagpaul, BMA council chair Working on the front line in the NHS, we are often accompanied by a sense of déjà vu.

Whether it’s seeing the same patient with the same problems in your surgery, the relentless queue out the door of the emergency department or the emails from senior managers about another change or reorganisation.

Our cover feature in this issue certainly incites a strong feeling that we have been here before: the private management consultants taking a bite out of the NHS. Our team of journalists has been particularly impressive in highlighting the role of consultancy firms in the work of the NHS in recent years – and as NHS England pushes ahead with its quiet reorganisation of the health service, through projects such as sustainability and transformation partnerships and integrated care systems, this scrutiny is more important now than ever.

The figures revealed in this latest research will be hard to read for many doctors. At

least £26m has been handed to private consultancy firms during the process so far.

The NHS simply does not have this money to waste – and to see so much funding being diverted away from the front line is galling.

In this issue we also announce the winner of this year’s BMA writing competition – Penny Ballinger.

In line with our Caring, supportive, collaborative project, which seeks to find solutions to the problems facing the NHS in 2018, this year’s competition asked entrants for the one thing they would change in the health service if they could wave a magic wand.

The entries were illuminating and inspiring and I support the decision of the judges to award top spot for a beautiful and thoughtprovoking piece of writing.

This issue again highlights the good work we do at the BMA, using expertise and evidence to suggest where things go wrong and, importantly, progressing towards a better future.

Millions spent on private consultancy firms to aid ‘transformation’

12-13

It pays to persevere Krish Ragunath was advised to go home within weeks of arriving in Britain, but with determination he has become a leading consultant

14-17

In place of fear Bullying is toxic to NHS staff, so how do we best tackle it?

18-19

Pinpoint process New guidance on clinically assisted nutrition and hydration

20-23

The seeds of hope How a ‘small gesture’ transformed a patient’s life

24-25

A spectre calls The centurion in the mortuary... and your other NHS ghost stories

26-30

Life experience A doctor’s first white Christmas

31

What’s on Keep on top of events

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The power of stories

FAILED PATIENTS: Capita’s incompetence has left many people with anxiety

briefing

Capitally incompetent

Current issues facing doctors

VAUTREY: Gross error is frankly appalling

After an MP referred to ‘Crapita’ in the Commons earlier this year, the Speaker stood up, not to rebuke him for unparliamentary language, but merely to remark that a group of school children in the public gallery had found it amusing.

It is evidence of just how ubiquitous the outsourcing firm’s reputation, and alternative title, has become.

However, this is no affectionate nickname and no one was laughing at its latest error.

It emerged last month that more than 40,000 women in England had not received information regarding cervical cancer screening.

They included invitations to screening and results of tests.

It was estimated that between 150 and 200 of the cases involved test results not sent out after abnormal results.

BMA GPs committee chair Richard Vautrey said: ‘It is frankly appalling that patients may now be at risk because of this gross error on the part of Capita.

‘Some women will now be left extremely anxious because they have not received important correspondence, particularly letters about abnormal smear-test results that need urgent follow-up.

‘This has been caused solely

by Capita’s incompetence.’

The question is, how long can this situation go on for?

It was only in May that a scathing National Audit Office report criticised Capita’s performance in such vital functions as delivering supplies to practices, reimbursing GP and pharmacy payments, the transfer of patient medical records and the handling of the NHS pension scheme for GPs. Capita had said it could make huge savings in costs while maintaining a consistent level of service – a rather common trope when the private sector bids for NHS work. And NHS England took the ‘high-risk’ approach of agreeing to it.

It makes you wonder what NHS organisations are thinking when organisations such as Capita make bids, which common sense would say are too good to be true.

Are they blinded by magical thinking about cost savings?

Or do they have such a low opinion of their own abilities that they really believe that someone else, facing exactly the same challenges, can just waltz in and do the job twice as efficiently?

We used print, digital and film last year to tell the story of David Knight, a young man who took his own life.

He was one of a growing number of adult patients treated in outof-area beds. His family faced a seven-hour trip to visit him, and psychiatrists told his inquest that this was likely to have had a bearing on his death.

This was followed in February by an investigation into the long waits patients endure before they receive the talking therapies they need.

Again, there was a patient at the centre of the work – Nikki Mattocks who waited for around a year and a half for the therapy she needed.

A fortnight ago, Keith Cooper, our senior staff writer, was joined by Nikki and colleagues from the BMA to receive the Mind Media Award for best publication for The Doctor.

In his acceptance speech, Keith said how a series of Freedom of Information requests had supplied the statistical basis for the articles.

‘The numbers told us that too many patients wait over a year for therapy. Nikki, here, told us what it felt like to wait for two. How she texted her dad with a traffic light system: red for – come get me, take me to hospital. The stories and experiences we’ve heard, filmed and reported, stick with us more than the statistics – and they’re spurring us on to do more,’ he said.

All these stories began with individual doctors and were shaped and guided by them through to publication.

Thanks for reading this magazine but you can be more than readers if you want to.

If you think there’s something we should focus on, contact us at thedoctor@bma.org.uk

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BEDDING DOWN: Who knows where some patients will end up this winter?

The capacity to hit new lows If summer in emergency departments is now as bad as winter used to be, then what about winter?

A BMA analysis of figures last month found, on a range of indicators, that the NHS was under more strain between June and September than in five out of eight of the previous winters. In England, trolley waits, emergency admissions and compliance with the four-hour emergency department waiting target were all worse.

The BMA had successfully predicted that NHS performance during the summer would fall somewhere between the winters of 2015 and 2016. Now it’s forecasting the winter.

It uses two projection methods, details of which can be found on its website. The most optimistic scenario from January to March sees 238,000 patients face trolley waits of more than four hours, more than 1.6 million emergency admissions and fewer than 85 per cent seen, admitted or discharged within four hours.

Keep in touch with the BMA online at

All the figures are worse than last winter – and last winter was the worst on record.

The solution is – needless to say – complex but a major part would be to stop the intense downward pressure on bed numbers, which has left England with a fraction of either France or Germany.

Based on bed-occupancy rates and trends from previous winters, the BMA says 10,000 extra beds are needed.

Lacking beds, we have a health service where the abnormal has been normal. Bed occupancy, which according to the National Audit Office should not exceed 85 per cent to avoid affecting care, peaked at 95 per cent last February. Tens of thousands of patients had operations cancelled at short notice, not because of a sudden, unpredictable demand but owing to a chronic lack of capacity.

Perhaps no patient will end up in a stable this Christmas but for many, it would be preferable to the hours they will languish in cramped corridors.

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Read more online

‘Medical training at risk, finds GMC report’ ‘Target driven, fearful and under pressure – a snapshot of working in the NHS’ ‘Measures to support whistleblowers win backing’ ‘Community care funds boost welcome’ Read all the latest stories online at bma.org.uk/news

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The wrong kind of consultants An investigation by The Doctor reveals that millions are being spent on private consultancy firms and creating new management jobs – to support a quiet reorganisation of the health service which lacks transparency or legislative backing. Peter Blackburn reports

P

STEVENS: Big push towards integrated care

NAGPAUL: ‘A lack of accountability’

rivate consultancy firms have been handed at least £26m from NHS budgets as part of plans to reorganise the health service – and a swathe of hundreds of new managerial and administrative posts have been created to drive the changes forward, an investigation by The Doctor reveals.

Some of the world’s biggest consultancy companies, firms such as KPMG, Deloitte, PwC and Ernst and Young, have been tasked with projects looking at ‘reviewing demand and capacity’ and ‘supporting sustainability’ – with several of the bills sent to NHS chiefs running into seven figures.

The health service’s reliance on consultancy, revealed by the responses to a series of FoI (Freedom of Information) requests sent to STPs (sustainability and transformation partnerships) and ICSs (integrated care systems) across the country

by The Doctor, also includes a number of smaller firms

often led by former NHS leaders who chose to leave or were made redundant during previous, costly, reorganisations.

It comes as NHS England chief executive Simon Stevens has urged local areas to push on with progress toward integrated care, which aims for local health leaders to take control of the entire care needs of their population and the budget for doing so – supposedly reducing the role of competition and market forces and attempting to cut duplication of services.

The figures collated by The Doctor, made up of new data from 30 of 44 areas and previous data from a further nine, have raised concerns about the NHS’s long-term workforce planning, retention of staff, and short-term haemorrhaging of muchneeded money away from frontline care. The true costs are likely to be even bigger, owing to some STP or ICS footprints either failing to update previously supplied

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FIVE OF THE BIGGEST PAY-OUTS

£448,000

Coast, Humber and Vale – PwC

£6.2m

Kent and Medway – Carnall Farrar

£821,000

Cheshire and Merseyside – KPMG

£1m

South Yorkshire and Bassetlaw – Deloitte

figures, or not providing any information at all.

BMA council chair Chaand Nagpaul says the findings would be ‘galling’ for doctors across the country struggling to provide high-quality patient care while having services cut from around them.

The north London GP adds: ‘Given the parlous state of NHS finances and patients suffering delays for essential services it is utterly unacceptable to see so much money flowing away from patient care to

private consultancy firms – particularly when the staff carrying out the work have often been on the NHS payroll and could have been working on these transformation projects from within the health service, rather than, much more expensively, from the outside.’

Influx of new managers It is not just on consultancy firms where the fledgling STPs or ICSs are forking out millions of pounds either – The Doctor’s research shows more than 500 jobs have

£3.3m

South-east London – PwC

been created across the country, with either new staff brought in or existing NHS employees seconded, with an annual salary bill of around £31m.

The figures reveal an expensive new cadre of senior staff being formed with 302 of the jobs created valued at NHS Agenda for Change bands eight or above – attracting annual salaries from £42,000 to £142,500, or even more at national discretion for ‘very senior managers’ of which there are at least 54. thedoctor | December 2018

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M IRVINE: Contracts are an unacceptable use of funding

HUNTER: ‘Strong links are retained between those in post and those who may have left’

Dr Nagpaul says: ‘Management staff are, of course, crucial to the NHS – without good management we cannot do our jobs to the best of our ability but there appears a lack of accountability with what can appear a profligate relationship with outsourced tiers of management.’

For many frontline staff – so used to seeing a lack of investment in workforce, equipment and buildings in their workplaces – it will be the money flowing to private consultancy firms which will be most difficult to accept.

‘Money flowing away from patient care to private consultancy firms’ Eleven of the 44 original STP footprint areas admitted to spending more than £500,000 on private firms in figures released to The Doctor and two areas, Kent and Medway and South East London, spent more than £12m combined. Only five areas say they hadn’t turned to consultancies for help.

NHS business has proved to be a rich area for the biggest firms throughout recent years and the STP process has been no different, the investigation reveals. KPMG, PwC, Deloitte and Ernst and Young all

benefited from deals in the hundreds of thousands of pounds.

A senior employee at one of the world’s top-10 global consultancy firms (ranked by revenue) told The Doctor the NHS provides huge business for his colleagues.

He adds: ‘The health service is guilty of losing, or paying-off, its best managerial talent only to often realise their services are again needed at a later date.

The reality is that short-term fixes along the line will cost a lot more money.’

Newcastle University health policy and management professor David Hunter agrees.

He says: ‘Each time there is a major change initiative in the NHS people in the system look to external help either because there’s a lack of in-house capacity or because strong links are retained between those in post and those who may have left… then sell their services back to the NHS.’ One consultancy company, Carnall Farrar, which is run by former NHS London chief executive Dame Ruth Carnall, was paid £6.2m by health leaders in Kent for ‘strategy, analytics and modelling’ – just a few years after its chair Dame Ruth and company partner and chief executive Hannah Farrar left the NHS.

Carnall Farrar also invoiced Hertfordshire and West Essex £315,250 for ‘development’ of the area’s ICS. Carnall Farrar did not respond when asked about the value for money their services gave the NHS.

‘No buy-in’ Maidstone and Tunbridge Wells NHS Trust consultant rheumatologist Mike Batley says the vast expense from the Kent and Medway STP comes at a time when local services are being reviewed and doctors involved feel they are being asked to choose ‘which finger to break’ when looking at where money could be saved.

‘There’s no buy-in to this plan and there’s not been a huge amount of clinical involvement in the STP,’ he adds.

‘I don’t mind money being spent on private firms, if it achieves something, but the history of the NHS is that you get huge reams of paper, most of which are blank or useless to us, and keep employing people to do the same things over and over again.’

Several other areas of the country spent money contracting firms who employ specialists who previously worked for the NHS. As well as forking out £1m to Deloitte for a review of hospital

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MOST JOBS CREATED

32 jobs

Cambridgeshire and Peterborough

36 jobs Kent and Medway

104 jobs Greater Manchester

25 jobs North-east London

26 jobs South-east London

services, South Yorkshire and Bassetlaw commissioned a consultancy called Attain for ‘ICS support’ at a cost of £827,000. Among the senior leaders at the firm is director Chris Walker whose previous job was in the NHS as director of programmes for the Yorkshire and Humber Commercial Support Unit and director Chris Spark who worked in NHS supply and procurement roles for more than seven years before moving to Attain. Attain did not respond to request for comment from The Doctor.

And in north-west London more than £400,000 was given to PA Consulting, a firm which says it believes in ‘the power of ingenuity to build a positive human future in a technology-driven world’. The firm’s head of healthcare consultancy Jonathan Pearson was an NHS management trainee and is independent chair of the Sandwell and Western Birmingham health system seconded from PA Consulting one day a week.

A spokesperson for PA Consulting told The Doctor

the firm was ‘proud’ of its work with the NHS and the value for money provided, suggesting such ‘specialist support’ was ‘not available’ in-house.

Health leaders in southeast London, one of five STPs covering the city, were the second-biggest users of external consultancy, revealed by the study, after Kent and Medway – forking out more than £4m, with PwC collecting more than £3m and Ernst and Young benefiting to the tune of more than £800,000. The STP’s response to The Doctor thedoctor | December 2018

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M

‘Each time there is a major change initiative in the NHS people in the system look to external help’ WALSHE: ‘There is a concern about the accountability and governance’

says the amounts paid to PwC cover ‘general advice and support’, particularly regarding ‘strategy development, programme support and financial and activity modelling’. Neither firm, nor the STP, responded to a request for further comment.

Lewisham GP Louise Irvine says the contracts are an unacceptable use of funding in a local health system which has been cut to the bone.

‘I’m shocked to hear they are spending so much money,’ Dr Irvine says.

‘Here in Lewisham we are seeing major cuts to mental health services, school nursing and district nursing.

We’ve had public health cuts like weight management, breastfeeding support and smoking-cessation services totalling millions of pounds.

This affects my daily work – we have no one to signpost people to any more.

‘To hear this money is available to spend on this kind of thing and taken away from vital frontline care seems profoundly immoral.’

Lack of legislation The investigation also raises important questions about the legitimacy of the quiet reorganisation of integrated care, which appears to be

moving forward at pace, but is not backed by any Parliamentary legislation or statute and, as such, STP or ICS organisations have none of the legal duties of transparency of other NHS organisations.

The BMA has repeatedly called for proper clinical and public engagement for the process – as well as for any reorganisations of the health service to be backed by primary legislation and the removal of competition and the internal market.

Despite these concerns the revolution appears to be grinding on at pace.

University of Manchester professor of health policy and management Kieran Walshe says: ‘[Lack of governance] remains a real area of weakness – they are not statutory bodies and don’t have to have a named officer dealing with FoIs for example.

‘That is a concern about the accountability and governance and the fact that STPs unlike NHS trusts don’t have any rules about governance arrangements. It’s things such as meeting in public and publishing papers and annual reports. It doesn’t exist for STPs and that matters.’

Professor Walshe says national direction would be needed soon but that the mistakes of the past –

reorganisations being too heavily dictated from the top – should be learned and rules and legislation should still be ‘loose’ to allow variation and local solutions to local problems.

Dr Nagpaul says: ‘New structures should be backed by statute, have proper transparency and should only be formed when proper, genuine clinical engagement has taken place.’

The job creation linked to these new structures is striking for two reasons – its quantity and the pace of progress. In June 2017 when the BMA first revealed the jobs being created to drive the process, the figure was just 150. Eighteen months on, that figure is now 525.

The investigation reveals a major disparity in the processes being carried out across the country. In some areas, such as north-west London or Devon, health leaders say they are using existing job roles in clinical commissioning groups – but in others, such as Kent and Medway, Cambridgeshire and Peterborough and south-east London, whole project-management teams, with senior leaders, have been created and swathes of analysts, press officers, and programme directors appointed.

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MOST MONEY SPENT ON CONSULTANCY

£1.8m

£1.9m

Norfolk and Waveney

South Yorkshire and Bassetlaw

£8.2m Kent and Medway

£2.6m

£4.2m

North-west London

South-east London

All figures for money and staff correct at the time of publication. More figures will be available in the online version.

Perhaps unsurprisingly the biggest structural changes by far appear to be taking place in Greater Manchester, where NHS England has formally transferred a number of responsibilities for health and care to local leaders.

Greater Manchester is not an STP or ICS but ‘a unique devolved area’, a spokesperson says.

Responding to The Doctor’s requests for information the devolved area’s spokespeople confirmed that around 291 staff now work on providing devolved health and care

in the area. They say 104 (the number recorded in The Doctor’s research) of those staff were charged with delivering specific programmes related to transformation. The total salary bill for those staff is more than £6m, which a spokesperson confirmed was footed by NHS England.

Dr Nagpaul says the varying direction across the country was ‘worrying’.

He adds: ‘The result of these plans will be more inconsistency, a deepened postcode lottery and,

ultimately, doctors and patients will suffer.’

As Dr Nagpaul says, the lack of shared direction in the process appears to have resulted in a degree of chaos and confusion, for local areas and for doctors and patients.

It may be that until national leaders provide direction, transparency and genuine statutory support for change – rather than a series of platitudes such as ‘blur the boundaries’ and ‘do first, ask permission later’ – clarity will be hard to come by. Over to you, Mr Stevens.

‘New structures should only be formed when proper, genuine clinical engagement has taken place’

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JOSEPH RAYNOR

It pays to persevere When young doctor Krish Ragunath left India to further his career in the UK he was met with disparaging remarks and even advised to return home. Yet, through sheer strength of will, he persisted with his dream until things started to go his way. Peter Blackburn reports

K

ON THE MOVE: Chennai, where Dr Ragunath received his medical education

‘I was struggling to fit into the system because it wasn’t welcoming’

12

rish Ragunath was told he wasn’t cut out for a career in the UK two weeks into his first job in the NHS. ‘This hospital might not be the place for you. Perhaps you might need to go back to India.’

These were not the words any ambitious, young doctor would have wanted to hear.

For Dr Ragunath, who had left his wife and two-year-old child at home in Chennai, leaving his country on a plane for the first time having sacrificed so much it was particularly dispiriting.

‘It was quite a difficult time,’ says Dr Ragunath thinking back to the locum post in a district general hospital in West Yorkshire where he began his UK working life in 1992. ‘There was no introduction to the whole NHS system, you were just thrown in, having been met by a junior doctor who told you what your jobs were.

There was no induction on any of the hospital processes as in how to make a request for an

X-ray or blood test or who to contact for what. You had to ask and find out.’

And then there was the accent. Being educated in a top school where English was the medium of instruction, and through medical school, as is standard in India, still did not prepare him for Yorkshire.

‘It was like listening to Geoff Boycott commentating. You would get a phone call and I couldn’t understand what they were saying – I had to go physically in person to see people to work it out.’

But despite being told his seniors were not confident in him handling the job – and even offering to continue to pay off the remainder of his two-month contract – Dr Ragunath stuck to the task.

He had not toured England on National Express buses and sent hundreds of application forms to hospitals for nothing.

‘It was frustrating, but it built resilience in me to stand up and say “no, I’m staying and I can prove them wrong”.

‘I didn’t have any doubts really, I was quite confident

with what I could do but I was struggling to fit into an unwelcoming system.

It expected me to perform like someone brought up in this country. So much about how the system and processes worked were different, but I was still hopeful that it would work out in time.’

On the up After West Yorkshire Dr Ragunath found himself working in South Yorkshire in another locum role – this time in a hospital with many Asian doctors, including some former colleagues from Madras Medical College.

A far more successful stint followed, with his first permanent job as a house officer in Leigh Infirmary, a small district hospital in Greater Manchester.

The initial job meant being on call for 24 hours every third day – and sleeping in the ward office – but it was a ‘fantastic’ environment for learning.

‘It was tiring and stressful, but the knowledge I gained there over six months was amazing,’

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JOSEPH RAYNOR

RAGUNATH: ‘If you have the will you can do it’

Dr Ragunath says.

Leigh remained home for a decent spell – after an initial six months Dr Ragunath was given a senior house officer job for a year, rotated through specialties and worked with a consultant gastroenterologist.

He then won a place as a research fellow in gastroenterology, which took another two years, and completed a postgraduate medical diploma.

‘Those opportunities would have been almost impossible to achieve in India. I would have been working in underresourced government hospitals.’

Missing out Another locum registrar post in the North-West followed, and another 12 months went by. But for Dr Ragunath, still living apart from his family, progress was not coming quickly enough. The thought of returning to India was a constant temptation.

‘I was being told I wasn’t the first choice in interviews

because I was from overseas – I kept telling my wife that we might have to go back. There were no emails or Skype. We only spoke over the phone. I used to write letters and send photographs.’

Ultimately, as during so many moments in Dr Ragunath’s career, he chose to stay and work in the NHS. He was rewarded for that decision with a training post in south Wales. Finally, the Ragunath family had some certainty, all coming together to make a new home in Swansea.

After five happy years there, Nottingham University was on the lookout for a senior lecturer – it was to be a new academic post and the professor in charge had just one goal: put Nottingham on the map as a centre of excellence for endoscopy.

He took his family, now of four with the addition of a six-month-old son in tow – and once again started afresh.

‘I was a bit nervous taking up something that was a first,’ Dr Ragunath says, ‘but I took it

because it was endoscopy.’

In terms of his own career, things could hardly have gone better.

‘It is all a dream compared to who I was when I came across on that first plane flight,’ Dr Ragunath adds.

‘I kept telling my wife that we might have to go back’

Will power ‘The point, I think, is that if you have the will you can do it. But you must have the will and really want it. Trainees come to me now and say I’m interested in this specialty because there’s jobs there – but that’s not how you should make decisions. I tell them to do what they like and enjoy because that will ensure they will excel.’

There are multiple morals to Dr Ragunath’s story. For individuals – where possible, persevere, a lucky break could be just around the corner.

And crucially, for NHS organisations – be supportive to those coming from different cultures and different systems. You never know how brilliant they might be. bma.org.uk/immigration

‘It is all a dream compared to who I was when I arrived’

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In place of fear Bullying continues to plague the NHS. Doctors remain scared of speaking out for fear of ruining their careers, and many feel the reporting process has yet to be taken seriously. However, the most passionate about the problem are starting to make inroads into a historically insurmountable issue.

Keith Cooper reports

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NAGPAUL: ‘It’s about how we treat each other’

here is something stubborn about bullying and harassment in the health service.

One in four experienced it last year, says the national NHS staff survey – and the one before that and the… you get the idea.

While there have been efforts to tackle it, there is a fear it may worsen still, as the ever-growing intensity of work and the unsettling nature of organisational change tends to bring out the worst in people.

So what can be done?

Steps are being taken and some show promise. Our understanding of bullying and its ugly cousins – harassment and incivility – is getting better. There are pockets of good practice.

However, finding a comprehensive fix is some way off. It’s a big, long job and one which must reach to the top, one source of the problem. That’s why the BMA is in it for the long haul, with its bullying and harassment campaign.

‘There’s only one thing which counts from this moment on: what we do to put things right,’ BMA council chair Chaand Nagpaul told the association’s bullying and harassment conference last month. ‘We need a solution across the whole system, starting with the Government.

It sets the tone,’ he added.

‘Then there’s the culture in NHS England and NHS Improvement.

It’s also about providers and each one of us doctors. How we treat each other. Bullying and harassment is everybody’s business.’

‘You blow people up’ We are still in a world where senior staff in medical schools complain of ‘too many Asian girls interested in marriage’ and studying in

their institutions, Caroline Elton, an occupational psychologist who supports doctors, told the conference. Another sought her support after being casually informed by a black and minority ethnic colleague that ‘you blow people up, you people’, as he was examining an X-ray. ‘He didn’t know what to do, so he worked harder and harder.

And so the more his colleagues saw him as different.’

It is not easy to talk about being bullied in much of the NHS. ‘I have been told that, should I report any bullying behaviour, “the doors of the hospital would be closed to me”,’ one doctor told Northumbria University senior lecturers Madeline Carter and Neill Thompson, who research bullying and harassment in the workplace. ‘It is generally not worth reporting unless your career is on the line. The process is soul destroying,’ another said.

‘We would like to have seen a difference in the levels of bullying and harassment in the NHS in the past two decades,’ Dr Thompson told the conference. ‘But we haven’t.’ Many policies, such as zero tolerance, which insist ‘it should never happen’ made every single problem ‘adversarial’, he added.

‘We see no evidence that they are an effective deterrent.’

Then there are the barriers to ending bullying and harassment.

From the toxic sub-cultures in departments and teams to the behemoths which organically grow, then ossify into the great NHS bureaucracy of trusts and Government agencies.

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‘We need a solution across the whole system’

‘It is estimated that bullying costs the NHS nearly £2.3bn a year’

‘Bullying and harassment is everybody’s business’

could improve patient care.

A survey by the National Guardian’s Office, which is aiming to instil a ‘speaking up’ culture in the NHS in England, found four in 10 hospitalbased ‘guardians’ are given no dedicated time to help staff. Just under half are appointed without interview, surely a sign they’re not taken seriously.

Room to speak

TURNER: ‘The process is important, but so are the people’

The same survey finds a link between ‘speaking-up cultures’ and highperformance ratings from the CQC (Care Quality Commission), strengthening the official case for their existence. Having a speakingup culture is much more than just posting a policy on a website, the National Guardian’s Office says. It’s about ‘walking the walk’, an attitude that treats staff who raise concern with a welcome, not a harrumph.

According to the criteria it applies the three big health agencies, NHS England, NHS Improvement and the CQC, would be in the company of trusts judged ‘requires improvement’.

It’s evidence, if any were needed, that culture must change at the top.

But it’s not just bullying and

MOWAT: ‘Problems must be dealt with’

harassment which are being seen as a problem. There’s growing evidence of another, perhaps less obvious, interpersonal hazard to patient care: incivility.

‘If you asked me 10 years ago what the answer is, how to avoid errors, I would have said process,’ Coventry emergency medicine consultant Chris Turner said. ‘If only everyone did what they were supposed to do. But I hadn’t thought about the whole picture,’ he added.

‘The process is important but is exists within an environment.

I wasn’t respecting the environment in which we are delivering healthcare.

The process is important, but so are the people.’

Dr Turner particularly wants to end incivility in the NHS. It’s no game or gimmick. With West Midlands junior doctors Penny Hurst and Joe Farmer he leads a campaign, Civility Saves Lives, circulating evidence that rudeness at work not only hits recipients but those around them, too. In the teamwork business of medicine, in the emergency room, theatre or clinic, civility makes a difference.

Dr Farmer signed up after seeing a

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colleague crumble under firm words of frustration from a consultant. ‘What had gone wrong? Though I couldn’t put my finger on it at the time, what I’d witnessed was incivility,’ he says (see column, right).

Bullying costs billions If these established effects of bad behaviour on poor patient care, hospital performance or harm to your colleagues fails to force action, there’s another factor which may, as BMA representative body chair Anthea Mowat pointed out.

‘As well as the moral case for dealing with the issue, the financial cost to the NHS organisation is high,’ she said, flagging a recent paper by academics Roger Kline and Duncan Lewis.

‘They estimate that bullying costs the NHS nearly £2.3bn a year,’ she said, and the figure is for England alone. It’s a figure which doesn’t include the cost of incivility, a factor they recognise as potentially costly but were unable to measure.

‘NHS bullying isn’t just toxic for staff: it’s costing billions,’ goes The Guardian headline, above its comment piece.

‘Despite a 2016 ministerial call for action there has been neither an improvement in the levels of bullying in the NHS, nor an increased willingness of staff to report it,’ it says.

But doctors are calling for the NHS to take speaking up seriously.

For bystanders to step forward too. Staff must be helped to challenge bad behaviour and there must be far better complaints handling in practice.

‘Those who experience bullying or harassment must be better supported,’ Dr Mowat said.

‘Problems must be dealt with and our working environments made supportive and inclusive, so we can work better together to provide the best patient care.’ bma.org.uk/bullying

Treating colleagues badly can worsen teamwork, delay diagnosis and harm patients – and there’s research to prove it, says junior doctor Joe Farmer

Uncivil partnerships ‘No. Don’t do it like that. You’re not doing it right. Move.

Let me do it.’

The words were said without threat or anger by the consultant to the senior registrar during a hysterectomy I assisted as a foundation trainee.

I’d got to know her well in the months we’d been paired on the on-call rota. She was leading the operation but struggling to insert the first port into the patient’s abdomen for the laparoscope. What happened next was difficult to watch.

The second-guessing. Each hesitation met with dismay and further frustration by the consultant. A cycle was set in motion, some sort of switch was thrown in the theatre. Staff began talking among themselves, avoiding eye contact. Little things took longer. Finding the right suture, counting swabs.

Overall, the operation was a success; no harm came to the patient. But something had turned sour. I felt frustrated for the registrar, a respected colleague. I felt frustrated for the consultant who wanted the best for her patient.

What had gone wrong?

Although I couldn’t put my finger on it at the time, what I’d witnessed was incivility. Through conversations with colleagues, Chris Turner and Penny Hurst, and the research that I’ve read, I’m now convinced of its effect. The research reflects what I witnessed that day. That incivility hits not just the recipient but those around them too. It worsens teamwork, delays diagnosis, and risks worse outcomes for patients.

This must be happening commonly in medicine.

These are the words Dr Turner, Dr Hurst and I believe.

They’re why we set up Civility Saves Lives. Not to accuse.

But to raise awareness of the research which reflects what we’ve all personally witnessed on reflection.

That incivility harms healthcare.

Joe Farmer is a junior doctor in the Midlands and a co-founder of Civility Saves Lives @civilitysaves www.civilitysaveslives.com thedoctor | December 2018 17

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Pinpoint process The BMA and Royal College of Physicians have drawn up timely guidance on clinically assisted nutrition and hydration

T

he Supreme Court confirmed in the summer that decisions about CANH (clinically assisted nutrition and hydration) did not have to be routinely referred to the courts.

Previously, as a result of a judgment 25 years ago it had been recommended ‘as a matter of good practice’ that reference be made to the courts where doctors withdrew CANH from a patient in a persistent vegetative state, but neither this judgment nor the Mental Capacity Act imposed a strict duty to do so.

The recent ruling is one reason why it is particularly important for doctors to be given comprehensive guidance on decisions around CANH. Following a detailed process, the BMA has drawn up the guidance with the Royal College of Physicians.

It has been endorsed by the GMC.

The process included: inviting randomly selected BMA members from relevant specialties to attend focus groups to ‘user test’ the guidance; a professional consultative group with more than 60 senior lawyers, clinicians and allied health professionals, with experience of making the decisions; and consultation with patient-support groups and families who had been through the experience.

The aim of the guidance is to ensure the law is followed correctly and to give practical advice to health professionals.

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‘Clinical, ethical and legal challenges for doctors’

While the starting point is a strong presumption that CANH should be provided, prolonging life, at the centre of any decision is whether beginning or continuing treatment is in the best interests of the individual patient.

Royal Berkshire Hospital intensive care consultant Chris Danbury says bestinterest decisions are about ‘putting yourself in the position’ of an individual.

‘I may be an expert on the treatment of critical-care patients but I’m not an expert in that individual person,’ he says. ‘There are people with far more information, knowledge and expertise in that area.

They are the people close to them, who have known them for decades. We need to listen to their stories.’

Best interests The guidance lays out how these best-interest assessments should be made, and the important role patients’ families and those close to them play in the process. It also includes ‘Practical detailed information on seeking necessary second guidance opinions from other clinicians. for health professionals The guidance covers decisions for patients who on how to lack capacity in England and follow the Wales, who are not imminently regulatory framework’ dying and could go on living for some time if CANH is provided. The broad spectrum of those covered by the guidance has been broadly divided into three categories: –– Patients with progressive neurodegenerative conditions –– Patients with multiple comorbidities or frailties, which are likely to shorten

life expectancy, who have suffered a sudden onset, or rapidly professing, brain injuries –– Previously healthy patients who are in VSs (vegetative states) or MCSs (minimally conscious states) following sudden onset brain injuries.

It’s difficult – and perhaps counter-productive – to attempt to sum up complex guidance in a short space but it is possible to identify some legal and regulatory principles: –– CANH is a form of medical treatment, much like artificial ventilation –– It should only be provided for patients who lack capacity when it is in their best interests –– Decision makers should start from a strong presumption that it is in patients’ best interests to receive life-sustaining treatment. This can be rebutted if there is clear evidence that patients would not want CANH to be provided –– All decisions must be made in accordance with the Mental Capacity Act 2005 –– All decisions must focus on the individual circumstances of each patient and on reaching the decision that is right for that patient –– There is no requirement for decisions to withdraw CANH to be approved by the court, as long as there is agreement on what is in the best interests of patients, the provisions of the Mental Capacity Act 2005 have been followed, and the relevant professional guidance has been observed –– As per GMC guidance, a

second clinical opinion should be sought where it is proposed, in patients’ best interests, to stop, or not to start CANH and the patient is not within hours or days of death.

At the request of BMA members at the focus groups, the BMA and RCP have produced a leaflet that doctors can give to patients’ family and friends, explaining the need for a best interests decision about CANH and setting out their role in the process.

Medical treatment BMA medical ethics committee chair John Chisholm says: ‘Decisions surrounding the withdrawal of CANH pose clinical, ethical and legal challenges for doctors, and can be needed at an incredibly difficult time for patients’ families and loved ones.

‘The law is clear that CANH is a form of medical treatment, much like artificial ventilation, and while there should be a strong presumption that starting or continuing this treatment is in the patient’s best interests, this will not always be the case. The aim of medical treatment is not simply to prolong life at all costs, and the courts have been clear that in some circumstances it will not be in the best interests of the individual patient to receive CANH. This guidance therefore provides practical guidance for health professionals on how to follow the legal and regulatory framework that is in place to make the decision that is right for each individual.’ bma.org.uk/canh thedoctor | December 2018 19

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Bright sparks For this year’s BMA writing competition, we asked you for ‘one small thing’ you would change or had changed to make life better. Your answers revealed much about the joys and pressures of being a doctor, says Neil Hallows

S

eed potatoes have no place in the British National Formulary but perhaps their time has come.

Many words, drugs and treatments are exchanged in primary care but, for Penny Ballinger, it was her gift of those half a dozen seed potatoes to a patient that had a transformational effect.

Dr Ballinger is the winner of this year’s BMA writing competition. We asked you for ‘one small thing’ you’d change or have changed to make life better for you, your patients and other doctors.

Dr Ballinger’s entry (overleaf) describes, in touching and vivid detail, a ‘bear of a man’, a Polish immigrant, who spoke of pain but whose ‘narrative resonated more with anger and depression’. He had lost his job, recently undergone cancer treatment, and rarely saw friends.

However, he had an allotment and thanks to Dr Ballinger’s intervention his life bloomed.

It lacks animals or pop stars but it’s a story that could be an advert for one of the big department stores (speaking of which, Dr Ballinger, a medically qualified advanced nurse practitioner from Gloucestershire, wins a £250 voucher and a framed copy of the illustration we have commissioned for her piece). It’s also a tribute to the kindness, insight and subtlety which happens every day in

primary care, largely unnoticed.

The judges (who are writers, doctors or both) chose three runners-up.

Our first runner-up, a staff-grade doctor, wrote movingly about her struggles with intense pressures while maintaining a façade of normality and insisting that everything was fine. Her change would be to give a truthful answer to the simplesounding question, ‘how are you?’

For Brighton consultant dermatologist Susannah George, the change is not one of personality but of policy. She has heard, rather too many times, the reasons why parents decline immunisations for their children – health scares, ‘natural immunity’, or the wholly erroneous claim that no one dies of measles any more – and she has had enough.

And an appalling first day on the wards, enduring hostile attitudes and a lack of support from colleagues, inspired (if that’s the word) the third of our runners-up.

It’s by a junior doctor who deserves a time machine so she could start her medical career in a wholly different manner but we can’t run to that, so she’ll get £100 of shopping vouchers and a framed print instead, along with the other runners-up.

We also gave a highly commended place to retired Renfrewshire consultant anaesthetist Hilary Aitken

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BMA writing competition 2018

who proposed a new test for the plethora of management jobs she sees advertised: Could they, in a single sentence, be explained to an averagely intelligent 12-year-old?

Willing to practise what she preaches, Dr Aitken offers a tween-friendly definition of anaesthetics, but you’ll have to wait for that. All these entries will be published in forthcoming issues of The Doctor, and online.

As you might have already established, the range of ideas put forward was staggering. Hospitals should routinely accept all referrals from GPs as a matter of professional courtesy. A GP who wanted to try an experimental growth hormone on his son in the 1940s should have gone ahead and hang the potential side effects. Appraisals, IT, basic communication skills … where do we start? Just, please, please make them better you said. Some of those which did not quite make the shortlist will appear as blogs.

It’s important to say that this wasn’t an ideas competition.

We didn’t, for example, rank the importance of saying thank you (a popular theme) above or below the effects of computers not working. We judged on the basis of who had used the most vivid, engaging language.

The most successful entrants

tended not only to put forward ideas but also based those ideas on their own lived and described experience. Writing is usually – not always, but usually – at its most engaging when we are telling some kind of story. It’s hard to imagine that anything written in the abstract about social prescribing, however well argued, could be as engaging as that bag of seed potatoes.

The writing competition has now been running for 20 years, and many doctors have found it a terrific opportunity to try this kind of prose for the first time. Some of our most successful contributors began their writing lives through the competition.

But it’s not the only way to get published.

Aoife Abbey, whom we thank, along with BMA medical ethics committee chair John Chisholm, for judging this year’s competition, began by sending us stories from the wards. She went on to serve a highly successful stint as our Secret Doctor and her book, Seven Signs of Life: Stories from an intensive care doctor, will be published in February.

Our blogs guidance is a good place to start. Visit bma.org.uk/ writebetterblogs The writing competition is great – but it comes but once a year. If you’ve got something to say, and you probably have, why wait?

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The seeds of hope Penny Ballinger’s ‘small gesture’ transformed her patient’s outlook on life. She is the winner of this year’s BMA writing competition

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A

handful of seeds and half a dozen seed potatoes; the strange contents of the paper bag in the drawer of my consultingroom desk awaited my next patient.

A small gesture, from one gardener to another – one that might have become horribly awkward; but worth the gamble perhaps, remembering the laborious conversation through the Polish interpreter.

We had been talking about pain, even trying to score it in some meaningful way, but in the fragmented answers his narrative resonated more with anger and depression.

An immigrant? He had been a pioneer, left his home and family, worked hard in an alien country and took heavy, manual work – and sent money home.

The pay was good but in the silo world of the factory it was his countrymen who oversaw production. In the smoking break, he shared joshing and stories of home with successively younger, hopeful fellow Poles whose backs and bodies took the strain of heavy repetitive work more yieldingly.

A gruff-voiced bear of a man, his seniority still respected, the youngsters warmed to his perseverance and looked out for him.

No time to learn English, with the long hours and perpetual tiredness. Missing his garden back home, he had been forward-thinking and rented an allotment, which he cleared during several weekends and encouraged a few others to follow his lead.

But now …

His perpetual cough he had shrugged off, so it was his workmates who had nagged and persuaded him to see a doctor when he struggled to swallow, made the appointment, accompanied him.

And so the diagnosis, the surgery and the chemotherapy unrolled.

He coped … coped with the tracheostomy and the speaking tube. He coped.

But the factory let him go and besides he hadn’t the energy or the speed to keep up any more.

Benefits? He said he struggled, heating, food … rent.

A bed-sitting room.

Four walls. No company.

His friends working hour after hour had little time to spare for visiting and bonhomie.

Strange how the translation ‘he can’t afford any seeds for his allotment’ had registered with me in this island of hopelessness.

So, reviewing his pain, the paper bag had been slipped across with his prescription.

Months passed and gradually his attendance became less frequent until one day a bunch of beetroot appeared in my in tray.

The interpreter, grinning widely, reported the source and I dutifully roasted and liquidised them that evening, handing her a vibrant pot of borsch to be dropped by on her way home, given that she was now herself a keen member of the allotment society.

And so a pattern appeared to have been set.

On the allotment, his status was now ‘king of the

‘It was his workmates who had nagged and persuaded him to see a doctor’

‘The muddied prints of his allotment friends trailed to his door’

plot’. Fierce slug opponent and source of brassica wisdom during potting-shed tea breaks …

At reception, he was no longer the angry Pole but the bringer of fresh vegetables, new potatoes, gherkins to be pickled, tomatoes to be bottled; while behind the scenes, the back-office staff reciprocated with liquidised soups and broths.

So, summer melted into an autumn of mellow harvest and delight at the produce the allotment yielded until, as a matter of course, the cancer recurred in the late winter.

He wasn’t alone any more in the last few weeks because the muddied prints of his allotment friends trailed to his door, along with the receptionists whose frostiness had been turned with green beans and kale.

A handful of seed potatoes and a few seeds had been all that was needed to change his perspective and had given him some months of joy and status.

A small thing, perhaps, but it had triggered the support and friendship he needed so that he did not die alone and impoverished in a foreign land but surrounded by friends, and friends who will remember him fondly – as the apple tree they planted in his memory, yearly, gets stronger and taller and finally bears fruit.

Penny Ballinger is a medically qualified advanced nurse practitioner from Gloucestershire bma.org.uk/ writingcompetition thedoctor | December 2018

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A spectre calls Long-dead doctors padding the wards, the bed the nurses told you not to sleep in, and why it’s good to exorcise regularly.

Your NHS ghost stories, compiled by Neil Hallows

H

ow do you find a ghost? First, switch off the lights. Next, take a deep breath.

And finally, publish a blog about the curious absence of anything supernatural in NHS hospitals and wait for the contradictory comments to come charging at you like a headless horseman.

A few weeks ago, the Secret Doctor, who is particularly strong on what you might call the sub-culture of the NHS, wrote a thoughtful piece asking why there aren’t more ghost stories arising from hospitals. They are, after all, places where a number of people, sadly, die, and they are are often old, imposing buildings replete with long, dark corridors.

The author’s conclusion was that ‘there is too much actual, intense human experience going on around us to leave room for phantoms’.

One thing we’ve noticed with our blogs is that if you want doctors’ opinions, the best way to get them is to publish the opposite view.

‘Ghosts: Not available on the NHS,’ was the headline of the blog. Oh yes they are, you said.

Freely available and without prescription.

So, since it’s Christmas, here’s a flavour of what you told us.

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‘I live in a converted mental asylum,’ one of you begins.

‘I saw a woman in Victorian dress throw a baby out of the window. I’ve also seen a Sister in full ’50s matron [attire] float past the window, heard old records playing and seen a hospital food tray floating in ‘We have mid-air.’

Well, it must be a relief to an on-call room where get to work then? ‘We have an on-call room that a spirit a spirit comes in and sits on the bed.’ comes in OK, have you tried security? and sits on ‘The security guard came to the bed’ investigate and saw a woman in a white nightdress jump off the roof.’

Well, top that. To which the profession replies, hold my drink.

There is the doctor who trained at the Queen Elizabeth Hospital in Gateshead, and thought they were smart in finding a bed in a disused isolation ward to grab some sleep. Don’t, seriously, don’t, warned the midwives, there is a ghost of a woman who died of septic shock.

‘I scoffed, but changed my tune when a freezing chill swept over me, and ‘The the door slammed.’

hospital arranged for an exorcism’

Door banging And there’s a bit of life advice for you – listen to the nurses and midwives.

‘If you want ghosts, talk to the nurses,’ says one person commenting on the blog.

‘Many will tell you about the footsteps or door banging heard just before a death on their ward at night, or of the strange shadows and the no-go areas they will not venture in to. It’s only the doctors who don’t see the ghosts.’

It’s nurses we can thank

for recounting the angry exchange between a patient and her husband, who visited her in hospital with the sole and malicious purpose of telling her she was a ‘dirty old crone’. The argument upset the nurse who overheard it, although she was more upset when she learned that the husband had in fact died two years previously.

It was a nurse who not only saw a ghost but was ‘woken by a strong pressure downwards on her chest’ while resting in a side room. The side room had recently been vacated by a patient who was a medium.

Isn’t it annoying when patients leave things behind?

Ghost in the mortuary A characteristic of ghosts which emerges from the stories is that, while they may traditionally be relaxed about passing through brick walls, they are positively sticklers when it comes to the horizontal.

At one hospital, a centurion is said to lurk by the mortuary, dutifully following the level of a Roman road. The ghosts at the former Evelina London Children’s Hospital in south London appeared to be paddling ankle-deep on the floor, walking as they were in the footsteps of the past.

‘What height do they walk at now most of the site is a garden?’ asks Marc Rowland.

Some of these stories are told for camaraderie, or perhaps the opposite given that their purpose seems to be to frighten the most recent recruits. But some of them have been reported and ‘dealt with’ by surprisingly receptive hospital managers.

Hats off (or heads off ?)

to managers at Warrington.

When a locum doctor reported ‘noises and footsteps’ in the disused ward in which he slept, he said he was not coming back unless he could sleep next time in the mess. ‘The HR department wasn’t surprised – they said this was not the first time they had been told this and respected my request.’

Smell of pipe smoke At Aberdeen and Newcastle, we are told, the hospital even managed to arrange for an exorcism. And to think that at some hospitals they can’t even manage to get a coffee machine fixed.

There’s a grey lady, a white lady, a confused little girl in a red coat. Buzzers buzz, taps burst into life, and there are ‘on-call rooms haunted by doctors who killed themselves wracked with guilt after a patient’s death and the smell of pipe smoke because a deceased porter has arrived to take a soul on their final journey’.

But what of the floating ghost of Galway?

At Merlin Park Hospital, a doctor tells us ‘the nurses in one unit were particularly freaked out by a ghostly figure they’d seen flying through the air outside the unit only a short while before. The apparition was a white, floating ghost, that flew past at speed in the dark.

‘What kind of mass hysteria was this?

‘It was me, on my bike, white coat flapping in the breeze...’

Doctors can be scary too.

– You can read the comments in full on the blog at bma.org.uk/ghosts thedoctor | December 2018

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

Bullying, underpayment, keeping holiday entitlement and receiving rotas on time – all issues the BMA has tackled and corrected for its members after they sought the association’s help Sick of the bullying

Carry on, carry over

Sick leave is a common consequence of bullying behaviour in a toxic workplace, as it was for one associate specialist in psychiatry helped by a BMA employment adviser.

Without proper consultation her employer sought to bring her back on a phased return, which was not required, instead of seeking to resolve the workplace problems which forced her off sick in the first place. With the support of our adviser, the psychiatrist was helped to draft emails and organise a meeting with senior staff, including the clinical director.

There, an action plan was agreed to tackle some longstanding issues which had been previously passed over by managers, despite her highlighting them repeatedly. This allowed her to return to work, with confidence that some sources of stress would be dealt with.

‘Your advice on how to negotiate in difficult situations has been invaluable,’ the doctor said. ‘You have also been the person to have a “sanity and reality check with”.’

A consultant psychiatrist has been allowed to carry over five days of his contractual leave to a new financial year after an intervention by a BMA employment adviser.

His trust had refused to allow him to carry over the days, which he had been unable to take, owing to sick leave. Its policy, which is not uncommon in the NHS, allowed carryovers only in ‘exceptional circumstances’ but the trust never gave the doctor the chance to make the case for carrying the days over. After the BMA requested and secured a meeting, the trust agreed to allow an independent party to review the evidence we prepared. This set out how the doctor had been disadvantaged. The trust finally agreed to carry over all five days and admitted to ‘communication errors’ on its part.

Out of pocket The frustration of sorting out pay-packet problems is an experience many of us don’t want but struggle to purge from our memory banks. But for one GP trainee, matters were made much worse by the fact that she had just gone on maternity leave. The first payment was missed and her tax codes found to be wrong. In total, she was temporarily £9,000 out of pocket until the problem was resolved two-and-a-half months later. It forced her to eat into savings as she prepared for the imminent arrival of her new child. After dozens of emails from a BMA employment adviser, the situation was finally sorted and she is now receiving the correct maternity pay.

Timely rotas after BMA pressure Incoming anaesthetic trainees at the Medway NHS Foundation Trust got their rotas 11 weeks before they were due to start, after intervention from BMA industrial relations officer and junior doctor representatives through the Junior Doctors’ Forum. This is a huge improvement on what happened in August, when doctors in medical specialties received rotas 10 days in advance. Under the code of practice for the junior doctor contract, drawn up with NHS Employers and Health Education England, trainees should receive their generic work schedule and rota template eight weeks before they start work. Their duty rotas should be with them six weeks beforehand.

Employers often fail to achieve this, meaning this is a key focus of BMA activity around the country. The BMA is grateful to the trust regarding this positive engagement.

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the secret doctor

Patients don’t ‘defy’ me by getting better ‘Mother of four defies doctors to walk again,’ ‘Brave tot defies medics to celebrate first birthday’ and ‘Injured teen defies doctors to win major award.’

What lovely, heart-warming headlines. A refreshing change from the negativity of so much of the news these days.

Who could be so Grinchlike as to object to these cheery tales of triumph over adversity? Well, I’m always happy to hear a success story but as regards the choice of language my heart remains firmly un-warmed.

Much has been written about the analogy of illness with a battle. In this narrative, we fondly tend to picture doctors as – at the very least – supporting the fighter, buckling on their armour and stocking their arsenals with nifty therapeutic weapons.

But if you look at headlines such as these, it turns out that’s not what’s going on at all. We are the naysayers, the obstructers, the prophets of doom – if not actually the enemy.

‘Defiance’ suggests opposition and even animosity. Plucky little

Belgium defied the Kaiser.

David defied Goliath. And when patients ‘defy’ doctors, what are we to conclude but that we have been on opposing sides all along?

The doctors obstinately predict the worst, and only by struggling against the medical establishment can patients recover and flourish.

One reason for this is the gap between realistic predictions and what people want to hear. If someone will probably die, or be severely impaired, modern professional ethics dictate we must share that with them.

Naturally, if there’s a 10 per cent chance of recovery, most people will focus desperately on that 10 per cent.

The 90 per cent who don’t make it will never tell their story to the press; the 10 per cent who do will feel they were painted an unduly dark picture. For the doctor to collude with the patient in anticipating a rosy future which we know to be improbable is considered unacceptably paternalistic but sticking strictly to statistical facts can feel like

twisting the knife in a wound.

From the patient’s point of view, hearing the doctor say, ‘wouldn’t you like someone to be with you?’ feels analogous to watching the judge don the black cap. And even to the doctor, giving a catastrophic diagnosis can often feel, irrationally, like imposing a death sentence.

The difference, of course, is that we are not the ones actually inflicting the horror that lies ahead for our patients but under the pressure of emotion it can be easy to forget that. Evidently, journalists sometimes fall into the same confusion.

Next time you hear of a brave sufferer defying the doctors to reach some milestone that once seemed impossible, think again.

The doctors probably weren’t all that cross about the patient’s ‘defiant’ progress. Maybe – who knows? – they even helped them get there.

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it happened to me Doctors’ experiences in their working lives

The silent killer His smell precedes him into the room.

I take one last deep breath and return his smile. Lovely chap, Mr Smith. Lives alone; wife died a couple of years ago, and he’s been getting smellier and smellier ever since.

It’s a sort of chemical interaction between his body and his clothes, feeding off each other, neither having had more than a nodding acquaintance with soap and water for at least the last six months.

It’s not his fault. He’s frail, and washing isn’t easy but he’s too proud to let carers in. You can’t smell yourself and if the reason there is something your best friend isn’t telling you is because you don’t have a best friend, you will never find out, will you?

This is the smell of loneliness.

A new sign, like Chvostek’s or Murphy’s. Probably not particularly high sensitivity or even specificity for that matter, but a clue. Smell as a marker for loneliness, and loneliness as a marker for ill health.

Back to Mr Smith. I check his itchy rash with a sense of futility. A cream has not yet been invented capable of combating the breeding ground for fungi and bacteria that is his unwashed body.

Then his blood pressure.

His meds were last requested sometime in the spring – but then, if he took the treatment and got better, what could he come to the doctor about?

You see the problem.

Loneliness is in the news a lot these days. A public health epidemic, we are told.

The Royal College of GPs’ action plan for loneliness this year suggests it carries a 50 per cent increased risk of

early death, and that we GPs need help to identify it.

Once we have identified them, I’m really not sure what we’re going to do about it here in GP land.

Being kind to the patients only encourages them, as one of my old partners used to tell me; but I can’t seem to stop myself. The sadness of an older man who is only ever touched by medics is beyond my ability to ignore.

I’ll keep seeing him every month, and ask Santa to bring me a quality air freshener for Christmas.

Maybe one of those fancy reed things sticking out of a jar. When I get home to my quiet nest tonight, I’m going to have a very long, fragrant bath.

Beatrice Duck is a GP. She writes under a pseudonym

28 thedoctor | December 2018

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the consultation The Doctor will see you now

HIGH FLYER: Dr Courtman (centre) at work aboard the Flying Eye Hospital

Plymouth consultant paediatric anaesthetist Simon Courtman is a volunteer for Orbis, which operates the Flying Eye Hospital – an operating theatre and teaching facility inside a converted cargo aircraft. He has volunteered in a number of countries including Indonesia, Mongolia and Peru Children without vision can quickly become a burden to their families.

They may not be able to work and contribute to their families financially.

In some countries this results in lives begging on the streets.

There is a look that the parents give you after the operation. It requires no interpreter or translation. One parent to another. You know what it means, and you feel great pride in the whole team.

It’s transformational for the whole family.

Suddenly, a child, who may have been destined to become a financial burden, becomes a vital part of the family business.

In Indonesia, watching the joy in a young boy when he realised he could now continue as a butterfly catcher with his father, was one of those moments.

For me, there’s something even more inspiring and that’s the emphasis that Orbis places on education and empowering local clinical teams to work towards restoring sight. The largest element of the operating sessions is training the local surgeons, anaesthetists and theatre teams.

I’ve seen Sellotape and garden hose put to good use in theatre. The local medical and nursing teams, without exception, are all committed to delivering the best service they can with the resources that are available to them. In Vietnam, the local anaesthetist had converted nasal prongs into an advanced anaesthetic circuit with some help from Sellotape. I’ve also seen garden hose attached to anaesthetic machines to remove waste gases, and phone torches used to supplement theatre lighting.

With a good team you can succeed no matter what obstacles appear.

The leadership and team ethic of the Orbis staff is remarkable. I was lucky enough to work beside [the charity’s former president] Oliver Foot. He knew all the doctors and nurses. But he also knew every member of the hotel reception staff, the airport security team and all the drivers for transporting us around. I’m not saying I will ever be as good as he was but that lesson has always stayed with me.

To donate or find out about volunteering opportunities, visit gbr.orbis.org thedoctor | December 2018 29

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and finally ...

Stories from the medical profession on a lighter note

When Christmas was all white It was a white Christmas, whiter than I could have imagined. It was 1964, and I had come to the UK from Pakistan a few months previously.

The ground was white. The cars, trees and buildings were all white outside Whipps Cross Hospital in east London.

On Christmas Day, the ward Sisters had prepared a turkey and waited for the consultant to serve it. He was dressed as Father Christmas.

One of my jobs, as a house doctor, was to push a trolley full of bottles of wines and spirits around the wards.

The consultant poured every patient’s choice of drink.

No one was excluded, even those with alcoholic cirrhosis.

There were carols and I tried to join in with the nurses, even though I knew neither the tunes nor the words. Some Pearly Kings came to the hospital and this was the first time I had seen Western dancing.

The nurses were friendlier

at Christmas. At other times, the ward Sisters could be unkind to house doctors, especially the female ones.

I was as cheerful, careful and tactful as I could be with them.

It was very peaceful, although this wasn’t just owing to good fortune. I had been advised by a charge nurse on Christmas Eve: ‘Doctor, write a laxative for each patient and the night nurse can choose to give it, without waking you up to write it.’

He then winked at me and said: ‘If you keep their bowels open, they keep their mouths shut.’

More than his advice, it was the winking I noticed.

Where I had come from, it was a sexual thing. I had to learn that in England it was usually just people being friendly. Perhaps this was one reason why I have had a lifelong professional interest in transcultural medicine, the most appropriate way to

deal with patients of different cultures, ethnicities and religions.

My hospital, my new home, and the whole country was at peace. I was a young man with thick black hair, a moustache turning upward, slim figure, and no sense of humour.

I was a typical easterner and the nurses thought I was very handsome. Fifty-four years later, I am no longer slim or need to trouble a comb but I’ve acquired a British sense of humour and I enjoy western music and dancing.

I continue to help people and I hope to remain a jolly good fellow for many Christmases to come. I wish all readers a merry Christmas and a happy new year.

Bashir Qureshi was a practising GP for 47 years.

He is an expert witness, and has written and lectured on transcultural medicine and clinical negligence

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what’s on

January 2019

February 2019

March 2019

18 Planning for retirement – delivered by the BMA, 9.15am, York

02 Clinical academic trainees conference, 10am, London

05 Practical skills ... time management and taking control, 9am, London

26-27 BMA junior members forum, 10am, Brighton

04 Appraisal training for consultants and SAS doctors, 6pm, Belfast

05 Public health medicine conference, 9.30am, London

30 Practical skills ... for effective communication, 9am, Glasgow

08 Planning for retirement seminar – delivered by the BMA, 9.15am, Edinburgh

29 Conference of medical academic representatives, 9am, London

25 Job planning workshop, 6pm, Belfast 27 Consultants conference, 9am, London Visit bma.org.uk/events for full details Download the BMA events app at bma.org.uk/events/events-app

Help us stay in touch with you Don’t miss out – ensure your membership details are up to date so we can keep you informed of important news, information related to your branch of practice and how we can support you in your professional and personal life.

Visit bma.org.uk/updatemydetails, email us at support@bma.org.uk or call 0300 123 1233 to make sure your information is correct.

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