The Doctor, issue 38, December 2021

The magazine for BMA members

thedoctor

Issue 38 | December 2021

In Bethlehem A hospital delivers hope and unity

Staying put Doctors in Syria stand firm

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Mandatory jabs Fears for staff exodus in already fragile health service

Like a circus Medical teaching 50 years ago

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In this issue 3 At a glance Urgent action required as winter pressures mount

4-7 Forced to choose Mandatory vaccinations for frontline NHS workers could worsen the recruitment crisis

8-10 For humanity’s sake The doctors who refuse to abandon their patients in Syria, despite appalling conditions

11-13 A star of Bethlehem A maternity hospital which is a beacon of unity in a divided land

14-15 At the circus When medicine was taught by humiliation and terror

16-17 Being heard Why public health can and must have influence

18-19 Vote, represent, lead Put yourself forward for BMA UK council and make a difference to the profession

20-23 Life experience Keeping patients in over Christmas, an inspirational consultant, and an exam passed at the final attempt

Welcome Chaand Nagpaul, BMA council chair The vaccination programme has been a critical component in the fight against COVID-19, with doctors playing crucial roles at every stage of the process from development to delivery, including protecting the NHS workforce itself.

However, the Government’s recent decision to make COVID vaccination mandatory for healthcare workers has raised practical and ethical questions which need to be addressed. These issues are serious for an NHS with an exhausted workforce, with unvaccinated staff likely to be redeployed or even have their employment terminated.

This issue of The Doctor examines the issues at the heart of this topic, including the dissonance between the Government’s focus on mandatory vaccination while at the same time placing relatively little emphasis on strict infection-control measures in public settings, such as wearing face coverings, ventilation and social-distancing measures.

The Doctor speaks to the president of the Faculty of Public Health, Maggie Rae, who aptly says, ‘sometimes people only see public health when there is a crisis’. It is a sentiment with which many public health specialists will identify. That has been particularly brought into focus during the past 18 months where doctors working in public health have been expected to do so much with so little – to protect the public and respond to the COVID-19 pandemic despite a decade of brutal cuts to budgets. Professor Rae makes a compelling argument for a significant increase in public health spending and the BMA will continue to urge the Government to do exactly that.

January will see nominations open for the new-look BMA UK council, with the number of voting members rising from 55 to 69, to include 40 geographical and 24 branch of practice seats, as well as five people who self-identify as Black, Asian or minority ethnic. A feature in this issue explains the new process and I would urge you to get involved if you would like to help shape the future for our profession and our NHS. A doctor working at the Holy Family Hospital in Bethlehem, an institution famed for its ecumenical approach towards the local community, offers an insight into doctors working under extraordinary circumstances in a place in many of our members’ thoughts at this time of year. We also look at what medical teaching used to be like, find out about doctors working in Syria and hear from a junior doctor on having to tell patients they will be in hospital for Christmas.

Read the latest news and features online at bma.org.uk/thedoctor

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

instagram.com/thebma

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AT A GLANCE With what is set to be the worst winter on record, increasing strain on an already exhausted workforce and potentially derailing the recovery of health services, the BMA is calling for urgent action. Its report, Weathering the Storm, makes a number of calls to governments across the UK: Protect the health, safety, and well-being of staff, including by taking a zero-tolerance approach to violence and abuse and providing personal protective equipment that ensures proper protection from infection

Retain existing staff and maximise workforce capacity by removing punitive pensions taxation rules which penalise doctors who take on additional hours to care for patients

Communicate honestly with patients and the public about health-service pressures and how long it will take to clear the backlog of care

Promote responsible public health policies to keep people safe and healthy and help manage demand on services

Direct resources to where they are needed most to manage health service demand

End punitive pensions taxation rules and take additional measures to maximise workforce capacity including restrictive immigration rules for international doctors

Cut red tape, remove unhelpful targets and barriers, and reduce unnecessary bureaucratic workload Read the report at bma.org.uk/weatheringthestorm bma.org.uk/thedoctor

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FORCED TO CHOOSE Mandatory vaccination for frontline NHS workers in England could worsen the recruitment crisis and place unbearable pressures on the system.

Tim Tonkin reports

T

he emergence of COVID-19 vaccines, developed and distributed as they have been at unprecedented speed, was undoubtedly a turning point in the pandemic.

With the first winter following the widespread roll-out of the vaccination campaign approaching, the Government has been looking at policies that would increase vaccine coverage, with health and social care settings being a high priority.

Initially mandatory vaccinations were introduced in adult social care settings in England and this meant that being vaccinated became a

condition of employment for these social care workers.

However, ministers have recently decided to extend this in England to all Care Quality Commissionregulated health and care settings and as such all health and social care workers who are in patient-facing roles in these settings will have to be vaccinated or will be unable to be deployed in these roles.

The BMA fully supports the vaccination campaign as it has with campaigns in the past. It recently passed policy at the annual representative meeting stating it believes every doctor should be vaccinated.

However, mandatory vaccination comes with its own consequences that it argues needs to be weighed up against any potential benefits. The association has called on the Government in its consultation to address the impact a vaccine mandate might have on dangerously thin staffing levels in the event that staff who cannot, or choose not, to be vaccinated are redeployed or even see their employment terminated.

It also successfully argued policy should be delayed until at least past the winter so as not to affect the workforce at the most critical time.

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The Government’s argument was that, given the specific nature of health and social care settings and the duty of care healthcare workers have towards their patients, mandatory vaccination made sense.

The BMA has also highlighted the dissonance between the Government focus on mandatory vaccination to prevent spread to patients, when in England it had until recently largely dispensed with rules on face coverings and social distancing measures in wider society where the same patients could become infected.

BMA consultants

committee chair Vishal Sharma says he is in no doubt vaccination is a critical component in the fight against the virus, adding that he fully supports vaccination among all individuals where medically appropriate.

He warns, however, that any plan to mandate vaccination of all staff working in frontline healthcare poses significant practical questions, particularly concerning timescales and logistics.

‘We certainly believe vaccination is essential to control the pandemic and people should be vaccinated wherever possible.

‘Whilst we believe everyone should have it [the vaccine] we also believe people should have personal choice. As doctors, we would never force patients to have a treatment even if we thought it was in their best interests and I think the same applies to staff.’

Promotion or coercion Dr Sharma says that rather than taking a coercive approach through mandating the vaccine, he would instead rather see the Government taking all steps to promote uptake among those healthcare staff still unvaccinated. thedoctor | December 2021 05

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BMA

BMA

SANFORDWOOD: We can’t afford to lose frontline staff

CHISHOLM: Mandating vaccine could reinforce opposition

‘Whilst we believe everyone should have it [the vaccine] we also believe people should have personal choice’

‘I’m concerned there could potentially be impacts on other vaccination programmes’

‘We really should be encouraging people wherever possible to have the vaccine.

Give people the time to weigh up the decision and as much support as possible to encourage them to voluntarily have the vaccine,’ he says.

While there are strong arguments for maximising numbers of vaccinations from a clinical point of view, mandating any form of medical treatment poses significant ethical considerations.

‘It is generally accepted that people have the right to make their own private healthcare decisions and ordinarily consent to medical treatment is also based on that principle of voluntariness,’ says BMA medical ethics committee chair John Chisholm.

‘Moving away from that model does need to be carefully thought about and properly justified and proportionate.’

Vaccine mandates already exist within the health service, with many staff required to be immunised against hepatitis B as part of their job.

Dr Chisholm says, however, it is misleading to draw an exact parallel between the two immunisations.

‘There are analogies from when hepatitis B vaccines were first available and then became close to mandatory certainly for people engaging in exposure-prone procedures,’ he says. ‘[However] Those who say that people already know that exposure-prone procedures will require hepatitis B immunisation before they pursue a career in healthcare, that’s true now but it wasn’t true when the policy was first changed.’

Highlighting how voluntary approaches to vaccination could be successful and respectful of individual rights and liberties, Dr Chisholm says there are potentially clinical as well as ethical concerns regarding mandating vaccines.

Citing lower uptake of the COVID vaccine among certain ethnic groups, Dr Chisholm says a blanket policy on vaccination could be regarded as unfairly targeting those groups.

‘Beyond the health service there is a risk that a mandate for vaccination could be counterproductive more generally as it could reinforce anti-vaccination opposition rather than understanding

and addressing the concerns that particular groups of staff may have,’ he says.

‘I’m concerned there could potentially be impacts on other vaccination programmes including childhood immunisations if people see that mandatory vaccination is being imposed on some groups. It could reinforce opposition and suspicion.’

The potential effects on frontline staffing resulting from the mandating of vaccination, is something the Government insists it is considering as part of its consultation. If enacted, it would require the deadline for double vaccination to be April next year.

In light of the proposed timescale for implementation if the mandating of vaccinations were to go ahead, these assurances have done little to allay concerns with what effect the loss of even small numbers of staff could have on the NHS. Published on 15 November, the Royal College of Physicians’ annual consultant census reveals that 48 per cent of consultant posts advertised in 2020 ultimately went unfilled, up from 36 per

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BMA

bma.org.uk/thedoctor

alternatives to patient-facing positions.

Dr Sanford-Wood warns, however, that large-scale redeployment within general practice is ‘a complete nonstarter’, owing to the limited numbers of staff and nonpatient roles available.

He adds that there is a very real concern among many healthcare staff that they could ultimately lose their jobs in the event of a vaccine mandate.

‘Within general practice we don’t have lots of redundant, non-patient facing roles that we could move people into. We run with pretty lean staffing rosters so if someone is deemed not capable or not allowed to fulfil their roles, we don’t necessarily have other roles we can redeploy them to,’ he says. ‘There is a natural limit to how much any workforce can be redeployed.

There have to be other unfilled roles for them to be redeployed into and, if they’re not there, then you effectively made yourself unemployable as you’re not able to do the job for which you’ve been employed.’

GETTY

cent in 2013.

Meanwhile a study by the BMA published in September this year warned the NHS in England was facing a shortfall of 50,000 doctors as it headed into the 2021/22 winter period.

Any further upset to the already precarious and razor-thin staffing margins in the NHS could severely compromise the health service’s ability to respond to clinical pressures posed by COVID and outbreaks of flu.

Following a 12-week grace period, the deadline for mandating COVID vaccinations among care home staff passed on 11 November, with around 32,000 staff in this sector still unvaccinated after this date.

‘You can argue that this draconian measure effectively forced 56,000 people who would otherwise have been unvaccinated to become vaccinated,’ says Mark Sanford-Wood from the BMA GPs committee. ‘But you can look at it from the other end of the telescope and realise that that means you’ve lost 32,000 care home workers that we cannot afford to lose.

‘The estimate is that there are around 100,000 NHS staff that have chosen not to be vaccinated. If the same proportion of them stick to their guns and refuse to get vaccinated, that would mean us losing around 35,000 frontline staff.’

The redeployment of staff who can’t or choose not to be vaccinated is cited as a means by which damage to staffing levels could be mitigated, with non-patient roles, remote working and phone consultations providing

Staff impact ‘We can’t afford to lose any staff at all from the NHS,’ says Dr Sharma.

‘We’re already incredibly stretched. The NHS workforce has a high vacancy rate and has massive problems with existing staff being exhausted and burnt out. If we were to lose any more staff, for whatever reason, it would be an incredibly difficult situation to manage.’

In the background papers to its consultation, the Government claims that while there has been a high uptake

in vaccination among the general public and health and social care staff, variation in rates exists within the latter.

Among NHS trusts uptake rates can vary from around 83 per cent to 97 per cent of staff for a first dose, and 78 per cent to 94 per cent for both doses.

For those staff who have not received the vaccine, it is unclear from the data how many are unvaccinated owing to medical exemptions.

‘We have to remember the vast majority of staff have chosen to be vaccinated already,’ says Dr Sharma.

‘Yes, vaccination is the right thing to do but it makes us uncomfortable to think it is being forced on staff who otherwise may not be able to work. Vaccines aren’t the whole part of the story. It can’t be a vaccine-only strategy; it needs to be a vaccine-plus strategy. It seems very heavyhanded to force NHS staff to have a vaccine when, at the same time, other measures such as face coverings aren’t being mandated in other areas.

‘We can’t just say vaccines are the only solution here.

It needs to be vaccines plus all the other measures that would reduce infection.’

SHARMA: ‘Vaccines aren’t the whole part of the story’

‘There are around 100,000 NHS staff that have chosen not to be vaccinated’

‘There is a natural limit to how much any workforce can be redeployed’

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For humanity R ‘We can see people are hungry, children are struggling with malnutrition’

asmia Abdullah* is haunted by the memory of a young boy who lived in her building until an air strike reduced it to rubble.

The blast killed the boy’s entire family; the child survived because, like Dr Abdullah, he happened to be out at the time of the raid.

All she knows of his fate is that he has gone to live with distant relatives.

‘I’ve witnessed countless stories like his, seen so many children who have lost their parents,’ says Dr Abdullah. ‘But what happened to that boy affected me deeply. I knew the family and now the child is not even living with close relatives…’

The boy is one of millions of children whose lives have been torn apart by Syria’s intractable, brutal civil war. He’s a civilian, displaced and damaged. He’s one of Dr Abdullah’s people.

Medical professionals must remain nonpartisan – even as war becomes personal. Yet, medical neutrality in the legal sense was one of the first casualties of the civil conflict. Right from the start of hostilities, hospitals and medical

centres were targeted as alleged hideouts for armed groups and terrorists.

Doctors were arrested, even ‘disappeared’, for trying to do their jobs. The BMA wrote to president Bashar al-Assad in 2013 to protest about the death in custody of British-born orthopaedic surgeon Abbas Khan. Dr Khan had been detained for 13 months, and reportedly tortured, for tending to injured civilians.

Health workers resorted to what they called ‘clandestine medicine’. In one northern area, MSF (Médecins Sans Frontières – Doctors Without Borders) used a cave, then a farmhouse, as an emergency department, complete with operating theatre.

Last bastion Dr Abdullah works in a rebel-held area in northwest Syria, straddling Idlib and Aleppo provinces.

It’s the last opposition stronghold and more than half of the four million people in the region are displaced, many living in overcrowded camps.

They have all been displaced several times, as have many of the medics who serve them. More

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MÉDECINS SANS FRONTIÈRES

Sheltering from a hostile regime in disease-ridden camps, one of the few sources of hope for the displaced people of Syria are the doctors who they know will not abandon them.

Seren Boyd reports

ty’s sake than half of Syria’s 22 million people have fled their homes since 2011.

Government forces have made little distinction between civilians and combatants in their use of aerial bombardments, chemical weapons and medieval sieges on Syria’s ruined cities.

In north-west Syria, many people live cheek by jowl under tents and tarpaulins, often without regular water supply or proper toilets.

Winter brings fresh torments: mud and freezing temperatures. One camp, Deir Hassan, west of Aleppo, is home to 120,000 people.

Even the camps and their humanitarian support are seen as fair game for air strikes and bombardments.

Dr Abdullah works for MSF, running mobile clinics in muddy cabins in these camps, providing general health care, vaccinations and treatment for conditions such as diabetes.

She also checks regularly on pregnant women whose antenatal care is generally confined to the camps.

‘The situation of the people here is really

difficult: their living conditions must be among the worst in the world,’ says Dr Abdullah. ‘Their tents are really close to one another. We can clearly see that people are hungry, that children are struggling with malnutrition.’

Lack of safe water Protracted conflict has left the health system in the north-west on its knees. Pressure on scant resources and depleted medical teams is building as military offensives continue to drive displaced people further north, into ever more overcrowded areas. Even health centres have had to be relocated.

Recent shortages of safe water in the region have meant conditions such as diarrhoea, hepatitis and scabies are rife in the camps, prompting MSF to scale up its water, sanitation and hygiene response. COVID has only exacerbated the local health crisis.

By mid-October, MSF was reporting its health facilities in the north-west could not keep pace with demand for oxygen or intensive care. Less than 3 per cent of the population of north-west

WINTER RESCUE: North-west Syria where more than two million people, the majority of whom are women and children, remain internally displaced

‘Their living conditions must be among the worst in the world’

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Syria was fully vaccinated at the time of writing.

Dr Abdullah says she and her team have been stepping up their vaccine promotion: many are wary of the COVID jab.

And all the while, another crisis is building.

Most people in the camps have suffered trauma; many children have continence problems.

Dr Abdullah’s team has a mental health specialist but the needs are vast.

‘These are children who have witnessed war, shelling and all the stress that comes with that, and many are orphans,’ says Dr Abdullah.

‘A lot of the adults have injuries, some have lost limbs. And now they are living in poverty, and no one can provide them with the care they really need. Most people living in this area are affected psychologically – including us medics.’

Medical personnel killed In Syria, it seems, the rules of war do not apply.

The NGO Physicians for Human Rights says it has ‘corroborated 600 attacks on at least 350 separate facilities and documented the killing of 930 medical personnel’ between March 2011 and June 2021. Often, rockets are fired twice with a few minutes between attacks. This ‘double-tap’ approach deliberately targets those who rush to help those injured in the first attack.

So medics live in fear for their lives, and patients are fearful of being in hospital buildings which remain within the gun sights of government forces.

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MÉDECINS SANS FRONTIÈRES

MÉDECINS SANS FRONTIÈRES

COLD COMFORT: A refugee camp in north-west Syria, and (right) displaced people receive winter supplies from MSF

ago,’ says Dr Abdullah.

‘We are impartial and independent, which means that we provide medical assistance to people regardless of their religion, gender, even their ethnicity and political affiliation. That humanitarian and medical work – and our staff – have to be protected, so we can keep doing our job.’ For most of her professional career, all Dr Abdullah has known is conflict. She could leave, as many medical professionals have done.

Sometimes, the temptation to start a new life abroad is strong.

‘We have this dilemma all the time, between our duty and our desire to support our community, and the opportunity to leave and have a better quality of life elsewhere,’ she says.

‘But getting support and solidarity from the outside world gives us the motivation to continue. And it makes us believe, again, that the values of humanity do still exist.’

Repeated international attempts to broker peace in Syria – efforts which have persisted for almost as long as the conflict – have failed to yield a settlement. Dr Abdullah is committed to her people: their struggle is hers. So, for now, for the sake of the little boy from her old apartment block, she’s staying put.

‘I want to serve my community. I feel for my people because I am part of them. We are part of the same struggle. Now’s the time when they need me the most.’ *Name changed to protect identity bma.org.uk/human-rights www.msf.org/syria

‘I’ve lost many colleagues, doctors and nurses, in the conflict’

‘We have this dilemma all the time, between our duty ... and the opportunity to leave’

bma.org.uk/thedoctor

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HOLY FAMILY HOSPITAL

EARLY DAYS: A new-born receives care

A star of Bethlehem In Bethlehem, maternity care has moved on a bit. Neil Hallows reports on a hospital offering high-quality care to all, regardless of faith, a beacon of unity in a divided land

‘W

e are the modernday manger, with room at our inn.’

The Holy Family Hospital in Bethlehem exists in two different dimensions. To the more-than 4,000 mothers who give birth there every year, it is a rare if not unique example of high-quality, subsidised healthcare available to a Palestinian population living in a profoundly difficult coexistence under occupation.

To some of the parents and staff who work there, it is also about making amends to a couple who had rather fewer facilities at hand when they

gave birth in Bethlehem just over 2,000 years ago.

‘I feel this is reparations to the Holy Family,’ says Ambassador Michèle Bowe, from the Order of Malta, a religious lay order of the Catholic Church, which runs the hospital, and continues to run dozens throughout its 900-year history.

The hospital is there for those of any religion and those with none.

Most patients are Muslims, reflecting the make-up of the Palestinian population.

And perhaps this is the third dimension – a place where

patients and staff alike report a remarkable sense of harmony and common purpose in an otherwise divided land.

Strive for excellence George Zoughbi is head of the neonatal department at the hospital. He is a native of Bethlehem, as were his parents. ‘I grew up in a conflicttorn region where medical aid was always a necessity, and I certainly had a dream of going to medical school.’ But the opportunities were just not there.

So, after school, he went to Canada to pursue an

‘With limited resources, we compromise with a little extra love and compassion’

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HOLY FAMILY HOSPITAL

HOLY FAMILY HOSPITAL

ROOM AT THE INN: Dr Zoughbi (below) and staff go about their work at the Holy Family Hospital

‘Patients have only been able to contribute very little or nothing towards their care’

undergraduate degree, then worked to raise money for medical school in the USA, before qualifying and starting his training in New York state.

With many, it would have probably ended there, a successful immigrant sending remittances home but focused on his new life. But Dr Zoughbi came back in 2008 to compete his training and has remained ever since. It does not take long to find out why.

He has a profound sense of identification with Bethlehem, through his family and his faith, and a pride in his hospital, of which he says: ‘We strive to bring the latest advances in medicine and medical practice to our patients. Sometimes we have great challenges doing so mostly due to limited resources, but we compromise with a little bit of extra love and compassion through our work.’

Financial need To outsiders, the idea of having ‘Bethlehem’ as a place of birth on a passport may be rather more quirky than a district general hospital in

the Midlands. There used to be, in fact, a small number of mothers, often foreign residents, who travelled from Jerusalem and other places to give birth there.

Whether it was for practical or cultural reasons, or just a desire for a good anecdote, these were often among the only patients who paid full fees at the hospital and the revenue was important. The ‘separation wall’, a barrier built by the Israeli authorities which runs along the pre-1967 boundary as well as through parts of the West Bank, made such visits much more difficult.

This is only a tiny reason why the hospital is in considerable financial need. Much more profound is the effect of COVID on an economy which relies heavily on tourists and pilgrims.

Ambassador Bowe says: ‘Patients have only been able to contribute very little or nothing towards their care since March 2020.’ Services are always subsidised by at least half of the cost. Social workers then make an assessment

about how much further subsidy they need and can increase it up to 100 per cent.

‘This 100 per cent is now nearly the norm,’ she says. In an area where almost half of the population are refugees, and many are uninsured, the hospital is – pardon the pun – delivering. It also provides employment to 191 Palestinian families. And it runs outreach clinics to isolated villages for examinations, lab tests and screenings and can transport emergency cases to the hospital, a necessity given the day-to-day practical difficulties in travel.

Harmony at work Despite the constraints, the hospital is equipped to deal with not only routine births but is a specialist centre for the more complex. Almost a tenth of new-borns require neonatal intensive care.

‘The NICU has 18 beds and regularly saves babies as small as 500 grams and as early as 23 weeks,’ says Ambassador Bowe.

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HOLY FAMILY HOSPITAL HOLY FAMILY HOSPITAL

To her, and to Dr Zoughbi, both devout Christians, there is a divine element to the survival of vulnerable patients, and this is an overtly Christian institution. A crucifix hangs in the intensive care department and to Dr Zoughbi, ‘it is our pride and our source of inspiration and it fuels the love that we give to our patients, regardless of their faith’.

Dr Zoughbi acknowledges it is a very different environment from many hospitals in the West, where staff are not allowed to wear religious symbols. But there is a multiculturalism here, perhaps not quite in the way it is interpreted in Britain, but a multiplicity of cultures nonetheless, working together for a common cause.

Staff cover for each other’s religious holidays, and Dr Zoughbi cannot recall a single religious argument between patients or staff in his eight years at the hospital.

I was interested whether the Christian patients at the hospital ever wanted to time their births for Christmas. This

would be quite a contrast with just about any other society where Christmas is celebrated, where the vast majority of patients, expectant mothers included, would rather be a long way from hospital on 25 December.

Christmas every day The answer is complicated.

Ambassador Bowe says: ‘It is always Christmas in Bethlehem,’ which could be misconstrued as Disneyfied optimism but is simply a statement of fact – Christmas mass is celebrated every day in the Church of the Nativity, which is less than a mile from the hospital.

Plus there are three Christmas Days, one each for the Latin and Orthodox rites and another for the Armenians.

And one reason not to expect a surge in Christmas births is that she says many marriages in the region are followed quite quickly by a pregnancy, and it seems unlikely that conception would be timed deliberately for Christmas.

Bethlehem represents

different things to different people. For those whose closest association with this town is a carol, there is perhaps little more than a certain festive continuity.

For devout Christians, it is a place not only where they can take direct inspiration from the nativity, but in some ways make amends for the primitive conditions in which it was forced to occur.

For the parents, there may be a mixture of motives, but surely all would agree with the Bedouin women who were surveyed by the hospital as to why they travelled so far to give birth. Away from the villages where they themselves had been born, through checkpoints, to a large white building on a hillside marked with the symbols of a different faith to theirs. The answer wasn’t complicated. They simply wanted the best for their babies.

For more information, and to make donations to the hospital, visit: https:// holyfamilyhospitalbethlehem.org/

‘It fuels the love we give to our patients, regardless of their faith’

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ALAMY

COMPELLING: Lectures could be terrifying and yet possess ‘huge entertainment value’

At the circus – how medicine was taught 50 years ago Stephen Glascoe was at medical school in the ‘Life on Mars’ era.

Lectures were theatrical, students were often humiliated, and the patients little more than props

A

medical school in northern England.

1973: the whole of the fifth and final year are congregating in a venerable, oak-built lecture theatre.

Three medical students are about to be quizzed by a panel of distinguished consultants about three patients, who will be wheeled on to the stage on hospital gurneys. There they will lie, probably scared out of their wits, while the students, no less terrified, question them, prod them, and then expound to the assembled masses on what they have been able to elicit.

I am in the fifth year, a year still to go before I sit my final exams, but the spectre of finals already looms large; I must drink in every drop of knowledge now, lest I fall into

the death zone: the dreaded bottom 10 per cent of students who are failed each year. And I am there, like everyone else, because I know the ‘circus’ provides, over and above its huge entertainment value, an unbeatable venue for learning how to pass the clinical components of the final exams.

The student under interrogation begins to waffle, always a bad sign. Sir Arthur Robertson now takes centre stage. Better known as ‘Blackjack’, he has zero tolerance for waffling. He leaps to his feet and pushes the student aside. Like some sort of conjurer he produces several large, dangerous-looking needles from an inside pocket.

‘Watch carefully. I am going to place needles in this gentleman’s thighs.

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‘Is that all right, Sir?’ Without waiting for an answer Blackjack leans over the patient and thrusts a needle deep into each of the man’s upper thighs. He winces as the needles go in.

‘Did you feel that at all, Mr Jones?’

The man has gone pale.

‘Yes Sir.’ ‘Now, watch carefully.’

He then goes round to the foot of the gurney and plunges a needle into each of the man’s calves. This time he doesn’t even flinch.

‘And did that hurt, Mr Jones?’

With a triumphant grin, he replies: ‘No Sir!’ The patient is wheeled out of the lecture theatre to loud applause, the needles still sticking in him as if he has been undergoing acupuncture.

Ignorance is not bliss The second case is one of the most extraordinary I have ever seen. A woman in her mid50s is brought out sitting in a wheelchair, and the student is invited, not to examine her but to take a history.

He doesn’t get very far.

She is about to answer his first question but breaks down into uncontrollable sobbing. Tears run down her face. A moment later she is roaring with laughter, all but slapping her sides in manic glee. Then she is weeping again. The audience is stunned into silence.

‘Any thoughts gentlemen?’

There are about 40 women in the audience, though they are presumably designated honorary men for the day. One brave soul offers: ‘Hysteria, sir?’

‘Good guess, but no. Any other ideas?’

There aren’t any.

‘Pseudobulbar palsy, bma.org.uk/thedoctor

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gentlemen. And how do you treat it?’

The student thinks for a moment, then admits he doesn’t know.

‘You don’t know. I see.’

The audience holds its breath.

‘As it happens, neither does anyone else. Pseudobulbar palsy is untreatable.’

There is a collective sigh of relief. The reason for the reprieve? The student admitted his ignorance openly.

No waffling.

An eye for trouble And now the third case. An older man is brought in on a gurney who is clearly not well.

Even from the back of the theatre his jaundice is clearly visible. This man is cachectic, dying, probably of cancer.

But what kind?

To his immense relief, the student has been able to detect the patient’s grossly enlarged liver. Step forward Henry Bignall-Brown, known to everyone as ‘BB’. He is questioning the student on stage when he spots me whispering to my neighbour and calls me out.

‘You, boy, in the bright red sweater.’

‘Who, me sir?’

‘Yes, you sir.’

He hands me an ophthalmoscope.

‘Now boy, examine his eyes and tell us what you find.’

I take a look. The right eye looks fairly normal, though the other looks completely black.

‘The right looks normal to me, Sir, though the left may have suffered a vitreous haemorrhage.’

‘Really? Watch this.’

BB produces a silver pencil from his top pocket, goes over

to the patient and proceeds to stab him in the eye with it.

There is a loud clacking sound.

Slowly the truth dawns.

‘Show him, would you, Mr O’Flannery?’

Mr O’Flannery removes his glass eye and gives it to me. I then drop it and it rolls away across the floor. I run to retrieve it but fall over my own feet and land on the floor with a crash. The place erupts.

BB calls for silence and helps me to my feet.

He picks up the eyeball himself, polishes it with his handkerchief and returns it to the patient, who pops it back in place. Then he says: ‘Here’s one to remember, boys.

Beware the glass eye and the big liver. Glass eye and big liver, eh? Now, I have to go. I have a post-mortem to attend, and my dog is getting puckish.’

With that he sweeps off the stage leaving me standing there. I am greeted with a thunderous round of applause, to which I can only bow. What did BB mean by his enigmatic remarks? It would be years before we figured it out…

GLASCOE: ‘Patients scared out of their wits, students no less terrified’

‘The student under interrogation begins to waffle, always a bad sign’

‘Without waiting for an answer Blackjack leans over the patient and thrusts a needle deep into each of the man’s upper thighs’

Stephen Glascoe is a retired GP from Cardiff. Some names have been changed thedoctor | December 2021 15

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CHARLIE BIRCHMORE

Public health has never had a more important role and yet, in England, it was put through a distracting restructure in the middle of the pandemic, and has suffered years of cuts. Faculty of Public Health president Maggie Rae tells Tim Tonkin how the specialty can and must have influence

RAE: ‘The big task of public health professionals will be to get their voices heard, be in positions of influence and power, and speak up for the health of the population’

BEING HEARD ‘S

ometimes people only see public health when there is a crisis,’ says FPH (Faculty of Public Health) president Maggie Rae. ‘They only see the chief medical officers when there’s a crisis, so [since COVID] I think everyone in the world has probably got a better idea about public health professionals and what they do.’

A greater awareness and understanding of the role of public health is one of the legacies of the pandemic that may affect Professor Rae’s specialty, although she is clear that is far from being the only or most significant one.

During her career she has occupied roles at almost all levels of the health economy including positions at PHE (Public Health England), Health Education England and twice serving as a director of public health.

Professor Rae also worked at the Department of Health where she led on health inequalities, an issue that is a driving force in her career and which she says has been thrown into sharp relief by the pandemic.

‘As a public health specialist, you serve the population you’re responsible for,’ says Professor Rae. ‘I think my public health practice is really driven by health inequalities and always has been. My grounding has always been how can we reduce health inequalities in this country, where there’s plenty to do, but also across the world.

‘What COVID-19 has demonstrated, which we knew already, is we [the UK] have massive health inequalities; it has also raised the profile of the ethnic minority community and, I think, shone a light on racism.’

Badly-timed restructure Public health professionals nationally, regionally and locally played a critical role, particularly during the early phases of the pandemic last year. 2020 also brought about a huge upheaval for the specialty following the unexpected announcement by the Government that PHE was to be overhauled.

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been cut by 24 per cent in the past six years.

This restructure, coming at a time when health The BMA and others have called on the professionals were already stretched to breaking point Government to reverse years of cuts to public health and facing spiralling levels of stress and burnout, left services by committing to a £1bn increase in the public many questioning the timing and motivation of the Government’s decision, as well as what would come next. health budget.

This recommendation ultimately went unrecognised Last month finally saw the transfer of all PHE health by chancellor Rishi Sunak in his 27 October autumn protection functions to the UKHSA (UK Health Security Agency) while the health improvement and public health budget and spending review, which disappointingly saw work of PHE transferred to the new no additional investment into the public Office for Health Improvement and health grant being announced.

‘Trying to restructure Disparities, NHS Digital, NHS England To Professor Rae, the failure by in the middle of a and NHS Improvement.

Government to invest adequately in The BMA already had concerns public health is a frustratingly obvious pandemic – I don’t about PHE’s ability to challenge the false economy. think anyone Government about individual public ‘If you compare and contrast to what thought that was health specialists’ ability to speak out. we spent on test and trace the public a good idea’ It has even greater concerns about health budget is a very minor amount, whether these successor organisations but public health interventions are very will be sufficiently independent. inexpensive and very cost effective,’ The association has also questioned whether the says Professor Rae. decision to separate former PHE responsibilities, such as ‘I think one of our problems is the Government does health protection, health improvement and healthcare not seem to want to fund local government. The reality public health, risks fragmenting the delivery of these is unless we improve the funding then there won’t be services. levelling up in terms of people’s health.’

While Professor Rae believes it’s still too early to judge Workforce stress whether public health doctors and specialists staffing As well as outlining the actions needed to reduce these new bodies will be able to speak truth to power, inequalities and improve services for patients, she recognises these areas of concern around the Professor Rae is acutely aware of the mental strain reorganisation of public health. and disillusionment felt by many of those working in ‘Trying to restructure in the middle of a pandemic – public health.

I don’t think anyone thought that was a good idea,’ The FPH is set to publish its survey on the wellbeing of she says. staff in the public health workforce, and ‘Public health is probably the what steps it believes employers should most reorganised of all the medical take to support doctors. This is likely to specialties and that does have its ‘We need to ensure reinforce the findings of the BMA’s own consequences. We did not vote for the the effects of the survey of an exhausted workforce with disestablishment of PHE, we have run pandemic on public low morale which doesn’t believe it is health-protection agencies separate being listened to. from the rest of public health before health staff are Dr Rae believes that listening to the and the conclusion was that that didn’t recognised’ workforce and ensuring that public work terribly well. We need to join up health doctors have a prominent voice public health and be sure that we’ve got in future plans for the NHS such as the the services necessary to improve the Health and Care Bill, are crucial. public’s health without silos.

‘What we have to do is get the acknowledgement ‘The big task of public health professionals will be to of the support needed for those public health get their voices heard, be in positions of influence and professionals,’ she says. ‘You need resilience in public power and speak up for the health of the population.’ health, but we also need to ensure the effects of the pandemic on public health staff are recognised.

Reverse the cuts ‘We want the role of public health to be recognised While increased investment in public health is another [in the bill] nationally, regionally and locally [and] I think critical factor in addressing the social and health organisations that are trying to embrace population inequalities so markedly exposed by the pandemic, health realise that some of the great skill sets actually sit funding given to local authorities in England for running with public health professionals.’ public health services such as smoking cessation has bma.org.uk/thedoctor

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thedoctor | December 2021 17

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RAY MCCRUDDEN

AT WORK: A wide range of issues affecting doctors’ day-to-day lives are discussed at BMA council

Vote, represent, lead Elections to BMA council give doctors the chance to represent their colleagues and help drive positive change. Jennifer Trueland reports

NOMINATIONS

N

ominations open in January for the newlook BMA UK council – and you could be part of it.

UK council is the principal executive committee of the BMA, setting the strategic direction of the organisation in line with policy decided by the representative body. It is responsible for formulation and implementation of policy throughout the year between annual representative meetings.

Following a review of the way council members are elected, the BMA’s RB agreed at this year’s ARM to make changes to ensure members are better represented.

The review, conducted by the organisation committee, was held in response to feedback from members, and from election scrutineers, who indicated the system was overly complex and confusing.

This resulted in a high number

of spoilt or incomplete ballots.

The new system increases the number of voting members from 55 to 69 (to include 40 geographical and 24 branch of practice seats, and five for people who self-identify as Black, Asian or minority ethnic).

The process for ex-officio (non-voting) members remains the same (these include senior officers of the BMA and chairs of committees and national councils).

Diversity reform Under the new system, there will be one single ballot paper, and members will have the opportunity to opt out of being elected to a geographical or branch of practice seat.

Branch of practice seats will be allocated first, which means local representatives will have a better chance when they are up against colleagues with a high national profile.

The new model also ensures

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RAY MCCRUDDEN MATT SAYWELL

a better gender balance – increasing the chances that women will be elected and improving representation.

In constituencies that elect three members, no more than two can be of the same gender, while in five-seat constituencies, no more than three can be of the same gender.

Specific seats for doctors from Black, Asian or minority ethnic groups should also help to improve diversity. Again, no more than three out of five should be of the same gender.

Under the new system, regions have been given an additional seat, as have junior doctors. Medical students will be elected for just two years (with an additional mid-term election only for medical students).

As a former chair of RB and of Scottish council, Peter Bennie had attended UK council for many years.

But when the last elections came along, he decided to stand – and is coming to the end of his four-year term as an elected member.

‘I would definitely encourage members to stand, and I would encourage everyone who is eligible to vote,’ says Dr Bennie, who has now retired as a consultant psychiatrist in Greater Glasgow, and who is a medical member of Scotland’s Mental Health Tribunal.

‘The BMA can seem quite a complex organisation, with a lot of different committees running different things.

But the council is the ruling bma.org.uk/thedoctor

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body – it’s the principal executive committee of the union, so that’s where the main influence over the BMA’s approach on the major issues of the day is. If you’re a member, particularly if you’re a voting member of BMA council, you’ve got a direct influence on issues such as Brexit, the NHS reforms (particularly in England), immigration, health and wellbeing of staff.’

Have your say Members of council also have a significant influence over the internal workings of the BMA and its work, he adds. In the last few years, this has included the decision to change the make-up of council to ensure greater diversity, and has also given members a say in the BMA’s work around major ethical issues, such as the survey of members’ views on the position the organisation should take over assisted dying.

‘Obviously the detailed work on that was done in the ethics committee, but the decisions on when and how to run that survey were taken at council level, and the follow on was allowing the ARM to arrive at a policy decision, which it did in autumn.’

COVID-19 ‘wasn’t on the radar’ when the last BMA council elections were held, but has dominated its work since March 2020.

‘The regular surveys of the membership were really useful in helping us make decisions on what to say about issues from supply of

personal protective equipment to use of face masks,’ says Dr Bennie. ‘The council was taking decisions, not just at its meetings every two months, but frequently between meetings too. It did mean a lot of extra work, but I think everyone contributing to that was conscious of how important it was.’

Sitting on council also gives tremendous insight into the work of health services across the UK, he says, adding that it’s a great opportunity for members from devolved nations to share what is happening with their colleagues in other nations.

But that’s not all. ‘It’s a great privilege to represent your colleagues and being able, as much as you can, to influence what the association does on behalf of doctors. It’s a very worthwhile thing to do.’

BENNIE: ‘I would definitely encourage members to stand’

‘You’ve got a direct influence on issues’

‘It’s a great privilege to represent your colleagues’

bma.org.uk/councilelections thedoctor | December 2021 19

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on the ground 20

GETTY

Highlighting practical help given to BMA members in difficulty

A junior doctor’s career hung in the balance when the BMA secured him one last attempt at a medical royal college exam Failing postgraduate exams happens often enough, but it can be expensive, timeconsuming and disrupt careers. Most doctors get there in the end.

One junior doctor was in a desperately frustrating position, with his career hanging in the balance.

He had passed all but one of the components of his final medical royal college examination, but he had failed a short-answer question paper four times, the maximum permitted number.

So close to becoming a consultant, it looked like he would fall just short.

But there was one highly significant factor that even the doctor himself didn’t know – he was dyslexic. He only found this out after his fourth attempt when he was assessed by an educational psychologist.

It is remarkable, and impressive, that he had reached such an advanced stage in his training, and passed countless tests and exams despite being dyslexic.

He appealed on this basis, and was given another chance, but in the run-up, a close relative died and his mother was ill – and he failed by two points.

This is where the BMA got involved.

Working with the law firm Gateley, the

employment adviser suggested to the doctor he try an early conciliation claim with ACAS, on the basis of disability discrimination.

This is where ACAS speaks to the claimant and respondent in a dispute and gives the chance to reach an agreement without having to go to an employment tribunal.

It was perhaps the prospect of this which convinced the medical royal college to give the doctor one last chance, on the basis he made no further requests for additional attempts in relation to his disability claim. And he passed. The doctor is now a consultant.

The doctor said: ‘My wife and I really want to thank you for your help and invaluable assistance during the harrowing legal battle.

‘It feels like a dream but I am thankful to God for His mercies and using you guys to support me and my wife those difficult times.’

Without BMA support, it’s unlikely the college would have granted an extra attempt, and the doctor would never have achieved his dream of becoming a consultant.

To talk to an adviser about work-related issues, call 0300 123 1233 or email support@bma.org.uk

thedoctor | December 2021

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it happened to me

GETTY

Doctors’ experiences in their working lives

Christmas on the wards In the December of my first year as a doctor, there was one question from patients that filled me with dread and frustration.

It did not matter whether it was asked by the sweetest or the most cantankerous patient.

‘Will I be going home for Christmas?’

How could such a simple question generate so much guilt? For those I had to tell they were staying, I hated seeing the hope drain from their eyes. No amount of mince pies or forced jollity in Christmas jumpers could make up for that.

Every single time I had to puncture someone’s hopes, I said sorry. But I’ve often wondered exactly what I was saying sorry for.

Perhaps it was the guilt when I had, against all odds, managed to secure some days off over Christmas for myself. That guilt extended equally to my colleagues left behind.

Perhaps it was the knowledge that, on the care of older people on the ward, there were plenty of patients who were medically fit to go home, but their family circumstances and the pressures on the social care system meant they couldn’t have a good and safe Christmas if they went there.

That ‘sorry’ was the best I could do for them. A word sometimes shunned for fear of litigation, a word we sometimes hear on the evening news when it can have

huge significance following some kind of catastrophe. But this was a different kind of sorry. It is one of the small but essential ones which junior doctors often find themselves handing out.

There is the sorry for the delay in seeing a senior doctor. A sorry for the patient left in pain because there are not enough nurses to give breakthrough analgesia in a timely fashion.

A sorry for the food, for the ambient temperature, for the incessant beeping of the drip stand that finished its bag of fluid two hours previously, but no one had got around to turning the machine off yet.

I know I shouldn’t say sorry so much. I definitely shouldn’t be apologising for Christmas.

And I should not have this constant feeling of guilt and shame about the health service I love and work for.

But with intense pressures on the system, exacerbated by winter, it is that constant stream of quiet apologies which are trying to resolve the huge gulf between the health service we have, and the one we would want for our patients.

Until it gets better, I will just have to carry on saying sorry.

Joe Sharpe is an F3 in ambulatory care in Greater Manchester thedoctor | December 2021

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viewpoint

RICHARD AND STEPHEN MEJZNER

One December morning, more than 40 years ago, a consultant’s kindness to an exhausted junior doctor provided an example to be followed for life

MEJZNER: Care extended beyond workplace

A lesson in compassion ‘Dr Mejzner sent me to deliver these to you.’

It was my fellow senior house officer Tom at the door.

It was 1978, four months into my new SHO job at St George’s Hospital, Lincoln. I had arrived from India only a year earlier with Hema, my wife, and we were still trying to adapt to an unfamiliar country, health service and weather.

I was working one-in-two on call, leaving only alternative nights with my family. Those nights I spent studying for the MRCP, unless Hema had mercifully hidden my books, or my two-year-old son had used them for scribbling (better that than his other pastime of putting butter blocks on radiators).

Dr Mejzner was a pleasure. I learned much more than medicine from him. He once invited me to dinner at his house. We didn’t have a car. He said public transport would be uncomfortable for Hema, who was pregnant, and he picked us up from our flat in his car.

In mid-December of that year, on a night of treacherous snow, Hema came home with our new baby, Smitha. With the worst timing, I came home from a heavy day’s work with the flu. We had very little food in the house.

The following morning, I called in sick. The first thing he did was to enquire about the health of mother and baby. The second thing he did was tell me not to worry. These were natural acts

for him, but perhaps evaded some others.

I’ve experienced and witnessed racism and intimidation. I’ve seen consultants express visible irritation when junior doctors phone in sick, their focus being on where they would find a locum rather than their colleague’s health.

I’ve even seen a consultant’s displeasure when hearing that the new SHO due to start on our firm would be taking maternity leave.

I can understand how even a minimal disruption to our pressured and precariously staffed departments can herald a crisis. But I wonder if we have become depersonalised and disconnected. Dr Mejzner was under pressure, we all were, and yet his compassion extended even beyond the workplace. I’ll always remember him.

Tom, at the door with a loaf of bread and a litre of milk, said: ‘And he asked me to do any shopping you might need.’

It’s one of the kindest and most thoughtful gifts I have ever received.

Radhamanohar Macherla, now retired, was for more than 20 years a consultant physician with Barts Health NHS Trust.

Stephan Mejzner, 1921-2002, was a consultant geriatrician at the then St George’s Hospital in Lincoln. We are grateful to his family for the picture they supplied

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06/12/2021 09:08

Your BMA The BMA is committed to fighting the greatest challenge of our times: climate change and together we can make a difference @drlatifapatel The festive period leading into the new year is a time of reflection for many people.

I’ve been considering my carbon footprint ahead of another seasonal period which can often mean food flown in from around the world and mountains of plastic presents you don’t necessarily need.

It is something that has been on my mind for some time – in the health service we are party to an overwhelming reliance on single-use plastics and during the pandemic I’ve felt particularly concerned about the seemingly-endless stream of PPE (personal protective equipment) we’ve worn for sometimes just a matter of seconds or minutes before casting into the bin.

I’ve also had experiences in the NHS which have highlighted the problems we face – such as trying to arrange a recycling bin for the doctors’ mess, only to be told the hospital’s PFI contract would mean I couldn’t do so. Sometimes my effect, and the effect of the health service, on climate change feels overwhelming.

The events of the UN COP26 conference in Glasgow have really sharpened my focus on this issue and I wanted to share with you what your BMA is doing to ensure we, as a profession, and as a trade union and professional association, are at the heart of progress in this area – and also appeal for your help to do more. I am, as ever, desperately keen for our members, from all parts of the profession and all areas of the country, to contribute directly to the work we do. We have some 163,000 members in this organisation and we can do great things if we work together.

The BMA has been actively lobbying on climate change for some time and we are a member organisation of the UK Health Alliance on Climate Change. The BMA is joined in the alliance by almost all of the medical royal colleges, the BMJ and The Lancet as well as a number of others. Together, the membership is some 900,000 including the vast majority of the NHS workforce. Did you know, that as BMA members, that includes you?

The alliance campaigns to mitigate the effects of

climate change – by far the major threat to global health – and emphasise the benefits to health that would follow from decarbonising our economy. There are also direct physical risks to the NHS itself too, with almost 10 per cent of the UK’s hospitals at risk of floods.

The alliance is campaigning on the Environment Bill, air pollution, the national food strategy, and a wide variety of other issues. We health professionals know that climate change is a major threat to health and many of us are seeing the effects in our patients – from air pollution, extreme heat, floods, and anxiety over the seriousness of our predicament. As a paediatric respiratory junior doctor I have certainly seen these first-hand.

Your BMA is also doing a lot of work independently around these issues. We know we have a great deal of challenges to address internally in the organisation, and in our work externally. We worked with leading health organisations and medical bodies to emphasise the need for a health focus at the COP26. We joined more than 450 organisations in signing an open letter to government leaders and national delegations ahead of the event, warning that the climate crisis is the single biggest health threat facing humanity and calling on world leaders to deliver climate action.

We have also lobbied the UK Government to introduce a legally binding commitment to reduce fine particulate air pollution (PM 2.5) across the country.

There is always room to do more though and on an issue of such monumental importance we cannot afford any complacency. I would particularly like every one of you with a passion for these issues, experiences of these problems or solutions for the future to come forward to help drive and shape our work.

If you have any stories to share or feel you could contribute to the debate and our work as an association please contact me via email at rbchair@bma.org.uk Dr Latifa Patel is interim chair of the BMA representative body thedoctor | December 2021 23

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NOTICE OF ELECTIONS TO BMA COUNCIL 2022

NOMINATIONS

thedoctor

Nominations will open on 10 January 2022 for the election of voting members of the UK council of the British Medical Association to serve for a four-year term of office for the sessions 2022-23, 2023-24, 2024-25, and 202526. The sessions normally run from June to June. BMA council is the principal executive committee of the BMA as a trade union. Further details on the activities of council are available from the BMA website https://www. bma.org.uk/what-we-do/ uk-national-and-regionalcouncils/uk-and-national/ uk-council

Candidates must be current members of the BMA and nominations must be made via the BMA website and will open on 10 January 2022. The closing date for nominations is 4pm on 14 February 2022. Candidates must ensure they read the document ‘Information for Candidates’ before completing their nomination form. This will be available on the BMA website at bma.org.uk/ councilelections along with a summary of the election process.

Further information on the electoral rules is contained in the BMA’s articles and byelaws. The full articles and bye-laws can be found at https://www.bma.org.uk/ media/4735/bma-articles-and-byelaws-2021-22-nov21.pdf A candidate’s electoral zone will be determined by their preferred contact address on the BMA’s register of members at the time when nominations in this election open (which is Monday 10 January 2022). A candidate’s primary branch of medical practice will be used for the purposes of the election and this will be determined by that category of medical work in which, at the time when nominations in this election open, they spend the majority of their remunerated medical time (except for medical students and retired members). Candidates will self-identify for the ethnic minority seats.

Gender constraints will also be applied to the election. If you think that your entry in our membership records may be

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

incorrect, please contact the membership records department on 020 7383 6234 or email membership@bma.org.uk to ensure that you are properly listed.

Nominations close at 4pm on Monday 14 February 2022. Ballot papers will be posted to voting members the week commencing Monday 14 March 2022.

Successful candidates will be expected to attend an induction session which will take place on 12 July 2022. Council meetings will normally be held virtually or at BMA House commencing at 10am unless otherwise indicated. Dates for the 2022-23 session are below: – Thursday 30 June 2022, time tbc (Chair election at ARM) – Tuesday 12 July 2022 (Council induction) – Wednesday 13 July 2022 – Wednesday 14 September 2022 – Wednesday 16 November 2022 – Wednesday 25 January 2023 – Wednesday 15 March 2023 – Wednesday 17 May 2023 Should you require any additional information please contact Sally-Ann Cole, senior governance and committee manager on scole@bma.org.uk Tom Grinyer Returning officer/Chief executive Independent scrutineer: Civica Election Services

Editor: Neil Hallows (020) 7383 6321 Chief sub-editor: Chris Patterson

Email thedoctor@bma.org.uk Call a BMA adviser 0300 123 1233 @TheDrMagazine @theBMA

Senior staff writer: Peter Blackburn (020) 7874 7398 Staff writer: Tim Tonkin (020) 7383 6753 Scotland correspondent: Jennifer Trueland

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.

Feature writer: Seren Boyd Senior production editor: Lisa Bott-Hansson Design: BMA creative services Cover photograph: Holy Family Hospital Read more from The Doctor online at bma.org.uk/thedoctor

The Doctor is a supplement of The BMJ. Vol: 375 issue no: 8318 ISSN 2631-6412

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