The Doctor – issue 61, November 2023 by The BMA

The magazine for BMA members

thedoctor

Issue 61

November 2023

Deprivation, inspiration Life as an inner-city GP

The right call

How ethics advisers help with day-to-day dilemmas

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Skin deep

Tackling bias in medical education

A good ending

Making palliative care more accessible

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JESS HURD

In this issue 3

Battling prejudice New guidance to support disabled doctors

4-7 Deprivation, inspiration

The GPs working to improve inner-city healthcare

8-11 The right call Vital, behind-the-scenes work by the BMA ethics department

12-15 All’s well that ends well Palliative care – a lack of access and awareness

16-19 Lives cut short A new strategy to reduce suicide

20-21 Skin deep Why medical education needs to reﬂect better British society

22-23 Your BMA The need to respect each other’s views

thedoctor | November 2023

Welcome Phil Banfield, BMA council chair For regular readers, it will not be a surprise to you that The Doctor magazine is a finalist for this year’s prestigious British Journalism Awards in the specialist journalism category. The nomination comes for the work looking at the effects of austerity and the cost-of-living crisis on health and communities and a series of investigations – called ‘Paucity of Esteem’ – which has shone a light on deficiencies in the provision of mental healthcare in the UK. It follows a series of other awards commendations this year, with the magazine regularly recognised amongst national newspapers, websites and broadcasters. I’m constantly reminded of the talent we can unleash – staff and members – to support and advocate for doctors and patients so powerfully. While secondary-care branches of practice beaver away to restore pay behind the scenes, in this edition of the magazine we spend time on the front line of general practice in one of the most deprived communities in the UK. In a corner of Edinburgh we find a community whose health is being deeply affected by austerity politics, the cost-of-living crisis and the fall-out from the COVID-19 pandemic. We witness a workforce being pushed to breaking point and a wider health system failing patients owing to years of chronic and systemic underfunding and mismanagement. Also in The Doctor we hear about the links between economic crises and suicide, the BMA’s prescription for action on the issue and speak to the Government adviser who has helped to draw up a national plan of action. We report on racial bias in medicine and speak to a medical student who is trying to rectify this bias. As Naabil Khan says: ‘Everyone deserves to be treated with the same level of competence and respect by the medical profession … People of colour are not “different”: everyone has their place in society.’ Also in the November issue we speak to doctors about prejudice and discrimination in the workplace as the UK celebrates Disability History Month and the BMA publishes new guidance to support staff and promote more inclusive working environments. Together with a piece on the phenomenal work of the BMA ethics department and medical ethics committee, we are reminded the BMA is much more than a trade union – it is unique. It is your BMA. Keep in touch with the BMA online at twitter.com/TheBMA

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AT A GLANCE

Battling prejudice CORRIGAN: Told to ‘reconsider’ her future in medicine, as a disabled doctor

‘Patients and colleagues don’t expect doctors to be sick; you’re supposed to be well, you’re supposed to be the one that is able to make things better.’ Emergency medicine specialty doctor, BMA equality advisory committee member and MS patient Clodagh Corrigan knows only too well the prejudice and discrimination disabled doctors and other healthcare professionals face in the NHS. It was almost a decade ago when, as a recently qualified doctor and new mum, Dr Corrigan had returned to work following a course of treatment to begin her latest rotation, where she was more or less told by her new line manager to quit her career. ‘I was told that “you can’t be a doctor, a mummy and a patient” and that I should “reconsider” my career,’ explains Dr Corrigan. ‘I know I can bring a lot to the table [as a doctor], and just because my legs don’t work, doesn’t mean I can’t still do good for my patients and make a difference to somebody.’ Sadly, Dr Corrigan’s experiences as a doctor with a debilitating medical condition, which range from the unempathetic to the outright ignorant, are likely to be familiar to many disabled staff working in the health service. Findings from the BMA’s 2020 Disability in the medical profession study reveal, of the disabled doctors and medical students responding to the survey, 23 per cent had not shared their status with their employer or school. Seventy-seven per cent meanwhile say they feared unfavourable treatment had they decided to be open about their disability or health condition. While its provisions do not apply to all parts of the bma.org.uk/thedoctor

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UK, the Equality Act 2010 states that disclosing a disability or medical condition to an employer is at the discretion of the individual. Despite disclosure offering a degree of legal protection, many disabled medical professionals feel compelled to keep silent, meaning that many are left feeling increasingly isolated and invisible in the workplace. UK Disability History Month runs from 16 November to 16 December, with the BMA using the occasion to publish new guidance aimed at supporting disabled doctors and offering practical advice to employers, with the view of promoting more inclusive working environments in the NHS. The guidance covers issues ranging from a manager’s responsibilities when a member of staff discloses a disability or health condition, to advising on how to create an environment in the workplace which normalises regular discussions about staff support needs. Dr Corrigan says she hopes the guidance, along with the BMA’s existing commitment to widening support and ensuring that workplace disability champions are mandated across all parts of the health service, will serve to broaden the conversation and raise awareness of the realities faced by disabled staff. ‘There certainly needs to be much more awareness that disabled medical students exist, disabled doctors exist, and they have a role,’ she says. ‘[By being more visible] we let patients know it is OK if your doctor, physio or nurse has a disability.’ By Tim Tonkin To read the BMA guidance and for more information on employment advice or wellbeing support from the BMA, visit bma.org.uk/yourwellbeing thedoctor | November 2023

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DEPRIVATION MEETS INSPIRATION

ora Murray-Cavanagh is scrolling through a morning’s worth of booked GP appointments. A daunting list – swiftly surpassing safe daily working limits even before any spare, scrabbled moments for lunch – is colour coded by urgency and stretches down the computer screen, never-ending. This isn’t the Mondaymorning madness GPs across the country have become accustomed to – and the worst of winter is likely weeks and weeks away. It is an autumnal Tuesday and, perhaps even more worryingly, the daunting length of the list is matched by the desperate need of most of those waiting for help. 04

MURRAY-CAVANAGH: Facing intense challenges

In the space of just a couple of hours Dr MurrayCavanagh is required to help a patient with severe breathing difficulties, another with a suspected heart attack, a complex pregnant urology patient, conduct reviews of cases other staff need support with, and handle a serious child-protection issue. It feels like each of these patients needs half a day with someone who cares and can make the system work for them – not just 10 minutes with a GP. The state of the system in which doctors work in Scotland, just like much of the UK, is illustrated starkly when the ambulance service tells the suspected heartattack patient there is no

‘This whole narrative that people choose between heating and eating – that’s rubbish. They can’t heat. And they can’t eat’

category-1 response available and to get a bus to hospital. This might seem troubling enough in affluent areas but this is a community in which patients often cannot afford the two-bus trip to the nearest hospital, and even if they could their chaotic lifestyles or, frankly, more pressing worries such as seeing the day through with a roof over their heads can get in the way.

Intense work In this part of Edinburgh, as with many other deprived areas, health isn’t a separate issue to employment, education and housing like many people can afford to make it. Here, Dr MurrayCavanagh’s interactions are

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In Scotland, 100 ‘Deep End’ surgeries focus resources on the most socio-economically deprived populations in a bid to redress the inverse care law. In the first of a two-part series Peter Blackburn reports from the front line of the Deep End – this time shadowing a GP and her colleagues in Edinburgh amid a cost-of-living crisis, the fall-out of the COVID-19 pandemic and the deepening impact of austerity politics and health inequalities dominated by the wider social determinants of health. It isn’t just bus fares either. During this morning’s consultations, patients’ health is blighted by insecure and inflexible social housing and some of those who do have a roof over their heads are being made unhealthy by the conditions they are forced to live in. ‘I think you have to not be afraid of the dark to work here,’ Dr Murray-Cavanagh says, reflecting on the intensity of each day and the needs of the community she works in. ‘And there’s not a single day where we can say “phew there is an appointment left”.’ Earlier this year, Deep End practices published a series of stories from the

front line – outlining the effect of the cost-of-living crisis on patients’ lives. Each was a shameful stain on a country which can afford to do things so differently. They tell of parents skipping meals so their children can eat but who still feel like they are failing, housing without basic washing facilities, people with diabetes swirling out of control and unable to eat nutritious food owing to relying on food-bank basics, lives blighted by panic attacks, two-year waiting lists for vital trauma psychotherapy and an overwhelming sense of hopelessness. One patient wrote: ‘It is not just the lack of heating, hot water or food that is the issue,

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TOUGH DAY AHEAD: Dr MurrayCavanagh speaks with a member of staff at the Wester Hailes Medical Practice, and social housing in the surrounding area

it is the impact of these things that has a huge negative effect on my ability to keep myself and my partner healthy, both physically and mentally. To provide regular washing facilities, decent food for preparing meals and to be able to plan our lives. The lack of being able to plan is very unsettling … Living without care for our welfare is a role that we can very easily slip back into and this could easily lead us back to chaotic and unhealthy lifestyles.’ ‘This whole narrative that people choose between heating and eating – that’s rubbish,’ Dr Murray-Cavanagh says. ‘They can’t heat. And they can’t eat. It’s a whole different slice of life here.’ She adds: ‘I could be thedoctor | November 2023

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saying to a patient “we need to address your blood-sugar control because if your kidneys, your brain and your heart are bathing in syrup for years that’s going to put you at risk of chronic kidney disease, heart attacks and stroke” – but they can’t prioritise it. Other things are more pressing. Going to a hospital clinic doesn’t happen. Change doesn’t happen.’ Dr Murray-Cavanagh – a daughter to educational activist parents from Northern Ireland who worked as the bombs went off – first became involved with inclusion health through a first-year project as a medical student with a homeless GP practice and later worked as a GP in the Scottish prison service before meeting a GP from the Deep End and then becoming involved a decade ago. Eventually she landed at the Wester Hailes Medical Practice.

Passion and motivation The Wester Hailes Medical Practice of 2023 is in an impressive, new building, 06

which sits next to the Wester Hailes train station and at one end of the community’s main central area – the Westside Plaza shopping centre and community buildings such as the library and job centre which gather around it. There is an almost brutalist imposition to the concrete structures which are overshadowed by fading and peeling tower blocks, but a very real buzz of life and a reassuring lack of boarded-up windows or empty buildings. Just across the plaza, the previous practice building – a grim-looking grey shell – is the one obviously unused property and staff are understandably thankful for its place in their past rather than present or future. Here, patients have about as good a chance of being seen when they need and hope to be seen as anywhere in the country. They will generally receive a call from a clinician on the day and then be invited to come into the practice if required or helpful. It is a system which, like any other,

AT WORK: Dr Murray-Cavanagh in her practice

‘It’s a whole different slice of life here’

cannot outsmart ultimate capacity limits but provides the best hope for this patient population whose lives can be chaotic and who need people to reach out to them rather than place obstacles in their paths. It is ‘constant fire fighting’ but even with the horrendous difficulties of recruitment and retention of staff they make it work. ‘The people who want to work here, by nature of working here, are really interesting and good people,’ Dr MurrayCavanagh says of the practice which is run by the local health board and employs only salaried GPs. ‘People are smart, passionate and innovative around things that aren’t good enough and ask what we can do to change it. That really appeals to me.’ It may be the case that some of the goodwill that has been lost in many parts of the NHS through staff being worked to breaking point in horrendous conditions survives here, because the staff clearly feel empowered – or at least not totally stifled – by their working arrangements and inspired by the needs of their community. On the day The Doctor visits, staff from the practice and the local hospital have joined together – very much asking ‘for forgiveness not permission’ and have launched a community diabetes outreach clinic. The enthusiasm is palpable and a group of complex patients who find health services aloof and tough to trust have been given access to consultant, GP and nursing care where they live. It could be transformative. Dr MurrayCavanagh and colleagues also run a similar scheme

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in paediatrics, which deals with a range of health issues including neurodiversity and has a CAMHS nurse attending their multi-disciplinary team meeting. The practice hopes to start an adult psychiatric outreach clinic next year. Each seeks to overcome the problems the health system has internally and for patients by bringing together, figuratively and literally, people who care. For all the positives on show at Wester Hailes, the difficulties of looking after the most deprived communities in 2023 cannot be hidden. Last year, Deep End GPs from across Scotland – alongside charities and community organisations – met, in a round-table meeting, to discuss the challenges of the cost-of-living crisis and how general practice can support patients experiencing financial hardship, with the link between poverty and poor health and widening health inequalities well established. Participants covered fuel poverty, inadequate housing, food insecurity and access to health and care services amid rising transport costs – discussing how to build teams and community hubs to challenge all these issues. But those present at the meeting also noted the effect working in these environments – with ever-increasing workloads amid so much trauma and suffering – was having on staff, and agreed morale was ‘as low as it has ever been’. It isn’t hard to see why. After just a couple of hours hearing about patients’ lives and the work of doctors and other healthcare staff in Edinburgh, it is easy to feel overwhelmed

by the sheer amount of need in communities, and just how far the structures and supports of whatever is left of the British welfare state are from meeting those basic human dignities. Dr Murray-Cavanagh takes a break to check if I’m OK. We ‘must look after’ ourselves and try to keep perspective because society needs storytellers to outline the case for change and to be able to continue to do so through thick and thin, she says, just as it needs the doctors and other healthcare staff here. Dr Murray-Cavanagh prescribes a moment of reflection at the end of every day to think of three things we are grateful for. If only GPs such as her, and the rest of the workforce, had someone who cared so much about whether they are being overwhelmed by what they are seeing.

Social housing in south-west Edinburgh

Retention problems To an outsider witnessing this inspirational, crucial, work on the front line, the effect of trying to care in such desolation and chaos has on the workforce is nearly as troubling as the trauma communities are living through. Together these tragedies ring an existential alarm bell for the NHS and society. Where will these people be if even the carers are no longer there? Dr Murray-Cavanagh says: ‘It’s worse now than it ever has been – and that’s because retention of staff is such an issue. You should have a full-time GP for every 1,200 patients at the Deep End and that should be in the high 50s or 60 sessions a week, roughly, for our population. We’re sitting at about 40 and

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‘Staff are smart, passionate and innovative around things that aren’t good enough’

will be closer to 30 by Easter 2024 as we lose another whole time equivalent GP. It’s a leaky bucket and that is not sustainable.’ Reflecting on whether the stored-up burden of this difficult job is a worry for the longevity of her career, Dr Murray-Cavanagh, seemingly asking herself the rhetorical question, says: ‘I’m 42 – and this job is probably for another 20 years. And I’ve been doing it for 10 years…’ But she continues: ‘Fundamentally, I believe that we are a smart country and a compassionate country and there are enough smart people to engage the political change that is required. I have to believe that.’ One day in Dr MurrayCavanagh’s practice is plenty to see the scale of the problems society faces and the reasons for hope. It is also ample evidence that investing in the NHS workforce is the right thing to do. In the second part of this series, to be published next month, Peter Blackburn will report from a Deep End GP practice in Glasgow . Images by Douglas Robertson thedoctor | November 2023

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The BMA medical ethics and human rights department is respected as a source of guidance for doctors but is less well known for its work in preventing damaging new laws and rulings from coming to pass. Jennifer Trueland reports

t’s a medical truism that prevention is better than a ‘One of the things I’m fond of saying is that good cure – and this can also be the case when it comes organisation work is a bit like effective marital to policy or legislation. Yet although there are clear therapy – you never know the arguments you didn’t benefits in preventing bad laws being enacted, or have,’ says Dr Wise. ‘So the real value of what the harmful policy being implemented, it’s often much medical ethics committee does isn’t just producing less visible than putting a stop to something when it the policy papers on how to do things; it’s the has already gone disastrously wrong. discussions with people developing policies or This is a challenge faced by the BMA ethics legislation to point out the risks if they go down that department and medical ethics committee. Although line. It heads off the disasters.’ well-known and respected for its headline work on high-profile ethical issues, such as assisted dying, Intervention pays off it’s less recognised for the work it does behind the Dr Wise, a psychiatrist, has chaired the BMA medical scenes to – to put it crudely – stop bad things from ethics committee for just a year, but has been a happening in the first place. member of it for more than two decades and has Recent examples include intervening in a Supreme also chaired the BMA medico-legal committee. He Court case to ensure that doctors don’t have to points to the recent McCulloch case where the BMA’s bombard patients with irrelevant information on intervention helped prevent a situation where doctors possible courses of alternative treatment they would have to explain the benefits and risks of every do not deem reasonable – so you don’t have to possible alternative treatment to patients, even if raise the pros and cons of these options were not homeopathy for a broken hip, considered ‘reasonable’ in ‘The BMA was able to help the for example. Supreme Court understand what their professional opinion. And GPs can also ‘The BMA was able to doctors actually do’ be thankful the police help the [Supreme] Court in England and Wales understand what doctors don’t have the right to access confidential health actually do, and why this wouldn’t be a good decision.’ information for blanket and routine purposes, putting He believes the work of the ethics committee confidentiality and the doctor-patient relationship is important for BMA members because of its in serious jeopardy. professional work – including reports on ethical issues such as organ donation – and because of the practical For Jan Wise, chair of the BMA medical ethics effect it has on doctors’ day-to-day working lives. committee, the work the BMA does behind the ‘The professional work we do buys us our scenes to mitigate the risks of potentially harmful influence [in the Houses of Parliament],’ he says. policy and legislation is vitally important, even if it is ‘Do not underestimate soft power. We are honest often under the radar. bma.org.uk/thedoctor

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ANDY BAINBRIDGE

ENGLISH: ‘This is a real, practical way the BMA is supporting members but it isn’t well recognised’

Scottish Parliament, Welsh Senedd, and Northern Ireland Assembly when it is sitting), but also in cases that reach the various courts across the UK. ‘Case law can have a significant impact on our members and on the requirements on them in the same way that legislation can, but doctors are often much more familiar with legislation because as it’s going through Parliament, there’s usually much more discussion and media coverage and so on. So, part of our role is to monitor developments in case law by looking at the cases that are coming through the courts then picking anything up that might have an impact on clinical practice.’

Legal intervention Raising awareness of potential changes among doctors, for example via BMA newsletters, is one response, or BMA guidance might need to be brought in line with new developments. But the organisation can also intervene if it fears a court case might bring brokers and that gets you listened to. We are able detrimental change to the way that doctors practise to have sensible discussions [with those preparing – such as in the McCulloch case. legislation] to help them understand what may or ‘The McCulloch case is an example of where we may not happen, and an informed politician at least can stop things that would have a negative impact doubles the chances of good legislation.’ from happening,’ she says. This is a real, practical way The work of the BMA ethics department can also the BMA is supporting members, but it isn’t wellhelp doctors to make ethical decisions in everyday recognised, she adds. practice. ‘It’s easy to know when you’re making a ‘We’re keen for members to be aware of that good decision and a bad decision. The difficulty part of our work, because sometimes people get is with the shades of grey – of differentiating the feeling ethics is something a bit airy fairy, a between bad, worse and worst. We all want to make bit academic. But the work we do is actually about the right decision but there are conflicts, such as doctors’ day-to-day practice and trying to act on resourcing, time, or something else, and sometimes behalf of our members.’ it’s about making the least-worst choice. We’re able Another example of the committee’s preventive to help people see that work was two years ago, when yes, you’re working under the BMA strongly opposed a terrible constraints, and we clause in the Police, Crime, ‘We all want to make the right understand why you want to Sentencing and Courts Bill, decision but there are conflicts, which would have ended at a do this, but let’s just help you such as resourcing, time, or think about this a little bit.’ stroke the common law duty Veronica English, BMA something else, and sometimes of confidentiality protection head of medical ethics it’s about making the least worst’ for some health information. and human rights, says As originally drafted, the BMA’s core ethics the Bill created a legal guidance (an updated requirement for CCGs (clinical version will be published online shortly) is based commissioning groups) and local health boards, to on the very practical questions doctors raise with provide information to the police for the purposes of the organisation. planning to prevent and reduce serious violence in But although this – and other guidance tools their local areas. This requirement to disclose would and reports – are often seen as the public ‘face’ of have overridden the obligation of confidence doctors the ethics department, a great deal more goes on and health providers owe to their patients. behind the scenes. This includes monitoring possible Doctors can, of course, provide information on changes to the law, either in terms of new or amended patients without consent on a case-by-case basis if legislation going through Parliament (including the there are compelling reasons to do so ‘in the public 10

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MATTHEW SAYWELL

interest’ in accordance with guidance from the GMC – but this bill would have made it possible for police WISE: Committee has a plurality to demand patient information routinely from CCGs of views and local health boards. Leading an alliance with the GMC and the National Data Guardian – and with the strong support of some peers – the BMA succeeded in persuading the Government to amend the original wording of the bill, ensuring the continuing protection of patient information. The BMA medical ethics committee is unusual in that, in addition to the medical members, it includes people who aren’t clinical, but who have different expertise – for example, as professors of ethics, or as lawyers. But in addition, the staff are linked in to networks in areas of interest, so that, for example, contacts will bring potential cases of interest to their attention. The department also offers ethics advice to individual doctors via the BMA’s first point of contact service. ‘A lot of enquiries can be dealt with from the questions they need to ask themselves when they’re guidance on our website, but in more complex cases, making a decision.’ doctors come to us for specific advice and, where When visitors attend the BMA medical ethics appropriate, we can talk through the issue with them,’ committee, they are often surprised by what they says Ms English. see. ‘I cannot remember anybody coming along who Part of this can be guiding doctors on how to didn’t leave genuinely impressed with the quality of approach an ethical question and how to balance the discussion, the evidence, the decision-making, competing interests when making a decision. If and what’s produced,’ Dr Wise says. there’s a straightforward legal answer, we will provide ‘Part of that is because we attract people who that information and refer to the guidance, but in want to sit on the committee who aren’t doctors: most cases it’s actually helping the doctor to think they are professors, leaders in their fields, whether through the ethical issues to make sure they’ve it’s moral philosophy, legal practice, sociology or considered all the relevant factors to help them make anthropology. That gives us a real plurality of views what they feel is the right decision, and one they that stops us being in a silo.’ can justify.’ The BMA’s new ethics Sometimes members guidance will be a vital tool ‘I cannot remember anybody will approach the BMA for doctors, he says, and will after being assured by their help them to do their job as coming along who didn’t leave medical defence organisation well as providing a measure genuinely impressed with the they will be supported in of protection. ‘If you don’t quality of the discussion, the whichever decision they take have an ethical compass evidence, the decision-making, in a particular situation (when you’re going to be adrift at there is no obvious ‘right’ sea. To paraphrase Risky and what’s produced’ answer, for example) but they Business a little, your job is are still unsure of how best dealing in human misery, to act. Dilemmas include various scenarios such as pain and suffering and it is so easy to get lost in that whether it’s right to give out patient information to the if you don’t know where north is. This guidance will police, for example. keep you on the correct path – it will see you home in ‘There’s a list of questions [on the website] such the darkest nights and the worst storms. The ethics as “is it possible to get consent?”; “Why do they secretariat and the members of the committee have need the information?”; “Is it a serious crime?”; done the heavy lifting to make it as safe as possible “Does it reach the GMC’s criteria for breaching for you.’ A fuller version of this feature can be confidentiality?”; “What sort of information is found on the BMA website needed?”. It’s helping doctors think through the 11

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Becky Hirst St Luke’s Hospice, Sheffield

ALL’S WELL THAT ENDS B WELL Palliative care can be transformative but a lack of access and awareness means many patients go without. Doctors tell Seren Boyd about their work to help everyone who needs it achieve a ‘good death’

ecky Hirst worries about how patients and health professionals view her specialty. ‘It’s a public health problem that so many people don’t understand what we do.’ Palliative care can transform the last days and even years for someone with a terminal illness. It can relieve the burden on families – and on other parts of the health system. If a patient is referred in good time to palliative care, they and their family have a support system and plans in place to make the most of life while it lasts and hopefully have a good death when it comes. Yet, despite the fact up to 90 per cent of all people dying in England may need generalist palliative care and support, fewer than half receive it, according to the charity Sue Ryder. The picture is repeated across the UK. Dr Hirst and the multidisciplinary team at St Luke’s Hospice provide specialist support to terminally ill adults with needs that cannot be met by other healthcare teams, in their homes and in the hospice. She sees their role as protecting patients from unnecessary interventions and medication, managing their symptoms and enabling them to live well for as long as possible. ‘Everybody with advanced progressive life-limiting

A patient receives a check-up at St Luke’s Hospice

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ST LUKE’S HOSPICE

St Luke’s Hospice staff

HIRST: Palliative care not widely understood

disease deserves palliative care,’ says Dr Hirst, ‘but people don’t realise how important it is until they or someone they love needs it.’

Threat to recruitment

political impetus and lay advocates for improvement that other specialties have, she fears. ‘The dead can’t complain and the bereaved are often not in a place to complain either.’

ST LUKE’S HOSPICE ST LUKE’S HOSPICE

The barriers preventing people from receiving ‘Squeamish attitudes’ specialist palliative care are many and complex. More pressing for Dr Hirst is the fact palliative care is The Government says it’s committed to ‘highnot widely understood, even by clinicians. Hospices quality palliative care’: local integrated care boards are commonly seen as ‘just for cancer’: palliative care have a statutory responsibility to commission it. But is mistakenly associated with the very last days of life. pledges have not translated into funding. Consequently, referrals don’t happen – or come late. Only 11 per cent of hospital trusts offer face-to-face Dr Hirst recognises it can be hard to assess when access to specialist palliative care 24/7, according patients are nearing death, especially those with to the Royal College of Physicians. The eligibility bar non-malignant conditions such as heart failure who to receiving care at home may come close to dying through the NHS in England ‘People don’t realise how many times. and Wales is high. ‘But we know if you’ve important palliative care is Hospices, which offer free had a certain number of until they or someone they care to 300,000 people a exacerbations in a certain love needs it’ year across the UK, have to amount of time, you’re more fundraise two-thirds of their income on average – and likely to die from the next one,’ says Dr Hirst. ‘So are struggling financially. And, as Dr Hirst points out, why aren’t we having some advance care planning hospices tend to be in ‘leafy suburbs’. The hospice conversations with these people to find out what they where she worked previously was two bus rides away would want? I can only help with the patients that I from the former mining communities it served, where know about.’ palliative care needs were higher. Meanwhile, the need for palliative care is growing. Dr Hirst is also deputy training programme ‘All specialties are keeping patients alive for longer but director for palliative medicine in Yorkshire and people have lower functional ability and we’re seeing Humber. She is concerned the specialty’s new more chronically dying patients.’ training pathway, introduced in 2022, may make Society in general and clinicians in particular workforce shortages worse. must overcome their ‘squeamishness’ over talking Trainees are now required to be dually accredited in about death and dying, Dr Hirst says, to allow palliative and internal medicine: Dr Hirst’s experience other specialties to work in a more collaborative fashion with palliative care from earlier in the as a former GP would no longer be eligible. Filling patient’s journey. higher specialty training posts has become much harder. ‘My perception is that the people who want to ‘Death isn’t going to happen any quicker just by do palliative medicine are not always the people who talking about it. The evidence is that patients want to want to be on an acute receiving rota.’ talk about end of life but they want their doctors to Outside the profession, palliative care lacks the bring the subject up: that gives them permission to bma.org.uk/thedoctor

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talk and tells them it’s safe.’ One of the great strengths of palliative care – and one of its great rewards for Dr Hirst – is having the time to talk to patients properly, especially about what matters to them. She is a strong advocate of these ‘tender conversations’ – a phrase coined by palliative medicine specialist Dr Kathryn Mannix – effective, he specialist palliative care team where Jamilla empathetic conversations which confront hard truths Hussain works has always had close working and explore positive ways forward. They’re what relationships with other teams in the Trust. enable a young woman with terminal cancer to marry But during COVID, the need for palliative care rose her fiancé or a wife to lie with her husband and hold sharply, as did awareness of what the team could offer. him as he dies. ‘With so many people dying, it pushed palliative care ‘Often, it’s the first opportunity they’ve had to into the limelight,’ says Dr Hussain. ‘The team in Bradford tell their whole story, from the beginning. Spending was innovative and stepped forward to help, allowing longer with patients in the first instance and setting people to see the value of palliative care in a way that had them up with a good plan reduces the amount they’ll not been appreciated before. They were not only having need to access services longer term. We forget that to support patients and family members but staff too, at time is a therapeutic tool.’ all levels.’ Dr Hirst rarely feels upset by her work: she’s part of Since then, the hospital palliative care team has a strong, supportive team and their work is positive grown to include three consultants, specialist healthcare and productive, even amid so much loss. When support workers and more specialist nurses, recognising people ask her how she copes, she tells them she the growing need for specialist palliative care support in found general practice in Glasgow harder: ‘You were hospital. Their role is to provide patients and their families powerless to do anything with dignified, compassionate about poor housing, abusive care that extends beyond ‘There’s always something relationships, poverty.’ medical needs into In contrast, she says: ‘In psychological, spiritual and I can do to make a difference’ social aspects of their life too. palliative care, once you’ve The hospital-based treated physical symptoms palliative care team also see it as their job to support so people are feeling better, you look at their goals and what’s achievable. It may just be getting out into colleagues in other specialties. Now, as soon as any team the garden because part of their spirituality is being a suspects a patient may be nearing the end of life, they gardener. There’s always something I can do to make can refer them to the palliative team for assessment. a difference. And there’s always hope: it’s just that we The number of patients receiving specialist input has have to change what we hope for, until the hope is of increased as a result. The palliative care team also now has a team working across emergency departments, a dignified death in the place of our choosing. One hundred per cent of us are going to die so let’s make the community and hospice, covering everything from advance care planning with patients to setting up sure we do that well.’ support for them going home. ‘We’ve got to recognise every team in the hospital and community have got their own challenges and they’re An art activity at St Luke’s doing the best they can to support people at the end of Hospice their lives,’ says Dr Hussain. ‘They’re, however, working with a broader spectrum of patients, including those with many years to live, and therefore require different expertise. We need to understand better how to support those teams and how palliative-care services can best work alongside them to deliver equitable end-of-life care to all.’

Jamilla Hussain Bradford Teaching Hospitals NHS Trust

ST LUKE’S HOSPICE

Tackling inequalities In many ways, Bradford NHS trust is tackling many of the barriers that Dr Hirst in Sheffield 14

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Bradford Royal Infirmary

HUSSAIN: Doctors need tact, and a willingness to learn

is concerned about. It’s important then that hospital care is flexible and It is a minority of trusts that offer 24/7 access to sensitive to families’ needs and values. specialist palliative care. The local hospice is in an ‘Very often, when a [South Asian] patient is asked economically deprived area. And most of the patients what matters most to them when they’re dying and referred to palliative care have the kind of non-cancer they can’t get home, they will say: “I want all my conditions such as lung disease that are prevalent family,” and we’ve got big families. When you’ve got among more disadvantaged groups. lots of visitors, managing infection control may be The palliative care consultants working across highlighted as a concern by the ward team but it’s Bradford rotate between hospital, hospice and also important for our team to challenge unnecessary community roles, giving them ownership of other barriers.’ areas of the team’s work and a broader awareness of It requires tact and sensitivity – as well as need. Yet access to palliative care is still low among representation in the workforce – to understand certain groups. For example, in 2016-17, people family dynamics and how these inform a family’s of South Asian heritage in Bradford only made up response to the offer of palliative care. 8 per cent of referrals to If a South Asian woman ‘We have to care enough specialist palliative care involves her husband and services, despite making son in decision-making, to go that bit further to understand up 47 per cent of the says Dr Hussain, ‘that isn’t what people need and population, according to necessarily a way of reducing try to do better’ the charity Hospice UK. her power, but can be a way These inequalities are writ large across all minority of making sure she’s protected’. Likewise, allowing a communities, from the homeless to trans people, says woman her say in whether she feels up to caring for a Dr Hussain. loved one at home is important, even if male relatives She combines her clinical role at the trust have said that the family can cope. with a research post where her focus is trying to And it takes determination to find out what address inequalities in end-of-life care. There’s a matters most to families and may require some soulstrong focus on enabling community members to searching too. contribute to that research: a recent project helped ‘In the drive to address health inequalities, many create safe spaces where Muslim Pakistani women organisations have focused on asking communities, could share their experiences of caring, dying “Tell us what you want.” What we’re not doing as much and bereavement. is turning the lamp on ourselves and saying: “What are Dr Hussain, who is of Pakistani heritage herself, the structures and systems that stop us doing things points out that equating ‘a good death’ too narrowly differently? What stops us having representation at with end-of-life care at home is unhelpful at leadership level?” times, especially for people and families who are However, Dr Hussain has come to understand marginalised. Some homes are too small for the why doing such work is hard. ‘I don’t have implicit equipment often required for end-of-life care, she knowledge of the experiences of trans people, for says; some people are socially isolated and some example, but I know they’re hugely marginalised. I choose hospital as their preferred place to die. will make mistakes, in my language and my approach ‘Our patients with, say, end-stage renal failure or to try to support equity for this group. But it’s my COPD, who have been in and out of hospital for many responsibility to push myself to learn more. We have to years, have often developed a good relationship care enough to go that bit further to understand what with the nurses and feel safe and well supported people need and try to do better, even if it is unfamiliar in hospital.’ and uncomfortable territory.’ bma.org.uk/thedoctor

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SARAH TURTON

Amandip Sidhu, with a picture of his late brother Jagdip. He says: ‘We all want our doctors to be perfect because our health is in their hands but doctors have the same physiology as all of us – they go through the same life experiences and they have the same vulnerabilities’

Lives cut short 16

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SARAH TURTON

A new impetus to reduce suicide should include urgent improvements to workplace culture, as well as help with the cost of living, doctors tell Peter Blackburn

‘I

t is the biggest risk we face – and the biggest concern for all of us working in suicide prevention.’ Professor Louis Appleby, possibly the country’s leading expert in the field, pulls no punches when The Doctor asks for his assessment of the links between economic crises and suicide, and whether the cost-of-living crisis risks undermining efforts to reduce tragedies. ‘Every major economic downturn has put up the suicide rate historically in the UK and in other countries,’ he says. ‘There’s no question it’s our biggest concern but that doesn’t mean it is inevitable.’ It is a critical question for the UK in 2023. The costof-living crisis dominates headlines in the media and the worries of people across the country. So, if there has historically always been a link between economic crisis and increasing suicide

rates, what does Professor Appleby mean when he says ‘not inevitable’? ‘When you look at what happened after 2008 some countries did better than others,’ he says. ‘It tends to be countries which had policies of social support and employment support. So, preventing people losing their jobs or, at least, getting into serious debt if they did. That kind of economic policy is difficult for governments because it’s costly. But it’s what happened during COVID with the furlough scheme, and it’s probably one of the reasons why the suicide rate didn’t rise during COVID, even though everybody thought it would. ‘Criticising governments is easy – it’s a national sport. But on the other hand, there have been measures to support people through energy bills, and other support. And I just think that we have to keep in mind that the effect of the costof-living crisis won’t be over

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APPLEBY: New policies should be assessed against their likely impact on mental health

‘The effect of the cost-ofliving crisis won’t be over soon’

soon. The protections that people might need will be long term.’

Deprivation risk These are exactly the sorts of questions and considerations posed by a BMA report – Suicide prevention during economic crises: a UK approach – which makes a host of recommendations in terms of preventing suicide in the general population, but also specifically among doctors working in the NHS. It could hardly be a more pressing issue. In 2021, there were 5,219 registered deaths in England alone from suicide, which equates to 14 people dying by suicide every day. Suicide is the leading cause of death in England for adults under 35. Economics and poverty play a crucial role, too. Those who live in the most deprived areas are at the highest risk. And a 2023 survey of more than 5,000 people found that nearly 80 per cent said their mental health had been thedoctor | November 2023

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SARAH TURTON

BAMRAH: NHS can be an unsupportive working environment

affected by the current costof-living crisis. In the space of just over six months in 2022, one charity reported a 196 per cent increase in people seeking their help with suicidal thoughts. The report calls for urgent action on the dominant factors causing suicide – calling for a ‘mental health in all policies’ approach to policy making, including a mental health impact assessment for all new proposals. It is a demand which was taken into account in the Government’s recent suicide prevention strategy for England, driven by Professor Appleby who is chair of the national suicide prevention strategy advisory group. 18

Among 100 proposals, covering a broad range of areas, the Government has committed to carrying out mental health impact assessments as part of policy processes. Here, actions will speak louder than words, but the promise itself is laudable. Professor Appleby cites recent policy in areas such as prisons or welfare, which would now have an extra lens of scrutiny. He says: ‘It’s very important for me… When new Government policies come through they are assessed against the likelihood that they will have an impact on mental health and suicide risk.’

Workplace support The BMA report also calls for collaborative efforts across

‘In the NHS there’s lots of bullying and harassment and some places are toxic’

Government departments to prioritise mental health and suicide prevention to protect the population’s health in the current economic climate and in future. It also urges adequate support in all workplaces, including the NHS – including provisions such as rest spaces, management training around wellbeing, comprehensive, confidential and timely occupational health services, a healthy and flexible work-life balance and the implementation of reasonable adjustments wherever necessary. The report also calls for stigma around mental health to be a priority and all suicides associated with workplace stress to be investigated in the workplace. Consultant psychiatrist and BMA lead on suicide prevention JS Bamrah says many of these issues are particularly important for doctors and the NHS. Not only does the health service often bear the brunt of economic crises through under-funding and the increased need in communities, but it can also be a notoriously pressurised and unsupportive working environment which takes a toll on the wellbeing of staff. He says: ‘We know at the moment in the workplace in the NHS there’s lots of bullying and harassment and some places are toxic. If we are not looking after the people who look after people then that’s a very sad story. So, we are saying there should be adequate support for doctors and nurses and we’re putting the onus on employers and bosses to

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make sure that happens. There’s massive burnout, there’s massive work-related stress and many people are heavily mentally fatigued from the pandemic.’ He adds: ‘We need to address the stigma around mental health and suicide and we need to have a system where we look at the suicide of every person, of every doctor. Suicide from work-related stress should be a never event.’ Amandip Sidhu founded charity Doctors in Distress after the death of his cardiologist brother Jagdip Sidhu in 2018. Dr Sidhu worked to the point of burnout and took his own life. The charity now seeks to raise awareness that doctors suffer from the same illnesses as the patients they treat and campaigns for better support for staff. Mr Sidhu believes doctors are vulnerable to suicide for many, complex, reasons including a lack of focus on personal wellbeing in medical schools and training, a total lack of compassionate leadership and support systems in workplaces which compound feelings of isolation and a major sense of stigma around vulnerability and perceived weakness. He says: ‘Doctors are trained to be seen as indestructible. We all want our doctors to be perfect because our health is in their hands but doctors have the same physiology as all of us – they go through the same life experiences and they have the same vulnerabilities.’ Mr Sidhu says: ‘I’m not an

expert on the NHS but one thing I realised very quickly through my work is that our health service has only survived because of the very strong goodwill from people who work in it. ‘If I had a magic wand, I would do three things: firstly, I would give, to the best of my abilities, the right resources to doctors and healthcare workers to allow them to do the job they want to do. ‘Secondly, we need to make the workplace an enjoyable and happy place to work, with a supportive and nurturing environment. Simple things like giving [staff] time off when they want it and having rotas well in advance make a difference. ‘And, thirdly, is having a compassionate workplace culture where people have proper access to mental health support and wellbeing services – not just tick-box things but meaningful services.’

‘Moral poverty’ The new Government strategy pulls together more than 100 measures which it suggests can reduce England’s suicide rate within the next two-and-a-half years. The plans include an ‘alert system’ which aims to notify relevant authorities such as schools and charities of emerging methods of suicide and risks, fresh guidance to first responders, ‘near real-time surveillance’ of trends in suicides nationally to drive ‘targeted actions’ and a pledge to stop the supply of dangerous and lethal substances.

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‘We need to make the workplace an enjoyable and happy place to work’

‘Suicide from work-related stress should be a never event’

The strategy also includes action in various areas of mental healthcare including a plan to give millions more children in schools access to a dedicated mental health support team by March 2025. Professor Appleby says: ‘It really matters to me… It’s an important statement about how necessary it is as a set of services, as a country and as a society that suicide prevention is taken seriously.’ While the efforts of campaigners such as the BMA and individual policies such as those announced in the recent Government strategy represent progress and welcome focus, Professor Appleby is clear there are also wider issues about how our society works and what sort of a country we want to be, which can have a huge effect in this area. Echoing Durkheim’s theories about ‘moral poverty’ as a driver for suicide which have rung true for more than a century, he says: ‘We have to be prepared to take on the idea that society’s values – the way that it works – are an important part of people feeling safe. ‘Of course that doesn’t mean that everybody is likely to be at risk of suicide. But it does mean that if you’ve got a society where some people are already vulnerable for different reasons and you add to that a sense of loss of hope, that there’s nothing here for me, that the future doesn’t hold much, that could put some people at risk.’ He adds: ‘If people feel their values are reflected in how society is run then that ought to be a more psychologically safe society.’ thedoctor | November 2023

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SHAKIB AHMED

KHAN: ‘Everyone deserves to be treated with the same level of competence and respect’

Skin deep Is it a bruise, a rash, or an unconscious bias? Seren Boyd meets the medical student highlighting the risk to patients from textbooks full of white people

R ‘During COVID, patients were asked if their skin had gone “pale” or their lips had turned “blue”.’ These descriptions are accurate, but only when observing lighter skin’

ed spots, pink rashes… these are not just presentations of chickenpox but also symptoms of racial bias in medicine. COVID may have cast a spotlight on health inequalities, but some are still hiding in plain sight. Third-year medical student Naabil Khan had noticed the textbooks and online images she was studying had a marked bias towards white skin – and decided to rectify this. She has created a website which demonstrates in

words and pictures the varied ways different skin conditions present on skins of different colours. Her ambition is not limited to improving representation in medical education. She wants to amplify a growing conversation about racial bias in medicine more generally and give patients the tools to start addressing it, too. ‘Everyone deserves to be treated with the same level of competence and respect by the medical profession,’ says Ms Khan. ‘People of colour are not “different”: everyone has their place in society.’

‘Going pale’ It was the COVID pandemic – and its lesson about diseases’ potential to affect different racial groups differently – which fuelled Ms Khan’s growing interest in representation in medicine. ‘During COVID, patients were asked if their skin had gone “pale” or their lips had turned “blue”,’ she says. ‘These descriptions are accurate, but only when observing lighter skin.’ So, one of the aims of her website, Skin For All, is to educate medical students. Each condition’s

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GETTY

listing has notes which include epidemiology, pathophysiology, investigations and management – as well as photos showing different presentations on different skin colours. Lyme disease, for example, which often presents as a bull’s eye rash in lighter skin can appear more like a bruise in darker skin. The ability to recognise conditions on all skin types is particularly important in conditions such as melanoma where early diagnosis can strongly affect a patient’s prognosis. Yet, Ms Khan was shocked to find family members studying medicine in Pakistan were also using textbooks with images of predominantly white skin such as Netter’s Clinical Anatomy or Gray’s Anatomy. ‘As medical students and clinicians, we have a duty to treat everyone equally,’ says Ms Khan, ‘and that means being able to understand what a condition looks like and carry out the right treatment.’

Fear and mistrust Diagnosis, of course, depends on patients coming forward for consultation. Skin For All is not the first such online directory of skin conditions but it is distinctive in its appeal to a non-medical readership too. Listings also include explanations in plainer English, common ‘myths’ (such as skin cancers being confined to sun-exposed parts of the body) and ‘Questions to ask your doctor’. These questions are

particularly aimed at people who feel intimidated by the prospect of visiting their GP – which applies to many older members of Ms Khan’s own South Asian community. She says people still refer to South Asian women in Coventry being given chapatis containing radioactive iron in 1969, apparently without their informed consent, during research into higher levels of anaemia in their community. Others fear they won’t be taken seriously because of ‘Mrs Begum syndrome’ – the tendency to dismiss older Asian women as exaggerating their pain. ‘It can take a lot of courage to go to a GP especially if you have that background of mistrust,’ says Ms Khan. ‘And trying to get your point across, when you’ve not had access to resources that show people like you, can be really challenging, too.’ The significantly worse outcomes for people of colour with skin cancer, compared with non-Hispanic whites, despite a lower incidence of skin cancer in darker skins, are partly due to late-stage diagnosis, which is three times more likely to occur.

Inclusive conversations Momentum to address racial bias in medicine is growing and Ms Khan believes medical schools, including Exeter University where she is a student, are making progress. She is concerned, however, that the focus on equality, diversity and inclusion can sometimes feel ‘tacked on’ or ‘something to think about in your own time’. A way medical schools

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could start to address inclusion is more teaching on inclusive conversations, she feels. ‘It is important to say to a patient, “I’m here to help you. Is there anything you need? Would you like a female to talk to you? Would you like me to address you in a certain way?” These small things can make a huge difference in building rapport and making the patient feel supported, especially where there’s a lack of trust.’ However, this conversation about representation in medicine needs to be global. Ms Khan can’t help but notice the clinical research she is studying still has a strong bias towards white patient groups. ‘People of colour are either not included or homogenised into one category, such as black, Asian and minority ethnic.’ Ms Khan cites US dermatologist Jules Lipoff and his analysis that ‘the white patient is shown as default and the black/brown patient as the asterisk’. ‘Being treated as “other”, as the asterisk, can be demoralising and dehumanising,’ says Ms Khan. ‘We must make sure that black, brown and other ethnic-minority groups don’t feel like the afterthought or add-on.’ To find out more, visit www.skinforall.co.uk

CONTENT BIAS: Textbooks tend to depict mostly white skin, says Ms Khan

‘People of colour are not “different”: everyone has their place in society’

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Your BMA It’s vital we maintain our empathy and respect each other’s views

thedoctor

One of the main reasons for writing this column has been to reflect on the biggest issues of the day and, most importantly, how the BMA can magnify your voice and ensure our profession is at the very heart of our work. In recent weeks and months social media has been dominated by two topics, with important conversations around industrial action and pay restoration and PAs (physician associates) at the forefront of many colleagues’ minds. These conversations are not always respectful and understanding. I’ve seen BMA members attacked by external critics and colleagues, for raising concerns. These are important topics – they do need to be discussed. I’ve reflected on the conversations I’ve seen, why these are important issues and, ultimately, why during times of conflict it is more important than ever that as many members as possible get involved in your BMA, bringing their diverse backgrounds, experiences and ideas to leadership roles so we can represent all members collectively. Our journey towards pay restoration began in June 2022 with a motion at your BMA annual representative meeting, which committed us to achieving full pay restoration for all members by 2027. These are shared principles voted for by medical students’ and doctors’ representatives democratically and they unite us. I have seen attacks on junior doctors and medical students. They are called militants and they are

@drlatifapatel smeared in the media. Sometimes the accusations and the criticism come from our own colleagues. This, in my view, suggests a fundamental lack of empathy. As a specialty trainee 7 I might still be a junior doctor but I graduated from medical school in 2011 so the truth is I can’t properly relate to what most of today’s medical students and junior doctors see in their daily lives – the lived experiences that have led them to campaign so powerfully for full pay restoration and for the future of the NHS. I didn’t join the NHS when there was a pandemic, I wasn’t parachuted prematurely on to the front line from medical school to see patients and colleagues die in unprecedented numbers, and I came into an NHS where I felt much more valued. I had the benefit of better financial support, NHS bursaries and lower interest rates on my loans. Ultimately, with lower waiting lists and better resourcing the NHS was a better place a decade ago. I wonder if those criticising elected members have put themselves in their shoes? When we put ourselves in their shoes I think things become much clearer. I don’t think those criticisms that striking doctors should be more ‘altruistic’ ring true at all. Our friends and colleagues are asking to feel valued, they are campaigning for respect and autonomy and better working conditions. Ultimately, they are fighting for the future of our health service and for patient safety because if there are no doctors

The Doctor

Editor: Neil Hallows (020) 7383 6321

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

Chief sub-editor: Chris Patterson

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

Senior staﬀ writer: Peter Blackburn (020) 7874 7398

@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 £170 (UK) or £235 (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 Warners Midlands. A copy may be obtained from the publishers on written request. The Doctor is a supplement of The BMJ. Vol: 383 issue no: 8406 ISSN 2631-6412

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Staﬀ writers: Tim Tonkin (020) 7383 6753 and Ben Ireland (020) 7383 6066 Scotland correspondent: Jennifer Trueland Feature writer: Seren Boyd Senior production editor: Lisa Bott-Hansson Design: BMA creative services Cover photograph: Douglas Robertson Read more from The Doctor online at bma.org.uk/thedoctor

06/11/2023 11:35

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left there is no NHS. If we know society depends on a healthy NHS then what is more altruistic than to fight for it now? And ultimately, fight for our worth? The other issue dominating discussions is PAs. The role and regulation of PAs is a debate which has been swirling with increased ferocity in recent months. I have seen doctors called ‘toxic’ for having strong, principled views. I have seen doctors called ‘snobs’ in high-level meetings with stakeholders when they call for regulation and clear differentiation between roles. Our raising of concerns might seem unhealthy or unhelpful to some but there is real concern from the medical workforce, and that is justified. Forgetting the insults and the mud-slinging, this is about patient safety. Just as the industrial action ultimately is, too. Patients should be able to trust that the person caring for them is a doctor, not another professional near-indistinguishable in appearance but who has a fraction of the training. When I get on a plane I expect a pilot with an airline transport pilot licence to fly, not a pilot associate with a few months’ training who happened to be in the same building. I’m proud of our membership. We are standing our ground and we are making our voices heard on the issues which affect our lives and our patients. Our stakeholders – those who hold sway over our working lives – should be on notice. It is becoming ever more clear. We won’t back down. We will be heard. In many ways these debates make it feel like we are at a crossroads, a turning point, or another important moment for our profession and the NHS. It has never been more important that as many people as possible get involved in the BMA so we can represent doctors to the best of our abilities. Join us. Get in touch @DrLatifaPatel or email RBChair@ bma.org.uk Dr Latifa Patel is chair of the BMA representative body bma.org.uk/thedoctor

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