The Doctor – issue 62, December 2023 by The BMA

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Issue 62

December 2023

Holding the line On board Ukraine’s rescue train

Christmas on call The strange things that happen at work

Sense of purpose Juniors’ leaders reflect on the pay dispute

Voices heard Representing doctors at the COVID inquiry

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JESS HURD

In this issue

At a glance If the Government really wanted safe staﬃng it could start by addressing the recruitment crisis

4-7

Humanitarian line, westbound The train evacuating sick and wounded civilians in Ukraine

8-13

A working Christmas

Your most memorable experiences during the festive season

14-17

First among equals The junior doctor leaders on the impact of the pay dispute

18-19

Getting your voice heard Ensuring doctors’ experiences are heard at the COVID inquiry

20-21

Reaching for the stars Aboard the Orbis Flying Eye Hospital

Your BMA The conﬂict in Gaza, the West Bank and Israel

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Welcome Phil Banfield, BMA council chair This time of year can bring out the best in people – and sometimes the worst. It will be the second Christmas in which Ukrainians are forced to withstand the appalling and illegal aggression waged by Putin’s Russia. We think of those who suffer in conflicts around the world, including in Israel and Gaza, urging all sides to respect international law and medical neutrality. Our thoughts also go out to our remarkable colleagues who continue to save lives and bring comfort to their patients despite overwhelming personal risk. We are fortunate in this issue of The Doctor to speak to Nataliia Pivovar, who works on a train run by the charity Médecins Sans Frontières, transporting patients from near the Ukrainian front line to relative safety in the centre and west of the country. A veteran of more than 100 evacuation trips on the train, she says: ‘Admittedly, war causes sadness and does not allow us to celebrate holidays as before, but people can adapt to anything and find happiness in small things.’ That same spirit is embodied by Shurma Pallan, a palliative medicine doctor in Birmingham, and one of several who have shared with us their experiences of working during the festive season. It’s about ‘making every moment matter’, she says, recounting that for one patient Christmas was brought forward three months because he was not going to survive to December. Doctors wanting the best for their patients is of course a major reason why doctors have taken industrial action this year. BMA junior doctors committee co-chairs Rob Laurenson and Vivek Trivedi explain why they were determined to improve an under-staffed, under-resourced health service, where real-terms pay has fallen dramatically. The urgent need to improve working lives for doctors – as well as the quality of political decision-making – has also been highlighted by the COVID inquiry, at which I have already given evidence twice. Doctors risked their lives working through the pandemic, with inadequate respiratory protection in traumatising circumstances. It is absolutely vital their testimony is heard. This requires a huge amount of work and expertise from BMA staff, and a feature in this month’s issue explains how our evidence is collated. I hope you are able to rest during the holiday period, but spare a thought please for those who can’t. There is still much to do in the year ahead with our collective voice and determination to make the BMA, NHS and wider world a better place to be. Keep in touch with the BMA online at twitter.com/TheBMA

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AT A GLANCE

So the Government wants to talk about safe staffing ... When the UK Government introduced its Strikes (Minimum Service Levels) Bill earlier this year, the BMA repeatedly warned it was the wrong thing to do. Interfering with workers’ right to strike in this way was heavy-handed, disproportionate and unnecessary, the organisation said, and would only serve to worsen already soured industrial relations. Ministers pressed ahead anyway, and after a rush that some might call unseemly, the legislation hit the statute books in the summer. This haste has meant the UK Government is now trying to play catch-up by trying to work out just what it means by ‘minimum service levels’. It has been consulting on minimum service levels for hospital settings – retrospectively, and after the primary legislation handing the secretary of state immense powers to set the level themselves has been passed. The whole idea of minimum service levels – intended to ensure there is what is essentially ‘safe’ staffing during strike periods – sticks in the craw of the BMA and other health unions for a variety of reasons. For example, the irony has not been lost on those who have been campaigning for safe staffing levels (already implemented in the Scottish NHS). While the UK Government has refused to legislate to ensure there are enough workers to staff services properly in non-strike periods, they gave precious parliamentary time to mandating safe staffing levels when doctors and others are exercising their wholly legitimate right to strike. The BMA has of course responded to the latest consultation, pointing out that the current state of the NHS – with 10,000 doctor vacancies in England alone – compromises patient safety. The Government should focus on that, the BMA says. ‘Curtailing doctors’ right to strike could lead to doctors’ grievances going unaddressed, resulting in even greater workforce attrition and subsequently bma.org.uk/thedoctor

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higher workloads, with obvious knock-on impacts for staff and patient safety,’ it adds. ‘The Government should be taking action to ensure the NHS is safely staffed 365 days a year, which means addressing lost value of doctors’ pay and poor working conditions that result in more and more doctors leaving the NHS.’ Calling on ministers to prioritise resolving disputes rather than attacking legitimate trade union activity, the BMA also stresses that the UK already has some of the most restrictive trade union law in Europe – and warns that the Government’s approach could remove striking doctors’ protection from losing their jobs. The BMA also says ‘life and limb’ protections already exist within current trade union law, making the new legislation unnecessary, and casts doubt on the Government’s figures. For example, the consultation points to 22 critical incidents declared during strike action since December 2022, but a BMA Freedom of Information request into critical and major incidents called during 2022 and 2023 found there were four critical incidents owing to operational pressures called during the 27 days of junior doctor and nine days of consultant strike action. It’s unclear whether these critical incidents were a direct result of strike action, the union adds, pointing out that there were 234 critical incidents declared in 2022 when there was no strike action. ‘Rather than demonstrating patient safety was compromised due to industrial action, the data shows the importance of tackling the stress the NHS faces daily, which means investing in the workforce, and clearly undermines the Government’s stated rationale for minimum service levels.’ The UK Government will issue its response to the consultation in due course. By Jennifer Trueland thedoctor | December 2023

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MSF

PIVOVAR: Has made more than 100 trips on the MSF train

HUMANITARIAN LINE, WESTBOUND

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s the train bucks and sways, Nataliia Pivovar holds the teenager’s gaze and his hands, speaking to him gently. He plays with the rings on her finger. The 17-year-old evacuee from Kherson has cerebral palsy: he can’t talk and is visually impaired. A few hours ago, the hospital he was in came under shelling by Russian forces. Now he’s on the medivac train run by MSF (Médecins Sans Frontières – also known as Doctors Without Borders). Playing with the rings on Dr Pivovar’s finger seems to ease his distress and bring him peace. Dr Pivovar too finds comfort in those rings, especially on the medical train. Before her MSF colleagues could start the evacuation from the hospital in Kherson, they had to take refuge in a bunker amid the shelling. ‘When I need to relax or calm down, I roll the rings around my finger,’ she says. ‘It’s such a small thing, but it connects me to home and

MSF

As Ukraine faces another Christmas fighting for its survival, a remarkable medical team transports the sick and wounded on a specially adapted train. One of the doctors tells Seren Boyd about life on board

gives me a sense of peace. It gives me strength.’ Dr Pivovar will often pause between carriages, to take a moment and twist her rings. She’s made more than 100 trips on the medical train, but she still finds it hard to forget the look in patients’ eyes.

SITUATION CRITICAL: The medical team inside the intensive care unit

Triumph of planning The MSF medical train has been running since March 2022, soon after Russia’s full-scale invasion of Ukraine, transporting thousands of sick and wounded civilians from areas close to the front line to safer areas in central and west Ukraine. In a joint project between MSF and Ukrainian Railways, carriages from the 1980s have been heavily modified to create a novel addition to Ukraine’s health service in a time of war. The patients being transported may be warwounded or injured, have chronic diseases, psychiatric disorders or disabilities. Almost all of them need specialist medical care.

‘The front line is very close and we can hear explosions’

The medical train, which MSF describes as ‘a cross between an ambulance and a state-of-the-art intensive care unit’, is a triumph of careful planning and resourcefulness. Its intensive care unit is connected to the generator near the engine by 2km of electrical cabling. Carriages can be added, removed or reconfigured depending on the number and type of patients being transported. ‘We have some equipment that is not even available in every hospital,’ says Dr Pivovar. The train has been busy, notching up more than 130 journeys so far.

Backdrop of war Meanwhile, Ukrainian forces continue inching forward in their counter-offensive: having resisted Russia’s assault on the north and the capital Kyiv, they’re now trying to break through Russian defences to the east and south. Kherson, where this medivac is being made, is strategically important as the gateway to the Russianthedoctor | December 2023

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MSF MSF

held Crimean Peninsula and has suffered heavy Russian bombardment in recent months. Eighty per cent of all healthcare facilities in the region have been damaged or destroyed. As the Russian military continues to target health facilities, with blatant disregard for international humanitarian law, the BMA has repeated its calls for the neutrality of healthcare services and professionals in Ukraine to be respected.

Place of safety In today’s evacuation, from a hospital in Kherson, many of the patients have limited mobility; most are elderly, suffering with dementia, cerebral palsy or other neurological conditions. Because of their conditions, it was very difficult to evacuate them to bunkers in time when their hospital was shelled. That’s why the Kherson regional health authorities called on MSF’s help, to relocate these patients to other hospitals. Dr Pivovar describes the confusion as patients are brought on board. ‘The front line is very close and we can hear explosions. 06

Some elderly people have impaired hearing so they aren’t sure what’s going on. They ask us if everything is alright. I have to reassure them, saying, “everything is calm. It’s important to get on the train now, and we’ll soon take you to a safe place”.’ Dr Pivovar works her way through the patients, checking blood pressures, giving medication. In carriages with upper and lower bunks, she makes a point of putting the psychiatric patients on the lower ones. ‘It’s important for patients with psychiatric conditions to feel the floor under their feet,’ she says. ‘It makes them feel calmer.’ The journey from Kherson to the far west of Ukraine takes 36 hours and there’s little time for Dr Pivovar and the team to rest. Once they’ve attended to immediate medical needs, they make tea and serve sandwiches, which helps calm the patients further. Serving in conflict zones is stretching. Dr Pivovar is a paediatric anaesthetist, but postgraduate training in psychology has proved invaluable too. ‘You need energy, strength and calmness

OUT OF CHAOS: MSF evacuates patients from a hospital in Kherson hit by shelling

to find a suitable approach for each patient, answer all their questions and make them feel safe.’

An ICU that rocks Dr Pivovar has got used to most things on the train – including inserting cannulae in an intensive care unit that rocks. But it’s a strangely intense working environment, working in a long, thin tube, ‘You need with everything and everyone at close quarters. energy, At the end of the journey, strength and calmness the medical team gathers in the staff carriage to eat, chat to find a and decompress. ‘We discuss suitable things unrelated to work and approach cook something delicious,’ she for each says. ‘Later, after the trips, the patient’ team tries to get together and spend time in nature, go for a meal, or do other recreational activities to help us unwind.’ But it can be hard to disengage fully. ‘You remember almost everyone, what condition the patient had, what they had gone through and what their hopes were.’ Most patients on the medical train, wherever in Ukraine they are evacuated from, come with little more than a small bag. Some may return to their towns and

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cities after treatment but many won’t: their homes no longer exist. ‘Some patients go to relatives, some go abroad, and for some our social workers try to help find dormitories and houses for them to live in.’ MSF also helps provide medicines and essentials such as hygiene kits, as well as support with replacing lost identity papers or finding work. Dr Pivovar feels for them; she had to rescue her own grandmother from her Russian-occupied village. ‘People ask me if it will be safe at their new destination and if they will return. I think about my own grandmother and how difficult it is for the elderly to change their surroundings and living conditions.’ Dr Pivovar mentions a woman of about 60 years of age with pulmonary fibrosis who was on oxygen and whom MSF transported twice for tests and specialist care, along with her husband. She was eventually told she needed a lung transplant. ‘They told us that we had become their family because, at a time when their relatives refused to help, complete strangers helped them. ‘They were very grateful and

EXPRESS CARE: Some medivacs on the MSF train are for the war-wounded

hugged us goodbye. ‘After words like that, you understand that your work and your attitude are vital for patients, because nowadays people forget about humanity.’

‘No right to be sad’ Last year, Dr Pivovar spent Christmas Day at the hospital in Kharkiv, in north-east Ukraine, where she works in both the paediatric intensive care unit and the emergency department. Knowing her country was at war last Christmas was no excuse for being anything less than cheerful on the wards. ‘You simply have no right to be sad during the holidays because, working with children, you first have to make a holiday for them,’ she says. ‘Children in intensive care without their parents are very sad. So, you want to give them attention, entertain them, make them smile and give them small gifts. Their smiles are the most fantastic gratitude for our work.’ Unlike the MSF train, where she’s worked since June 2022, her own hospital often runs short of medicines and medical supplies. She regularly ‘fills gaps’ from her own purse.

‘People can adapt to anything and find happiness in small things’

‘I hope we will be able to celebrate Christmas this year’

She’s never thought of leaving Ukraine herself, though she has tried to persuade family members to go abroad. ‘I wanted to take my mother and grandmother abroad, but they refused because this is their home,’ says Dr Pivovar. ‘I love my city, my country, and I understand that I am needed here, especially now. ‘I hope we will be able to celebrate Christmas this year. However, we cannot predict when and where our help will be needed: we’re always ready to work. Admittedly, war causes sadness and does not allow us to celebrate holidays as before, but people can adapt to anything and find happiness in small things.’ It’s almost two years since the full escalation of the war in Ukraine, and the media is frequently distracted now by other conflicts. But Dr Pivovar remains focused on her work and committed to her people: Ukraine is still home. ‘Ukraine is a strong country and what is happening here with the war deserves to be known. I do not believe that the world will forget about Ukraine.’ With additional reporting by MSF thedoctor | December 2023

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WORKING AT CHRISTMAS

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What is it like for you to work at Christmas? Three doctors tell Seren Boyd their experiences, from carving turkey on the wards to bringing festivities forward so patients can have one last Christmas

In charge of the drinks trolley

ashir Qureshi’s first Christmas in the UK in 1964 was very white – and not just because it snowed. He had arrived at Whipps Cross Hospital in east London from Pakistan that September, and was still adapting to British culture when Christmas and its traditions arrived in force. ‘On Christmas Day in London, everything was covered with snow,’ says Dr Qureshi, then a 29-year-old house officer originally from India. ‘And I noticed for the first time that everyone was white except me: the patients, doctors, nurses, paramedics, porters, and the cleaners.

Dr Qureshi and one of his medical publications

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‘As a child, I learnt angels were white, made of light. I thought I was in heaven.’ A consultant dressed as Father Christmas carved the turkey on the ward and poured every patient their favourite alcoholic tipple, ‘including the one with alcoholic cirrhosis’. Dr Qureshi pushed the wine and spirits trolley, while the formidable ward Sister handed out the drinks with an uncharacteristic smile. ‘Pearly kings and queens came to the hospital, sang carols and danced,’ says Dr Qureshi. ‘England was so peaceful, everyone looked happy. It was magical.’

gestures were very disconcerting. When one male charge nurse advised Dr Qureshi to prescribe laxatives for every patient so the nurses wouldn’t have to bother him in the night, the nurse followed up the advice with a wink. ‘I was taken aback because winking is a sexual gesture in the east and I’m a strictly heterosexual soul.’ Language had its trip hazards too. ‘A staff nurse asked, “Would you like a date this evening, doctor?” “No,” I replied, “I find them hard to eat.” I thought turkey was a country. My English was different from the English and I am still learning.’ Dr Qureshi, who trained in Pakistan, was one of the 18,000 doctors from south Asia to be given work permits by the UK Government in the early 1960s, in response to an appeal by then health minister Enoch Powell. He has stayed in London for almost six decades. Christmas traditions have become more familiar over the years. But Christmas has

ANOTHER ERA: Dr Qureshi on Christmas Day in 1964 at Whipps Cross Hospital, London, where he was a house officer

‘Pearly kings and queens came to the hospital, sang carols and danced’

Cheeky wink But that first Christmas was also a crash course in British body language and tact for Dr Qureshi. ‘I joined the nurses in carol-singing, without opening my lips. I didn’t know carols or the tune, but I joined in.’ The ward Sisters were powerful and fierce, he recalls, ‘but nicer at Christmas’. It was strange enough that several of the charge nurses were male, but some of their

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Dr Qureshi

sometimes been demanding in other ways. ‘One night in 1966, I was on call at a hospital in London, when I was called to see a nurse who had died after jumping from a window,’ recalls Dr Qureshi. ‘I noted then that at Christmas, couples meet and split. Emotions are high and it is wise to care for mentally ill patients as much as possible. ‘When I worked at Christmas, I was paid double and I served all patients with double energy. I knew that patients who arrived during Christmas were more ill.’

The English way After four years in London hospitals, Dr Qureshi worked as a GP for 47 years, and still has a licence to practise, issued during COVID. He is also an expert in transcultural medicine, lecturing and writing on how to interact with patients of different cultures, ethnicities and religions, and an expert witness in cases of clinical negligence. That first Christmas of ’64, Dr Qureshi recalls that he had ‘thick black hair, a moustache turning upward, slim figure and no sense of humour’. Dr Qureshi is now in his 80s and ‘no longer needs a comb’ but he is starting to get the measure of the English. ‘I’ve learnt the English sense of humour and that often, what is said means the opposite. An Englishman might say, “I may be wrong,” but he really means that he is right.’ 10

When Christmas comes early

PALLAN: It’s about making every moment matter

eelings run high at Christmas and never more than when you fear it may be your last. For the team at Birmingham Hospice, there’s an emotional intensity to their care at this time of year and they pull out all the stops for their patients. And if that means celebrating Christmas in September as they did for one man last year, then so be it. For ‘12 days of Christmas’, a patient with no family had daily presents, a giant inflatable snowman, fake snow and a real Santa. During Christmas proper, every patient in the Erdington and Selly Park inpatient units has presents, as well as a Christmas tree in their room and Christmas dinner of their choosing if they would like them. The local community goes into fundraising overdrive too, with raffles, jolly jumper days and Rudolph runs. ‘When people have a life-limiting illness, they have a chance to make the most of whatever time they have left,’ says Shurma

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‘LIKE A WARM BLANKET’: Staff and patients at Birmingham Hospice

BIRMINGHAM HOSPICE

Pallan, a specialty doctor who provides palliative medicine in the hospice and the community. ‘So we always do the best we can, so that they can live well and make every moment matter for them and their loved ones. When people first come here, they say, “It’s like a warm comfort blanket around you, as soon as you come in.” Nothing’s ever a bother.’ One question has dominated Dr Pallan’s conversations with patients and their families for months now. ‘Throughout the year, a lot of our patients will ask us: “How long have I got?” But when it comes to the end of the year, it’s more often, “Am I going to make it to Christmas?” Or “Is my family member going to be here for Christmas?” ‘Christmas is an important milestone, even if you don’t celebrate it, because it’s linked with the new year when people make new plans and reflect on the year they’ve had with their loved ones. It brings up a lot of emotions.’

Most of Dr Pallan’s patients will not see another Christmas so the festivities too can evoke mixed feelings. ‘One patient changed her mind about what decorations she wanted on her Christmas tree on a day-to-day basis but that was fine: we want to make that difference for our patients. But we don’t force Christmas on them.’ For all the jollity, carols and roast turkey, it can be a very difficult time for patients who are struggling with their symptoms or for relatives whose loved one is close to death. Like everyone on the team, Dr Pallan is generally on call for one day over the Christmas period and she has worked Christmas Day. ‘When someone dies at Christmas, that’s always going to be hard for that family as an anniversary because you can’t avoid Christmas at this time of year. It can be a constant reminder of their loss.’ Working over Christmas can be hard for the medical team too: ‘not taking work home’ becomes doubly important at this time of year. But it’s easy to be ambushed by personal

‘Patients ask, “Am I going to make it to Christmas?”’

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THE ENTERTAINER: Mr Denham carves the turkey with Dr Curtis’s aunt and uncle as children

connections and feelings. ‘As a human being you can’t help making similarities with people you meet, someone who’s the same age as me or with similar-age children as me. ‘And it’s somehow harder when you see people in their home, in their environment, and you’ve got that little extra insight into how they live. ‘Later, whilst typing my notes and reflecting, I tell myself I’ve done as much as I can to help my patients. I can’t stop them from dying but I can make a difference in the way that they die.’ The multidisciplinary team has a monthly debrief together, called ‘Learning from deaths’. It’s an opportunity for staff to share their feelings and experiences around deaths in the previous month and review if anything could be done differently. This shared reflection is an important part of protecting the team and their wellbeing: they look after each other. But staying boundaried is often harder at Christmas. ‘We try to separate out work and home life for our own wellbeing. But January’s meeting will probably be busier because it’s that time of year when people find it a bit more difficult.’ 12

Miss World on the wards

rom her earliest years, Olivia Curtis learnt that ‘Christmas Eve was for family, Christmas Day was for the hospital’ – because Granddaddy insisted upon it. Her grandfather, Robin Denham, would spend every Christmas Day visiting every ward, whether or not he was on call as an orthopaedic surgeon. He took very seriously his role of carving the turkey for his patients as the senior consultant – and always dressed up for the occasion. Indeed in 1964, the year of Dr Qureshi’s first ‘white Christmas’, Mr Denham was making a memorable appearance as ‘Miss World’ in Queen Alexandra Hospital in Portsmouth. He would often take his children with him, dressed as elves or angels, to hand round the plates and be spoiled by the nurses. His granddaughter Olivia is now Dr Curtis, a specialty trainee 7, who completes her respiratory training this month in Kent. When she has worked over Christmas, her grandfather’s example has always helped.

MISS WORLD: Mr Denham crowned on the wards

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‘I think he felt it was his responsibility to be there because they were his patients,’ says Dr Curtis. ‘But also, he felt that Christmas wasn’t a time to be by yourself because you were in hospital: he didn’t want his patients to be missing out. It was very jovial and cheerful with lots of crackers and silly hats. ‘The way he prioritised his patients reminds me how important our work during the holiday period can be. It has always felt worth it and important to be there.’

Traditions upheld Decades later, his family still exchange gifts and have their ‘big dinner’ on Christmas Eve. It works well for them: Dr Curtis has a sister who is a midwife and another who is a stage manager in the West End so any time together around the Christmas table is ‘always a bit of a Christmas miracle’. But it’s mostly because of Granddaddy and the tradition he started. Mr Denham’s daughter – Dr Curtis’s mum – still talks fondly of childhood Christmas Day at the hospital, even though she shared her father with his patients. Yet, it was Mr Denham’s grandchildren who followed him into medicine: a midwife, a nurse and two doctors. ‘Granddaddy was a bit of a cliché as an orthopaedic surgeon because he was very good at woodwork, made lots of furniture,’ says Dr Curtis. ‘Because I was interested in medicine from quite a young age, he’d always show me bits of bone and models and strange X-rays. ‘He was a big part of our growing up: he was always very encouraging and larger than life, quite eccentric.’ Mr Denham was also something of a pioneer, with inventions such as a knee replacement and the ‘Portsmouth method’, an external bar to fixate tibial fractures. ‘Work was very important to him, part of who he was and how he defined himself. ‘We always think of Granddaddy while planning our Christmas Eve: we know it’s because of him that we do things that way around.’

A research post and two periods of maternity leave in recent years have meant Dr Curtis has not worked over Christmas and New Year for a while – but she used to, quite often. There may not be turkeycarving on the ward these days but teams still work hard to bring festive cheer: Christmas trees made of latex gloves, plenty of tinsel, carols on a loop and (a specialty in respiratory) cartoon angels with lungs for wings.

No Christmas jumpers Sharing good news, allowing people home, is particularly heartening at Christmas. But bad news can feel even more heart-breaking. There’s a real need for sensitivity. ‘I tend not to wear Christmas jumpers, or too many comedy things, because I don’t want to have to be breaking bad news wearing a reindeer jumper,’ says Dr Curtis. ‘But I know some people think differently: they want to be projecting as much joy and happiness as they can in case people are feeling sad and it helps them. ‘For people who get sick or die around Christmas time, it will change their families’ Christmases forever. And so being able to care for them as kindly or as peacefully as possible – important parts of medical care throughout the year – feels a bit more important at Christmas.’ This Christmas, thoughts of Granddaddy will be particularly strong for Dr Curtis: she starts a new role as a consultant next year. ‘I’ve been thinking about whether, next Christmas, I’ll do the same for my patients as Granddaddy did. I must admit I’m not certain. ‘But I am expecting to have to go into work over Christmas at some point and it’ll be a good opportunity to talk to my own children when they’re older about what really matters at Christmas.’

CURTIS: Inspired by her grandfather’s dedication

‘He felt that Christmas wasn’t a time to be by yourself because you were in hospital’

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FIRST AMONG EQUALS A year on from the ﬁrst industrial action ballot being called, BMA junior doctors committee co-chairs Rob Laurenson and Vivek Trivedi speak to Ben Ireland about how far they have come and what lies ahead

‘W

e are just regular doctors.’ Vivek Trivedi is keen to stress this point throughout an interview with The Doctor in which he and fellow BMA junior doctors committee co-chair Rob Laurenson reﬂect on the challenges and achievements of the last year. It’s been quite the year. The BMA – driven in no small part by the actions of its junior doctors committee – has reached record levels of membership, organised the biggest coordinated strike action in NHS history and set huge policy decisions on touchstone issues. The importance of the JDC co-chairs being representative of working doctors is not lost on the pair, who have been thrust into

the spotlight through live TV appearances, social-media fame, and being the subject of special attention from certain newspapers. Balancing the workload that comes with the co-chair positions while in specialty training (Laurenson GP; Trivedi, anaesthesia), is not without its logistical challenges. As Dr Laurenson explains: ‘We’re in touch with 40,000odd doctors at the end of our phones. We communicate daily, responding within hours.’ Noting the importance of organisation in eﬀective trade unionism, he adds: ‘Members can feel that. Their union is incredibly responsive now, which gives them faith and trust in the function of the institution.’

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Empowerment

‘Doctors are willing to stand up for ourselves. That can only be a good thing’

Dr Trivedi recalls how, early in the pay restoration campaign, a major challenge was getting doctors – especially those on rotations – to update their details with the BMA so their votes could be counted (a successful ballot requires a majority to vote in favour from a minimum turnout of 50 per cent of eligible voters). This was of course comfortably achieved in February, with 98 per cent in favour from a turnout of 77 per cent and followed up with 98 per cent voting in favour from a turnout of 71 per cent in a summer reballot which extended the JDC’s strike mandate beyond Christmas. The long-term effect of the initial engagement drive was a sense of empowerment and camaraderie among doctors, not just in the fight for pay restoration but a range of issues. ‘Doctors are not being taken for a ride any more,’ says Dr Trivedi. ‘We are willing to stand up for ourselves. That can only be a good thing. It will hopefully help them seek out more training opportunities or prevent them from feeling burnt out and victimised – things which might push people out of the profession.’ Pay has been central, however. Dr Laurenson says it has been crucial to ‘destigmatise’ conversations about remuneration, which can ‘often feel uncomfortable’. ‘One of the prominent

MARCHING ON: Dr Laurenson and Dr Trivedi on a rally in the summer

underlying stresses that anyone feels stems from financial pressures,’ he explains. ‘If you turn a blind eye to that you’re going to leave thousands of people feeling a bit lost, rudderless and disenfranchised.’ Dr Laurenson adds that doctors can feel ‘disempowered, disrespected and devalued’ working in an NHS which now ‘looks very different to how it did when you signed up’. A ‘cultural shift’ over the past year has seen doctors across the board become more confident to talk about pay and working conditions, and to identify the underlying problems, he says. ‘It’s OK to talk about these issues, and then you can present solutions which people can get on board with.’ The co-chairs say a renewed energy, momentum and confidence has manifested itself in a groundswell of BMA members getting involved at a grassroots level, creating a ‘positive feedback cycle’ that helps effect change in all manner of ways. Their plan, from the outset, was ‘flattening the hierarchy’ of the BMA, so

that members and elected representatives felt a common sense of purpose and importance. Harnessing social media has been key in driving engagement. So has setting clear objectives. Reflecting on the 2016 strikes, Dr Laurenson says arguments were lost in the nuance of contract renegotiations. By contrast, the ‘big idea’ of pay restoration this time round is more tangible. The JDC co-chairs don’t elaborate on the potential outcome of talks, which were ongoing at the time of interview, with agreements to keep details in the negotiation room. But assessing the virtue in long-term promises against concrete changes to remuneration, Dr Trivedi says the experience of 2016 taught doctors ‘you need things written down’. ‘There’s an age-old adage that “if it’s not documented, it didn’t happen”, so doctors want to make sure that whatever is dangled in front of them is robust because ultimately if that slips through the net then we’re letting slip the ability thedoctor | December 2023

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to retain our colleagues in the future – which will only go to harm everyone in our healthcare system,’ he says. Becoming the faces of the campaign has unavoidably raised both co-chairs’ profiles, and while they appreciate kind words from BMA members thanking them for their efforts, they are at pains to point out the hard work of many other representatives in less public positions. ‘We’re not doing anything more than pulling the legal levers that allow members to defend the profession,’ says Dr Laurenson. ‘I don’t think many people will ever understand just how important the people behind the scenes have been.’

Media attacks Dr Trivedi agrees and describes the co-chair roles as being ‘a conduit’, ‘channelling a collective voice, that many people probably didn’t know they had’. He adds: ‘We wouldn’t be in this position if the profession wasn’t in the position it is in now. If doctors weren’t willing to stand up and speak up for

themselves at local levels, which gives us strength at a national level, we wouldn’t be here.’ ‘I didn’t get into this from a profile point of view,’ Dr Laurenson stresses. ‘I saw this movement growing and I thought, “I can’t go out without a fight. I need to do something”.’ But putting himself forward as a spokesperson has led to media ‘hit jobs’ from the right-wing press and even death threats. While he shrugs off some of the stories written about him as ‘amusing’, Dr Laurenson says his views on how some parts of the media operate have been affected by his experiences: ‘I always used to have a lot of hope and thought negative views of the mainstream media were conspiratorial, but when vested interests are involved it feels quite obvious how the media is used as a weapon rather than a tool for disseminating facts and information.’ Dr Trivedi has faced fewer personal attacks but praises his co-chair’s handling of the situation as ‘admirable’. For his part, Dr Trivedi has appeared on political talk

shows and prime-time news programmes answering sometimes politically loaded questions from journalists and facing down MPs in debate. Again, being a regular doctor helps, because: ‘It usually just feels like a conversation about a subject I understand. ‘I’m not embarrassed ‘The media about what we’re trying to is used as say, I’m not trying to hide a weapon anything, so I find it easy rather than to answer questions quite a tool for disseminating directly without trying to remember the perfect way facts’ to say it.’ Talking about the level of responsibility on their shoulders in the public eye brings us on to the term ‘junior doctors’. Work on a replacement name for this group of doctors is under way after a motion passed at this year’s BMA annual representative meeting to discontinue its use. ‘It ties into so many aspects of professional life for doctors,’ says Dr Trivedi, who explains how doctors, often on rotation, introduced as a ‘junior’ feel like ‘they are seen as lesser, in some way’. Dr Laurenson He blames structural and Dr Trivedi at systems for infantilising a rally this year TRIVEDI: ‘Channelling a collective voice’

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many experienced doctors in the eyes of their colleagues and patients. Dr Laurenson believes an attempt to tackle historic elitism in medicine by terming some doctors as junior has ‘gone too far’ and can have a negative effect on outcomes for patients. Blurred lines of responsibility and scope takes us to the debate about medical associate professions, such as PAs (physician associates). The BMA is now calling for ‘an immediate halt’ in the employment of MAPs until the Government and NHS put guarantees in place to make sure they are properly regulated and supervised. ‘You can’t just say you’re doing the role of a doctor when you’re not a doctor,’ Dr Laurenson says, pointing out that a ‘manufactured workforce crisis’ through years of austerity has led to the lack of doctors and thus government plans to train and recruit as many as 10,000 PAs.

Lack of retention plan There is a ‘little bit of a repeat’ with the NHS Long Term Workforce Plan, he says, in that while there is a proposed expansion in medical school placements, ‘there is no retention plan’ to stop the increasing numbers of doctors leaving the NHS. Dr Laurenson argues: ‘The same thing is going to happen. Doctors are going to get trained and they’re just going to leave.’ Before standing for BMA election, he himself had bma.org.uk/thedoctor

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‘made a decision to leave the country’, because ‘I couldn’t see anything getting better’. He describes a sense of ‘civic responsibility’ to prevent ‘a tragedy unfolding’ in the profession. Involvement with the Doctors Vote slate, which began with frustrated doctors talking on social media and now counts dozens of elected BMA representatives as its backed candidates, was critical to Dr Laurenson’s decision to stay and fight. He compares Doctors Vote to ‘a trade union within a trade union’ with ‘a coherent strategy, and communication’. ‘It’s all about collective action and power,’ he notes, arguing that having slates within a union can help empower greater democracy in the organisation and encourage more groups to form around specific issues or to champion certain groups of doctors. Dr Trivedi says: ‘It’s no secret Doctors Vote was a catalyst in getting the profession engaged, because there was a lot of disillusionment before. ‘I’m a prime example of this,’ he adds. ‘I wasn’t a member for a very long time and saw a group of people who thought “let’s see what we can do”. ‘Ultimately, you can sit around and complain about how things are, or you can try to make a difference, and that’s what Doctors Vote is trying to do. A lot of people have resonated with that ethos. Initially it

LAURENSON: ‘It’s all about collective action and power’

‘Doctors are going to get trained and they’re just going to leave’

was very much about full pay restoration. Over time, a plethora of other issues have risen to the forefront. ‘That shared feeling helped get members engaged and has kickstarted the BMA, which is now keeping members engaged in its own right.’ Again, championing the democracy of the BMA, the co-chairs are aware that – however the negotiations go – they will be ‘held accountable’ by members. Members will always get the final say on any government deal on pay and conditions in a democratic vote. But whatever the outcome, as Dr Laurenson points out, a re-energised BMA with record numbers of members will not be sitting still, whoever is pulling the levers of the ‘junior’ doctors committee. With the wheels in motion on policies covering conditions, rotation, training, regulation and many more issues, Dr Laurenson points out: ‘The conversation will very quickly become “what do we need to fix next?”.’ Note – this article went to press on Monday, 4 December thedoctor | December 2023

04/12/2023 10:58

GETTY

LOOKING BACK: Doctors’ experiences must inform future pandemic planning

GETTING YOUR VOICE HEARD It’s vital that doctors’ experiences of the pandemic are heard and learnt from. But giving evidence to the COVID inquiry requires a huge amount of work behind the scenes. Jennifer Trueland reports

he UK COVID-19 inquiry is a major enterprise expected to last until at least 2026. The BMA successfully applied to be a core participant in the first four modules – meaning the voice of doctors will be heard throughout. BMA council chair Phil Banfield has already given evidence to the inquiry twice, sharing first-hand testimony from doctors about how the pandemic affected them, and showing how the BMA raised concerns with ministers and Government officials directly, as well as through public statements, from early 2020 onwards. He also detailed how so much of this was ignored or disregarded. But these high-profile appearances – although important – are only the tip of the iceberg when it comes 18

to the enormous amount of effort which goes into the BMA’s contribution to the inquiry, says Professor Banfield. ‘BMA staff across the organisation have been working incredibly hard collating and presenting evidence held in thousands of documents, emails and reports which reflect BMA members’ and staff’s central roles during the pandemic, to make sure the authentic voice of doctors is heard throughout the COVID-19 inquiry,’ he says. ‘Doctors and other care staff risked their lives simply by going to work – it’s morally and professionally imperative the BMA ensures their testimony isn’t ignored and that this is recorded so preparedness and responses to future pandemic threats are improved. It is not a matter

of whether but when these will most certainly come our way again.’

Members’ testimony The BMA’s COVID steering group – chaired by Prof Banfield and including representatives from the main branch of practice and professional committees – has played an important role in shaping the BMA’s response to, and involvement with, the inquiry. However, the process and work behind the inquiry is also a huge enterprise for BMA staff across a wide variety of departments. There are also challenges with communicating this to members, because being a core participant means much of the work the BMA is doing to feed into and influence the work of the inquiry is confidential and successes

‘Doctors and other care staff risked their lives simply by going to work – it’s morally and professionally imperative the BMA ensures their testimony isn’t ignored’

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bma.org.uk/thedoctor

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make sure workplaces are better resourced, and that our members are better protected from contagious and dangerous diseases.’ To be accepted as a core participant, the BMA had to demonstrate it had a significant interest or role in the topic area of each module, says Claire Chivers, who is part of the BMA’s population health team, headed by Suzanne Wood. ‘There are a limited number of organisations or individuals that can be core participants. The fact that the BMA is there demonstrates the organisation’s commitment to making sure that if there is a future pandemic, it doesn’t have the same impact on doctors and other healthcare staff as this one did.’

BMA

cannot be shared with members, says Lena Levy, the organisation’s head of public health and healthcare. ‘The BMA is playing a very active part in the COVID inquiry, and it’s taking up a huge amount of staff time and resource,’ she says. ‘We’re doing it for a very good reason – because we want the voices of doctors to be heard – but we’re not really able to shout about it and tell members about everything we’re doing.’ She believes it’s vital for the BMA to be closely involved in the inquiry process. ‘The pandemic affected all our members – their work changed significantly, they put themselves in harm’s way – often unprotected. This inquiry is about setting the record straight on what happened and ensuring the profession and wider public will be better protected going forward. That’s why we’re part of it.’ A lot of the work involved in being a core participant in the inquiry is behind the scenes, she says, such as reviewing witness statements and suggesting lines of questioning for the inquiry to ask witnesses. BMA staff have also pulled together testimony from members affected by COVID – partly gleaned from the organisation’s regular surveys of members throughout the pandemic. ‘What matters is that the testimony of our members is at the heart of the inquiry, and that, with the help of our members’ intelligence and knowledge, the right questions are being asked. ‘It’s on us to make sure we scrutinise and help the inquiry to find the right answers to make things better, to

led to doctors being exposed and possibly harmed as well. ‘We want our members to have confidence we are an authoritative voice, and that we will reflect their views and experiences. And we know we are being seen as an authoritative voice in the inquiry, speaking for doctors.’

BANFIELD: Pictured at the inquiry

PPE warnings BMA senior research adviser Duncan Bland believes the BMA’s position as the largest membership organisation for the profession gives it a unique responsibility to represent doctors during the inquiry. ‘We want to represent the issues that we know are important to doctors, where they feel they have been badly exposed and let down and poorly protected throughout the pandemic,’ he says. It’s also important to demonstrate that the BMA’s advice and warnings throughout the pandemic, albeit not always listened to, were right, he adds, including on when to impose and unlock restrictions, for example. ‘We were also very vocal throughout the pandemic around the lack of PPE – and we’ve got evidence that this lack of protective equipment

Elements of the inquiry The UK COVID-19 inquiry has five active modules These are: – Resilience and preparedness – Core UK decision-making and political governance – Effect of the COVID-19 pandemic on healthcare systems in the four nations of the UK – Vaccines and therapeutics – Procurement. Future modules – the first of which will be the care sector – will be announced in the coming months.

thedoctor | December 2023

04/12/2023 10:58

it happened to me 20

GEOFF OLIVER BUGBEE/ORBIS

Doctors’ experiences in their working lives

IN PLANE SIGHT: Mr Ferris (right) aboard the Flying Eye Hospital with Joan Higginbotham (left)

Reaching for the stars

t is not every day that you get to work with an astronaut. Joan Higginbotham, an outstanding electrical engineer, flew as a mission specialist to the International Space Station in 2006. When you’re training to be an astronaut, there is a huge emphasis on simulation training. Not surprising, really, given the perilousness of space travel. Just as we wouldn’t want new astronauts to be launched into space without practising first, simulation also allows surgeons to practise in a controlled environment. So, it was a real pleasure to have Joan with us for an Orbis Flying Eye Hospital trip to Peru in 2018, the first week of which was dedicated to simulation training. Orbis is an international eye-care charity which has been a pioneer in the prevention and treatment of avoidable blindness for more than four decades. The Flying Eye Hospital, which on the outside looks like any other aircraft, is a state-of-the-art accredited ophthalmic teaching hospital. It goes all over the world, and the volunteer faculty – mostly ophthalmologists, anaesthetists and nurses – travel to those places to train the local eye-care team on the aircraft and within a local hospital. With Tom Oetting, a professor of

ophthalmology from Iowa, we taught on the aircraft and in local hospitals, with first-, second- and third-year trainees. The Orbis nurses were training local nurses, the anaesthetists were training local anaesthetists, and live surgeries were performed in the final week of the project. We were teaching the local eye-care teams cataract surgery, strabismus surgery, glaucoma and oculoplastic surgery. We also taught corneal surgery and laser treatments. It was a combination of virtual reality simulation, with the high-tech simulation kit on the aircraft, but also low-tech simulation

SMALL STEPS: The Flying Eye Hospital provides a highquality training environment

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with model eyes, which can be used to practise almost all of the steps involved in most common eye operations. Joan, who was there with UTC Aerospace Systems, which partnered with Orbis for the project, watched the simulation training and then tried it herself, and wasn’t bad at all. Joan was able to see Orbis’s effect, because the third-year ophthalmology students, whom we had taught in the morning how to do strabismus surgery, were now confident enough to teach the first-year trainees, who had arrived after lunch. The students were even using the exact same phrases we had been using to teach them. Joan said to me: ‘There’s your legacy – within the first morning of the trip.’ I’ve been on two projects with Orbis, the second being in Chile in 2019, the year after the Peru trip. The team spirit has always been terrific. What I particularly like about Orbis is the way it adds value. If you can teach 10 local surgeons how to do a procedure, and how to teach others to do it, it means thousands will go on to be carried out. I have also learnt a great deal from my fellow medical volunteers, which I have brought back with me. The biggest impression my Orbis trips have left on me has been the level of enthusiasm the trainees have for learning. It is tremendously rewarding to see the progress they make in such short periods of time. Back in the UK, I strive to encourage that same level of enthusiasm in my trainees. For more information about Orbis, donating, and volunteering, visit www.orbis.org.uk John Ferris is a consultant ophthalmologist based in Gloucestershire

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thedoctor | December 2023

04/12/2023 10:58

Your BMA The BMA stands in solidarity with members aﬀected by the conﬂicts in Gaza and Israel

thedoctor

Responding to trauma and alleviating suffering are fundamental aspects of our roles as medical students and doctors. Sometimes, however, trauma and suffering are of such magnitude it is impossible, even for medical professionals, to not be affected on a human level. I know you will all be aware of the conflict in Gaza, the West Bank and Israel. Many will have seen the harrowing images of death and destruction. As of 23 November, more than 14,800 Palestinians (including 6,000 children) and 1,200 Israelis have been killed. Following a fragile truce, and a temporary cessation to the violence to allow the arrival of crucial aid, the humanitarian tragedy in Gaza has continued. Since the start of the conflict, the BMA has issued several statements including the call for a ceasefire, a position rooted in our long-standing commitment to principles enshrined in the association’s democratic policy – these are issues of fundamental importance to our members. While conflicting accounts and accusations permeate the fog of war, we continue to ask leaders and combatants to respect international humanitarian law. These principles include our absolute opposition to the targeting of civilians or healthcare facilities in conflict areas. Healthcare workers in the conflict areas are exhausted, working under unimaginable pressures, and many without necessities including adequate water, fuel and medication, limiting their ability to care as well as affecting their own physical and mental health. The only side doctors take during conflict is that of their patients, and no healthcare professional should ever have to make a decision on who they provide treatment to or be the target of military action.

The Doctor

We stand in solidarity with doctors and healthcare workers in Gaza and anywhere else who are living and working under intolerable conditions. With the approach of winter, Palestinian people, two thirds of whom are women and children, and more than 1.8 million of whom have been displaced by the conflict living without access to adequate water, food, fuel and shelter, will continue to need urgent humanitarian support, and our healthcare colleagues will continue to work under extreme pressures. I know many of you will have been deeply and personally affected by the conflict, and I want to offer my sympathy and support to those of you with friends or family in Gaza, the West Bank or Israel. We have heard concerns from individual members, groups and representative organisations. The conflict has also resulted in an appalling rise in racist and xenophobic abuse and attacks across the world, including the UK, with this victimisation coming in person, online and even within the health service. Let me assure you, the BMA is absolutely resolute in our opposition to any form of bigotry, be it Islamophobia or anti-Semitism or any other form of discrimination, and to any of our members being targeted by such discrimination in their workplaces; your BMA is here for you – please do get in touch – email: support@bma.org.uk or call 0300 123 1233 A statement offering support for UK doctors affected by the conflict can be found on the BMA website. If any medical student or doctor is in need of wellbeing support our helpline is here for you 24/7 and can be reached on 0330 123 1245. In turn, NHS England and employers must ensure doctors, medical students and other healthcare staff affected by this tragedy are able to discuss the crisis, and to talk about what they are going through within a psychologically safe environment in which their mental and emotional wellbeing are supported. As ever, I welcome your thoughts and I thank the many members who have already been in touch. Dr Latifa Patel is chair of the BMA representative body RBChair@bma.org.uk @DrLatifaPatel

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: 8410 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: MSF Read more from The Doctor online at bma.org.uk/thedoctor

04/12/2023 10:59

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HELP SUPPORT OUR MEDICAL TEAMS TODAY WE CAN’T OPERATE WITHOUT YOU Every year, MSF teams carry out tens of thousands of surgeries. From treating war wounds to emergency caesareans and reconstructive surgery, our surgeons are at the frontline of our lifesaving care. In 2022, MSF teams around the world conducted more than 118,000 major surgeries. In the places where we work, demand for surgical services has never been higher. We need your support now more than ever to provide people with lifesaving medical care.

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Jessica Comi (left) and MSF surgeon Dr Federica Lezzi extract a bullet from a patient shot just above the knee during fighting in the Sudanese capital. Bashair hospital, Khartoum, 13 May. Photograph © Ala Kheir/MSF

“We arrived in Khartoum on a Monday and started operating at noon the following day. The first week was incredibly challenging. Every time we heard explosions, we got ready for a mass casualty incident – a situation where lots of wounded people arrive at the same time. You never know if it will be 20 or 40 or 100 patients. One day, 127 patients arrived in a short space of time after a series of explosions. Very quickly we were inundated with wounded men, women and children. Seventeen people were dead on arrival. The emergency room was full, the two operating theatres were full. In one theatre, we were trying to manage the most complex cases; in the second, we were working on cases that were a bit less complicated. That day, we ran the operating theatres until four or five in the morning. We worked non-stop.

War surgery is complicated. Working with wounded patients brings a lot of challenges and, if you aren’t used to doing this type of surgery, it can be especially difficult. You need to know the potential risk for a patient if they are not treated immediately – risks such as infections or losing a limb or haemorrhaging. Bullets and shrapnel are dirty and they create massive wounds, so in a war zone you treat every single wound as already infected. These injuries are complex and you need to act quickly. Our team was experienced and that expertise made a big difference.

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JESSICA COMI IS AN OPERATING THEATRE NURSE WHO WORKED FOR MSF IN KHARTOUM, SUDAN.

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