The Doctor – issue 11, July 2019 by The BMA

The magazine for BMA members

thedoctor

Issue 11 | July 2019

My patients went to the Moon An interview with the Apollo 11 doctor

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

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Editor Neil Hallows (020) 7383 6321

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Chief sub-editor Chris Patterson

0300 123 1233 @TheDrMagazine @theBMA The Doctor is published by the British Medical Association. The views expressed in it are not necessarily those of the BMA. It is available on subscription at £160 (UK) or £225 (non-UK) a year from the subscriptions department. All rights reserved. Except as permitted under current legislation, no part of this work may be photocopied, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical or otherwise without the written permission of the editor. Printed by YM Chantry. A copy may be obtained from the publishers on written request. The Doctor is a supplement of BMJ vol: 366 no: 8207 ISSN 2631-6412

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

In this issue 4-7

Briefing: ARM 2019 Fighting inequality in the workplace, the pensions crisis, and junior doctors vote yes to contract changes

Welcome Chaand Nagpaul, BMA council chair Welcome to the July issue of The Doctor – the first following our 2019 annual representative meeting in Belfast. This year’s meeting showcased much of what is best about our profession and the BMA. We discussed the biggest issues facing us as doctors, the NHS and wider society – and, most importantly, considered solutions as well as identified problems. From homelessness and mental health to contracts and pensions, the BMA will be a leading voice for positive change in the coming year, as a result. We showcase some highlights of the ARM debate in this issue, but many more are available online at bma.org.uk/news It is a pleasure to feature the story of Bill Carpentier, flight surgeon to Neil Armstrong, Buzz Aldrin and Michael Collins, who made history 50 years ago as part of the Apollo 11 mission that landed on the Moon. The piece is a fascinating insight into the stories behind the ‘giant leap for mankind’, and also speaks to the humanity that is at the heart of our vocation. This month’s issue also includes an important investigation, which reveals that people with severe mental ill health are being routinely ‘warehoused’ in locked, private wards hundreds of miles away from their homes for want of NHS provision in their area. As one of the interviewees in this piece says: ‘This is a human rights issue.’ For too long we have denied mental health patients the care and priority they deserve. This simply has to change. We are an advocate for the NHS and patients but our mission is also to improve the terms and conditions and daily working life for doctors on the front line in every part of the UK. Our research into hospital trusts’ use of escalation beds, long after the winter has passed, highlights the pressure doctors are under every day – and we will be demanding the NHS is given proper funding for beds and staffing, in line with our European neighbours, based on these findings.

8-13

Sent away, locked away Patients with severe mental ill health are being sent far from home to locked private wards

14-19

The man behind the astronauts Meet the Apollo 11 doctor, 50 years after his patients landed on the Moon

20-23

The lights are on... Two years without politicians might seem tempting but in Northern Ireland it has caused serious harm to the health service

24-27

Nature’s remedy In Shetland, doctors can prescribe the islands themselves

28-29

For want of a bed Beds meant only for emergencies or spikes in demand are being pressed into service all year round

On the ground A visually impaired doctor’s battle for justice

What’s on Keep on top of events

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briefing: ARM 2019 Current issues facing doctors: The Doctor reports from the BMA annual representative meeting in Belfast last month

Equality matters Equality is a value often associated with the NHS – but not one reflected in its workforce, BMA council chair Chaand Nagpaul has said. In his keynote address to the BMA annual representative meeting in June, Dr Nagpaul (pictured above) said doctors from BAME (black, Asian and minority ethnic) backgrounds were ‘more likely to be bullied, less likely to raise concerns, more likely to feel blamed and less likely to feel included’. Dr Nagpaul raised awareness of BAME doctors and medical students having lower pass rates in UK exams, despite no evidence of a lack of ability. He said the BMA had campaigned hard against this ‘gross injustice’ but that doctors should recognise it was not ‘someone else’s problem’, and announced a new ‘equality matters’ programme to provide training on bias, equality, diversity and inclusion to every elected member, with all BMA members able to access online modules. Dr Nagpaul pledged to put measures for members to speak up in place, including an

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independent helpline, early intervention and learning to resolve issues. He said: ‘We must role model the standards of civility that we expect of others so that doctors can demand the same of their own workplace in our determination to stamp out discrimination across the NHS.’ Fairness and equality were also about ‘proper pay, terms and conditions’, Dr Nagpaul said, warning that ‘perverse and punitive’ pension rules for doctors would ultimately make patients suffer because it would drive doctors to retire early or not take on extra responsibilities. Dr Nagpaul used his speech to send a message to the Government. He said: ‘I’ll say this to ministers. If you want doctors to pay to go to work, they won’t. I tell you who pays – our patients, left without doctors in a desperately understaffed health service. ‘The Treasury is taxing doctors out of the NHS and seriously undermining patient care. It must act now to avert a workforce meltdown.’

ARM 2019

A ‘yes’ to success Junior doctors in England voted overwhelmingly in favour of accepting negotiated contract improvements – accepting an investment in terms and conditions of £90m over four years and a 2 per cent pay uplift each year. Announcing the news at the ARM, a delighted BMA junior doctors committee chair Jeeves Wijesuriya (pictured below) said the deal represented a ‘clear answer’ from members. ‘I wanted to be able to come here today and tell you that we had succeeded. I’m pleased to say that I can. Colleagues… it is a yes,’ Dr Wijesuriya told a packed audience in Belfast, to strong applause. ‘It’s a yes to safety. To junior doctors no longer having to choose between driving home exhausted after a long shift or paying to stay. It’s a yes to humanity, to extended periods of leave when we need it and time off when we need it most. It’s a yes to new money – £90m over four years and a guaranteed 2 per cent pay uplift each year. ‘It’s a yes to better pay for weekends and late shifts

– something the Government told us three years ago that it would never concede. ‘To £1,000 a year extra for less-than fulltime trainees and an extra point on the pay scale for the most senior registrars. ‘It’s a yes to using exception reporting when we miss out on our training. It’s a yes to the independently validated study of the impact on equalities.’ Dr Wijesuriya added: ‘Our fight for working conditions is not over, and it never will be. But we are already on the road to delivering stepon, step-off training, and more flexibility so we can reflect the reality of our members’ lives.’

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FREE STANDING: An ARM delegate browses the Faces of the NHS exhibition

Tax-charge trigger Pensions can normally be seen as simple machines for a simple job. You pay in for an income on retirement. Like aeroplanes or cars, there’s no need to understand their complexities – as long as they do what they promise. The NHS pension scheme for doctors is, however, in a horrible fix, forcing the profession to open the lid and get intimate with its complexities. Senior doctors are cutting their hours, retiring early and turning down extra responsibilities or shifts because of the machinations of punitive pension rules. Rules on their tax-free annual pension allowance are ‘rewarding’ this extra work or responsibility with tax bills, not remuneration as you’d expect. In an increasing number of cases, doctors are billed more than they’d earn for going the extra mile. It’s like the Treasury’s ditched a bloody great spanner into the pension works and at a time when the NHS needs all the help that it can get. BMA consultants committee deputy co-chair Phil de Warren-Penny (pictured above, bottom left) likened the NHS pension scheme to a complex system of tiny, linked cogs at the ARM in Belfast. 06 thedoctor | July 2019

‘We only have control of one cog,’ he said. ‘The Government has, in its control, all of the others. The only way we can mitigate our tax charges is how much we earn.’ So doctors are sticking to contracted hours and turning down roles to manage services or oversee the training of trainees. Psychiatrists are declining to carry out Mental Health Act assessments on patients for fear of incurring a personal cost through a tax charge for providing this vital service. When asked to cover a shift to help colleagues, doctors are forced to do so for time off in lieu – not pay – as bumps in remuneration would spark the tax charges. ‘These are already things that are taking place,’ Dr de Warren-Penny said. BMA pensions committee deputy chair David Bailey (pictured top, centre) said the punitive pension rules were having a ‘catastrophic effect’. ‘In a climate where acute shortages are damaging patient care, the Treasury doesn’t appear to understand the ins and outs of this absurdly complex piece of tax legislation which it put in,’ he added. The Government’s offer to solve it, the so-called ‘50-50’ response, was a ‘cynical insult’, Dr Bailey said. ‘It is practically robbery for a GP. It’s Alice in Wonderland economics.’ For information about the new pensions calculator and the BMA’s lobbying work, visit bma.org.uk/pensions

ARM 2019

A plane-sized tragedy The airline industry’s take on life preservation is often put on the pedestal in patient-safety debates. When a single mistake – or oversight – can cost hundreds of lives, it’s taken very seriously indeed. So could the same logic apply in mental health services? This was the question posed by doctors at the ARM. BMA consultants committee mental health lead Andrew Molodynski (pictured above, right) invited the audience to imagine they’d boarded a mid-sized aeroplane. ‘There’s about 120 to 150 passengers. Imagine that they’d all taken their own lives this week,’ he said. ‘That they’d got to a point in their lives where they had no hope. ‘Think about the plane you will get on tomorrow, the same size. About 120 people. Imagine they’ve all died from alcohol-related disease at one time or another this week. Because they have.’ The Office for National Statistics recorded 5,821 suicides and 7,697 alcohol-specific deaths in the UK in 2017.

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The airline industry would pull out all the stops if so many were dying each week. ‘What patients and their families, including many of us, need and deserve, is parity of resource, parity of access and parity of outcome; not parity of esteem,’ Dr Molodynski said. ‘We’ve had that for many years and we are where we are.’ Mental healthcare is 25 per cent of healthcare activity, but ‘our funding settlement is around 12 per cent of healthcare funding, if we’re lucky,’ he said. ‘We need to steadily move towards 25 per cent of NHS funding within the time of the 10-year plan.’ Middlesbrough GP Rachel McMahon challenged the idea that a quarter of NHS resources should be earmarked for mental health services. ‘What about patients who have complex physical and mental health problems, who present with physical symptoms which clearly have a psychological component?’ she asked. Doctors at the ARM voted overwhelmingly to align mental health resources with activity, at a quarter of the NHS budget.

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Read more online The NHS is not a bargaining chip Doctors urged to lead change Doctors condemn pay review body Pressure builds on social media to step up antibullying measures Demand to improve healthcare for the homeless bma.org.uk/news

twitter.com/TheBMA thedoctor | July 2019 07

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Sent away, locked away Research by The Doctor has found that patients with severe mental ill health are being sent far from home to locked, private wards because of a lack of local provision. Keith Cooper reports

eople with severe mental ill health are being routinely ‘warehoused’ in locked, private wards hundreds of miles away for want of NHS care closer to home, an investigation reveals. Research by The Doctor magazine has found that five million people live in CCG (clinical commissioning group) areas in England with no NHS wards at all for mental health rehabilitation, a service that helps people with severe illness get their lives back on track. While some CCGs pay for such beds in the NHS, most depend heavily on private hospitals and care homes – and increasingly so, according to data obtained by our Freedom of Information requests. Hundreds of private beds are hours and hours away from patients’ homes, analysis of 2,600 journeys found. Seven hundred are sold to CCGs as ‘locked rehab’, a type not recognised in NHS guidance – raising concerns about patient care and human rights. Stays on private wards last twice as long as in the NHS, doubling the expense, the pain of separation from families, and frustrating efforts by local staff to bring people back home.

‘Extremely disturbing’ The findings have alarmed senior psychiatrists. ‘Out-of-area placements in rehabilitation wards have become endemic in the NHS,’ says consultant psychiatrist Andrew Molodynski, mental health policy lead for the BMA consultants committee.

‘Warehousing unwell people in locked wards far from home goes against the very nature of mental health rehab – to help them reintegrate back into society.’ Chair of the rehabilitation faculty at the Royal College of Psychiatrists Raj Mohan describes the findings as ‘extremely disturbing’. ‘We are failing people who need rehabilitation care,’ he adds.

Private beds Mental health rehabilitation is supposed to help people regain independence. It unpicks and treats the mesh of social and health issues, which can arise with serious illness, trapping some in cycles of short stays on acute wards, where they’re only patched up. It takes time. Stays last six months to a year, sometimes longer. Patients often start in ‘highintensity’ wards. Most are detained under the Mental Health Act to keep them safe. As they improve, they’re ‘stepped ‘We are failing down’ to less secure units, before being settled back home by people who need community teams, working closely rehabilitation with staff on the wards. Most return to care’ supported accommodation. This pattern of treatment or ‘care pathway’ has, however, become badly fractured in parts of England where permanent NHS mental health rehabilitation wards are closed and replaced by private beds far from home. Many of these private placements are arranged ad hoc by CCGs, as ‘spot purchases’. thedoctor | July 2019 09

Tees, Esk & Wear Valleys NHS Foundation Trust 85 miles NHS East Lancashire CCG Humber NHS Foundation Trust NHS Manchester CCG NHS Lincolnshire East CCG

150 miles

100 miles

Northamptonshire Healthcare NHS Foundation Trust

NHS West London CCG Somerset Partnership NHS Foundation Trust West Hampshire CCG

This use of spot-purchased beds – especially in areas with no services of their own – raises an obvious concern: who checks on the care of these patients when they’re away? Some trusts don’t even know where patients in their patches are sent. Two, Birmingham and Solihull Mental Health NHS Foundation Trust and Dorset HealthCare University NHS Foundation Trust, held no records for people in ‘spot-purchased’ beds, they said. It was their CCGs, the bodies responsible for commissioning – not providing clinical care – which knew about them.

Far from loved ones The BMA’s Dr Molodynski points to known risks of sending patients to wards far from their families and close clinical supervision. ‘As seen in the extreme cases of Whorlton Hall and Winterbourne, the “cut-off” nature of these institutions can be a breeding ground for the development of harsh and abusive cultures.’ The Doctor identified three instances of patients sent to Whorlton Hall, the private hospital closed after Panorama exposed horrific abuse of patients by staff in its investigation. In all three cases we identified, patients came from areas more than 100 miles away. The human cost of poor care in mental health rehab is well known to David Shiers, a retired GP, who campaigns for better 10 thedoctor | July 2019

150 miles

mental health rehab following the awful early experience of his daughter Mary (see ‘Road to recovery’ on page 13). Mary’s schizophrenia transformed her from a normal teenager into a ‘terrified young woman’, he says. She was admitted to an adult asylum before being offered a place 50 miles away. Her family fought for years before a local service was opened. It transformed Mary’s life but was closed after she moved out. ‘Where would Mary be if she didn’t have parents who were health professionals?’ Dr Shiers asks.

Greater costs While the Shiers’ battle is past, many other families face similar or worse problems, The Doctor’s research indicates. The replacement of local wards with ad hoc out-of-area beds has not just ‘Warehousing unwell had a human cost. It’s costly to the NHS, too. people goes against the An extensive study of very nature of mental mental health rehabilitation health rehab’ by the CQC (Care Quality Commission) last year found that stays in private beds cost twice as much as in the NHS because they last twice as long. It found the annual cost of rehab was £535m and that private beds were on average 30 miles away from patients’ homes but just nine miles away in the NHS. The NHS has taken steps since the CQC report. NHS Improvement launched a ‘Getting

Sample distances between NHS organisations and the private facilities they send patients to 259 miles 208 miles

341 miles

252 miles 194 miles

It Right First Time’ programme for mental health rehab last year, led by respected London consultant psychiatrist Sridevi Kalidindi. It helps trusts in England to improve. ‘This is an enormous, long overdue opportunity to upgrade rehabilitation services nationally,’ she says. For its part, the CQC tweaked inspections. It now checks that the right staff with the right skills are on wards and that they’re geared towards helping people leave; not acting as expensive hotels.

Missed abuse Inspections are far from perfect, however. They failed to pick up abuse at Whorlton Hall during checks in 2018, a missed opportunity for which it has apologised. It’s hard to ‘get under the skin’ of places where people are placed for long periods far from home, CQC deputy chief inspector of hospitals Paul Lelliott admitted last month. CCGs, however, seem split about the CQC’s findings on costs. Sandwell and West Birmingham CCG, which commissions no inpatient rehab for its half a million population, ‘contests’ the view that private beds are more costly. Its patients are ‘tracked’ in their private beds by the CCG’s own mental health clinicians, a spokesperson says. They ‘challenge the local NHS provider to recover people in a timely way to their own local community solution’.

MOLODYNSKI: ‘Cut-off institutions can become breeding grounds for harsh and abusive cultures’

Worsening situation

Sandwell and West Birmingham has spent £20m on private beds in the past three years. More than 100 were out of area, one hour’s drive away, on average. NHS commissioners for the Lancashire and South Cumbria Integrated Care System, however, admit that its service ‘does not always represent best value for money or best experience for patients or their families’. One of its CCGs, Greater ‘Out-of-area placements Preston, spent £10.3m on private beds up to 229 miles in rehabilitation wards away. The care system is have become endemic talking to Lancashire Care in the NHS’ NHS Foundation Trust about opening wards for ‘quality, value for money and less restrictive post-hospital care, closer to home for patients’, a spokesperson says. The investigation, however, points to a worsening picture for mental health rehab across England as parts of the NHS try to improve. It found patients were sent to private beds up to 341 miles away, leaving families and NHS staff with a five-and-a-half hour drive for a single visit. Hospitals in Northamptonshire sent patients to Scotland. Devon bought beds in Harrogate, Yorkshire. More than half thedoctor | July 2019 11

Journey lengths for patients sent out of area for want of available NHS beds

Expenditure on mental health rehabilitation beds

Journey roundtrip

Number

Proportion

Less than 1 hour 1 to 2 hours 2 to 4 hours 4 to 7 hours More than 7 hours

577 764 735 437 141

22% 29% 28% 16% 5%

of beds were over an hour’s drive away; one in five were more than 100 miles from home. 90 per cent were in the more costly private sector. CCG figures are also increasingly reliant on private providers, we found. The NHS spent 56 per cent of its rehab budget on private beds last year up from 53 per cent in 2016/17. The number of beds bought from private providers jumped 10 per cent in the same period. And the appetite for growth in the private sector shows little sign of receding.

Private beneficiaries Market analysts speak of ‘sharp’ revenue rises for private mental health services. They swelled a ‘remarkable’ 12 per cent in 2015, followed by 4 per cent in 2016, according to analysts, LaingBuisson. 87 per cent of independent sector mental health services income is from the NHS, the CMA (Competition and Markets Authority) reported in late 2017. Not all rehab psychiatrists are opposed to the involvement of private providers in their patients’ care. But many are worried about services’ exposure to market forces, something greatly increased by the Health and Social Care Act of 2012. Some damage has already been done by this exposure. There’s the proliferation of outof-area beds in the private sector and the use of ‘locked rehab’ wards by CCGs which have no or too few beds of their own. Almost all locked rehab wards (97 per cent) are run by private hospitals, the CMA report says. The Doctor investigation found 700 were used by the NHS last year. The trouble with locked rehab wards is that 12 thedoctor | July 2019

NHS £146m

NHS £142m

Non-NHS £158m

Non-NHS £175m

Non-NHS £181m

2016/17

2017/18

2018/19

NHS £139m

Research is based on Freedom of Information requests sent to all CCGs and mental health trusts in England in February 2019. 176 CCGs and 43 trusts supplied data of varying quality. Figures for 2018/19 are either partial year or predictions.

they are not specified in NHS guidance, so doctors can’t be sure what they’re like. They’re thought to resemble the ‘high ‘Why should dependency’ wards of the NHS rehabiltation you be sent ‘care pathway’ – wards which patients need special permission to leave. This means away just people can be locked in for their whole because you’ve been stay – with no chance of more freedom as their illness improves – a key principle of dealt this rehabilitation. unlucky ‘No mental health service should be hand of specified by the locksmith,’ the RCPsych’s cards that Dr Mohan, says. ‘Restrictions on freedom gives you should be short, determined by people’s need, complex psychosis?’ and stopped as soon as is feasible.’ ‘This is a human rights issue,’ says University College of London professor of psychiatry, Helen Killaspy. ‘Why should you be sent away just because you’ve been dealt this unlucky hand of cards that gives you complex psychosis? It’s just wrong that you should be marginalised, shuffled off, even if it is to a comfortable hospital room in the private sector – people don’t need to be there for as long as they are staying. They don’t need to be treated out of area and they don’t need to be always locked up.’ The BMA’s Dr Molodynski says the Government should ‘get a grip’ on the worrying practice of patients locked up in the ‘gilded cages’ of unplanned and expensive ad hoc placements. ‘There are no positives at all here for patients, families, care services, or the public purse – quite the opposite. We need to ensure that care is available closer to home to give patients the best possible chance of recovery and reintegration.’

JOHN HARRIS

Road to recovery: a family’s fight for its daughter’s life

t’s some time since we first shared a personal view about our daughter’s (pictured right, centre) early experience of care for schizophrenia and how we felt the NHS had failed her (Who Cares? BMJ 1998) This severe illness transformed Mary from a normal 16-year-old schoolgirl into a terrified young woman, unable to think, communicate or take part in life. ‘First came a year of appointments in children’s clinics and the apologetic assurance: adult services would be ‘more into psychosis’. Support at home became unsustainable. Mary was admitted to an acute adult ward, then to a rehabilitation unit in a local asylum, an eight-bed Dickensian dormitory. She was drugged, lost in her own world, barely acknowledging us. There was nothing to do on her ward, nowhere to go. Just older patients wandering long, dismal corridors, a foresight of Mary’s future. A strength of rock bottom is that you cannot sink lower. But with support from her excellent psychiatrist we fought back. We asked our local health authority: was her care satisfactory, given that numerous agencies had catalogued serious unmet need? Providing a bed met its responsibility, came the reply. After months of fruitless exchanges we contacted the regional health authority. Its mental health lead called. He listened. He saw where Mary was staying. He agreed this was not meeting her needs. Our local health authority then offered Mary a choice of five community rehabilitation services, but all more than 50 miles away. With Mary’s psychiatrist we challenged again: had they considered the effect of separating Mary from her family and home environment? Why weren’t there local services? After two long years of pressure, health and social services finally commissioned a local rehabilitation service in the community for Mary and 16 other young people.

It was a modern home in the real world. She had her own room, her own pictures. She listened to her own music and liked being with other young people. Within weeks, Mary began to improve and to find her identity. There were activities, focusing on her strengths, not her weaknesses. She tentatively explored her new surroundings, went to a local college, went shopping. She began to enjoy family activities. Free from the ward regimen, her days took on meaning. After 18 months, Mary successfully moved on to a residential care home. The community rehab service closed soon afterwards; the old asylum became a smart housing estate. Now in her 40s, Mary lives in an excellent residential care home, free of symptoms of psychosis but still requiring support for daily activities. Her world revolves around the town she grew up in. She lives for today, takes pride in her appearance. We’re so proud she has come through. But where would Mary be now if she didn’t have parents who were health professionals? If she hadn’t had a brave and principled psychiatrist or a mental health lead with skills, experience and compassion? David Shiers is a retired GP (pictured above, right). Ann Shiers is a retired district nurse (pictured above, left). Dr Shiers is: an adviser to the NICE (The National Institute for Health and Care Excellence) centre for guidelines and a member of the NICE guideline development group for rehabilitation in adults with complex psychosis and related severe mental health conditions; board member of the NCCMH (National Collaborating Centre for Mental Health); and his views are personal and not those of NICE or NCCMH.

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The man behind the astronauts E When Neil Armstrong’s crew returned to earth, it was flight surgeon Bill Carpentier who looked after them. Fifty years on, he tells Neil Hallows about his weeks quarantined with the moonwalkers, his arduous training for the job, and his determination to make space safer for future astronauts Images courtesy of NASA, Don Blair, Bill Carpentier and UBC Okanagan. With special thanks to Bob Fish, Apollo curator of the USS Hornet Museum, for his invaluable assistance in preparing this article

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very time Bill Carpentier looks at the Moon he thinks of the men who fell to Earth and how he cared for them. Dr Carpentier had perhaps the best medical job of the 1960s. As the flight surgeon for Apollo 11, he looked after Neil Armstrong, Buzz Aldrin and Michael Collins before they embarked and, 50 years ago this month, he waited with an anxious world for their return. Now 83, and speaking from his native Canada, Dr Carpentier tells The Doctor of his sense of adventure,

MEDICAL BACKGROUND: Flight surgeon Bill Carpentier, just visible through the window of the quarantine facility with Apollo 11 crew Neil Armstrong, Buzz Aldrin and Michael Collins

wonder and purpose. ‘I cannot look at the Moon without thinking, I knew those guys. There were 12 guys who walked on the Moon, I knew them. What a time to be alive.’ While involved with several missions, including the desperate, ingenious and successful bid to save the crew of Apollo 13, it’s the one under Armstrong’s command which is closest to his heart, not just because it was the first to land men on the Moon but because of the three weeks he spent quarantined with the crew when they landed.

Jumping off bridges His job at NASA was the epitome of modernity but he was prepared for it by a childhood which could have been from a previous century. He swam in lakes, jumping off bridges into the water, finding all the fun there was to be had in a small town in western Canada in the late 1940s. Robust and adventurous, he worked on ships during his summer holidays from college and gained his pilot’s licence. Following a medical degree at the University of British Columbia, he took a three-year residency in aviation medicine at Ohio State University. It included a third-year work placement, usually in manufacturing or for an

‘He recalls the ‘‘bang’’ as he hit the water’

airline, but NASA had recently become part of the scheme and took him on for six months at the Manned Space Centre in Houston, Texas. This far from guaranteed a job. Counting against him was the fact that, as a nonUS exchange student, the immigration rules said he had to return home and wait for two years before he could apply for a green card. There’s an exasperated saying when confronted by petty obstructions of a bureaucratic nature: ‘But they can put a man on the Moon…’ To the agency which actually did just that, the US immigration rules were not a hurdle. Dr Carpentier was hired. He had kept up with his

swimming at college, and had taken scuba diving lessons, and it all helped. As well as the physiological testing and analysis of the astronauts, he needed to train for the recovery of astronauts from the sea. The rescues were carried out with the US Navy’s UDT (Underwater Demolition Team), the precursor to the SEAL special forces. He heard they were expected to jump out of a helicopter at 20 to 40 knots (23 to 45 mph) from 40 feet, so trained to do the same, with only a wetsuit jacket for flotation. He recalls the ‘bang’ as he hit the water. Only later did a UDT officer tell him no, he had been misinformed: this was not standard procedure. thedoctor | July 2019 15

GETTING IT RIGHT: (clockwise from right) Bill Carpentier tests quarantine elements prior to the Apollo mission, and jumps into the ocean during training

In the water, he practised carrying out CPR on a pliable raft in a high swell. Difficult, yes, but ‘we just kept working at it until we found the best way to do it’. Fortunately, he never had to do it for real.

In quarantine Just before dawn on the morning of 24 July, 1969, he was on board the USS Hornet, a Second World War-era aircraft carrier, as was President Nixon. As the module containing the astronauts headed to its splashdown in the Pacific Ocean, Dr Carpentier was dispatched on one of four helicopters. The astronauts were winched up, and Dr Carpentier helped them out of the recovery net into the helicopter. ‘We didn’t exchange words,’ he says. ‘They were 16 thedoctor | July 2019

‘I got a thumbs up from all three of them. My life was complete’

in biological isolation suits, the helicopter was very noisy, they were on respirators. We had hand signals – “are you OK?”. One by one they came up. I got a thumbs up from all three of them. My life was complete.’ Once on board, he and project engineer John Hirasaki followed them into a converted Airstream trailer where they spent the first three days of quarantine, before they were flown to more spacious facilities in Houston. Some people, in close confinement with three global heroes just back from the Moon, would have driven them mad with questions. But Dr Carpentier was not there to talk about small steps and giant leaps. Apart from the odd stint as a bartender, he was busy with his work. ‘I tried to do everything in the trailer that we were

doing pre- and post-flight. To get the data to understand changes in physiology that were happening… it was what we could learn. We had to learn because we wanted to keep doing this.’ His responsibility was enormous, not just for the individual astronauts but that the system of quarantine was successful. The idea of there being life somewhere other than on Earth is profound but the immediate need was not to philosophise but to protect the Earth from possible harmful lunar microbes. ‘The possibility of life existing as we knew it was difficult to contemplate, but you could not say it was zero. Maybe just a short distance below the surface of the Moon there may have been something harmful so when you took that incredibly small possibility and multiplied it by the Earth’s population, it

MOON BOUND: Buzz Aldrin on board the lunar module and about to take his first steps on the Moon

‘The whole aircraft carrier, including the president, could have been quarantined’ became a significant number. It was important to do what could be done to protect the biosphere.’ In the picture of Dr Carpentier following the astronauts out of the helicopter into quarantine, there is a look of intense concentration on his face. He had to get it right. ‘We had to make sure everything was done to plan, because [if not] the whole aircraft carrier, including the president, could be quarantined.’

For all mankind Fifty years on, you still get a sense of Dr Carpentier’s sense of duty and discipline.

Rarely at the time did he dwell on the historical significance of his work. Constantly, the thought was ‘don’t mess up’. NASA entrusted young employees with enormous responsibility – he was 33, and the average age in the control room when Apollo 11 splashed down is said to have been 28. ‘There was a job that needed to be done. You were asked if you could do that job, and if you said yes, you did whatever it took to make sure that you could do it,’ he says. He points out that when John F Kennedy said the USA would put men on the Moon by the end of the 1960s, there were two parts to that promise – to get them there, and bring them safely back. ‘The second part was where I got involved. To evaluate these guys when they returned to Earth.’ The austere surroundings

of quarantine were followed by a lavish ‘Giant Leap’ world tour as Dr Carpentier and the crew met presidents, prime ministers and the Pope. He recalls Neil Armstrong’s diplomatic skill and facility with languages. ‘Everywhere we stopped there was an incredible reception. There was never a negative comment. The plaque that was left on the lunar landing module – “we came in peace for all mankind” – that was the attitude. It was an incredible achievement and it was done in this spirit for all mankind.’ By the time Dr Carpentier returned from his tour, Apollo 13 was about to set off. A different doctor had been assigned as flight surgeon but Dr Carpentier was asked to help out as staff support to the Mission Operations Team in Mission Control. What followed was a technical thedoctor | July 2019 17

SAFELY HOME: (from left to right) Dr Carpentier (in the orange flight suit) follows the astronauts from the helicopter which recovered them, the crew in quarantine, and Dr Carpentier with his wife Wilma, having received an honorary doctorate last month from the University of British Columbia Okanagan

achievement in some ways even greater than the first Moon landing. An oxygen tank exploded, crippling part of the craft. The crew had limited power, loss of cabin heat, a shortage of portable water and needed to carry out makeshift repairs to the carbon-dioxide removal system. Dr Carpentier stresses that it was the engineers who were the heroes, improvising a solution. His job, however, was vitally important, calculating the effects rising carbon-dioxide levels would have on the crew. 18 thedoctor | July 2019

He remembers the intense anxiety he felt as the capsule returned to Earth, and the huge cheer from mission control as communications were re-established. Watching the film version, starring Tom Hanks, decades later, his instinct was to leap up once again and cheer.

Safety designs For his work on Apollo 13, Dr Carpentier was included in the Mission Operations Team that was awarded the Presidential Medal of Freedom. After the Apollo

programme finished in 1972, Dr Carpentier took a university residency and then pursued a successful second career in nuclear medicine for the next 30 years. He returned to the USS Hornet, which is now a museum, to pay tribute to Neil Armstrong when he died in 2012. But his involvement with NASA was much more than a matter of attending funerals and reunions. His determination to make space travel safer never left him. He is writing a book to gather together the medical data on the American

space programmes from Alan Shepard’s first flight in 1961, through Mercury, Gemini, Apollo and Skylab. ‘It cost millions of dollars and thousands of man hours to acquire and it needs to be used,’ he says. Some of the data was in boxes in his garage – he has always been a bit of a hoarder, and is grateful for that now. It may seem strange that it has not been collated previously, but stringent privacy rules meant that health data could not be published about an identifiable astronaut without their permission. Dr Carpentier has written to all the surviving astronauts from the programmes to obtain it. ‘Almost all of the data that has been published in papers and books are about specific systems – a chapter on the cardiovascular system,

another on the pulmonary system, the nervous system. But it has not all been available to integrate. ‘But you’re not sending a cardiovascular system

‘You’re not sending a cardiovascular system into space, you’re sending a person’ into space, you’re sending a person. The data needs to be integrated to understand that,’ he says.

Space and beyond In caring for future astronauts, Dr Carpentier also cares about the future in space. Fuelled by Apollo euphoria and unaware of impending funding cuts, NASA was speaking of a manned mission to Mars by 1982. But despite numerous presidents promising to revive the ambition, the

prospect seems distant. The Moon walks seemed to offer the future of permanent settlement but instead seem like three short and distant years of wonder. ‘If someone asked, do we need to go back to the Moon, I’d say you bet. Further exploration, going to Mars, doing all of these things, understanding human physiology. We need to keep learning new things,’ he says. When it comes to what space has taught him, perhaps the most profound lesson speaks to the humanity which drives all doctors in their work. He quotes Stephen Hawking: ‘When we see the Earth from space, we see ourselves as a whole. We see the unity and not the divisions. It is such a simple image with a compelling message. One planet. One human race.’ thedoctor | July 2019 19

A lack of politicians might seem superficially attractive but while the Northern Ireland Assembly has lain dormant, the pressures on doctors have mounted. Jennifer Trueland reports

e are standing in the chamber at Stormont, home of the Northern Ireland Assembly. It is empty of politicians, of course; it’s more than two years since the Members of the Legislative Assembly sat in its fine leather-backed seats. A chirpy and enthusiastic guide is telling an assorted group of tourists that one advantage of the political situation is that tours can venture into the chamber itself. Otherwise, she says, we would be crammed into the public gallery. This attempt at finding a silver lining might be admirable but it cuts no ice with Northern Ireland’s doctors. Medics across the area are tired of the political failure to restore devolution and bring back muchneeded ministerial decision-making power. For some, the idea of living without a legislative assembly might seem like a dream come true. Health so often becomes a political football that the thought of just being able to get on with it could appear refreshing, and rather appealing. However, the fact of the matter is that the power vacuum is already causing problems for important areas such as health and care, according to doctors in the region. ‘The lack of government over the past two years has 20 thedoctor | July 2019

JENNIFER TRUELAND

The lights are on…

OUT OF POWERS: The Assembly chamber at Stormont lies dormant

thedoctor | July 2019 21

‘There’s a workforce crisis in general practice and hospitals in the north, west and south of Northern Ireland’

had a real impact,’ says BMA Northern Ireland council chair Tom Black, a GP in Derry. ‘There are areas where we have been able to make some progress but there are some policy decisions which need ministerial sign-off. That means, compared with the rest of the UK, Northern Ireland’s health and social care services have been at a real disadvantage.’

Graduates deterred The delay in establishing a new medical school is a case in point, Dr Black says. Queen’s University, Belfast, is the only place to study medicine in Northern Ireland – and it’s accepted that medical graduates tend to stay and work near to where they trained. This means that not only is there a shortage of doctors in Northern Ireland as a whole but the distribution is such that some parts are hit harder than others. Although plans to establish a graduate-only medical school at Ulster University’s Magee campus are well under way, as things stand they cannot be fulfilled without ministerial approval. ‘There’s a real workforce crisis in general practice and hospitals in the north, west and south of Northern Ireland,’ says Dr Black. ‘We really need a second medical school. At the moment we have one medical school for two million patients, ‘We need an active while there are six in the Republic of Government to make Ireland. But it takes the change and a long time to train improvements that doctors, and even are necessary’ if the new school is signed off soon, we’re still talking about losing two or three years.’ The workforce crisis is making itself felt in primary and secondary care, he adds, and this is only likely to become worse as the medical profession continues to age, and the incumbents (40 per cent of whom are over the age of 55) retire. GP practices are already closing, creating pressure on those that

BLACK: Progress is waiting on ministerial approval

remain, as well as giving patients a raw deal. ‘Some people are having to make a 25-mile round trip just to get a dressing done,’ warns Dr Black. ‘It’s simply not good enough.’ Secondary care is seeing rota gaps which are not only generating massive bills for locum cover (where available) but are contributing to Northern Ireland’s dire performance figures, which make the rest of the UK look positively efficient. For example, by March 2019, more than 97,000 people were waiting more than 52 weeks for a first outpatient appointment (yes, that’s more than a year) in Northern Ireland, compared with less than 0.1 per cent in England.

Plans on hold Dr Black is quick to point out that there has been some progress. Primary care has implemented ways of working to make much better use of the wider health professional team, for example, with enhanced roles for nurses, pharmacists and allied health professionals such as physiotherapists. But, he adds, there’s a crying need to make progress with radical transformation plans, largely put on hold with the suspension of devolution. ‘Like the rest of the UK, Northern Ireland has people who are living longer and with more complex conditions. Successive reviews have shown that we spread our resources too thinly – we need to rationalise services to make them fit for the future, but the authority to take these decisions lies with ministers.’ BMA Northern Ireland consultants committee chair Anne Carson is equally frustrated. ‘Significant investment is needed to move forward effectively with transformation but that can’t happen unless there is a minister in place and the legislation to support change can’t be introduced without a legislative assembly,’ she says.

Losing doctors CARSON: The need to attract and retain doctors is urgent

22 thedoctor | July 2019

Dr Carson, a consultant radiologist, says that urgent efforts are needed to attract and retain doctors – and that the longer the country is without a functioning government, the worse the situation will become. ‘We’re losing our young doctors to the Republic [of

ISTOCK

STOUT: Patients are living in pain

Ireland], Australia and North America. Northern Ireland even lags behind the rest of the UK in terms of pay, and clinical excellence awards have been frozen since 2010.’ Doctors in Northern Ireland are not immune to factors affecting their peers in the rest of the UK – such as punitive changes to pension arrangements – which only makes action more necessary. ‘We need an active Government to make the change and improvements that are so necessary for the people of Northern Ireland,’ ‘Some people are she says. Richard Pengelly, having to make a 25-mile the permanent round trip just to get a secretary in the dressing done’ Department of Health, has some decision-making power, and has signalled his commitment to transformation and recently blogged about why he felt it was necessary. He also outlined some areas where work was continuing, even in the absence of the legislative assembly. This includes consultation on stroke services, and on breast-assessment services. Again, however, under the current arrangements, ministerial approval will be needed before real action is taken.

Waiting times rise Mr Pengelly has also previously announced extra resources for general practice. While this investment has been welcomed, GPs fear it is not enough. Alan Stout, who chairs the BMA Northern Ireland GPs committee, paints a picture of a health and care service under huge pressure, with GP practices on the front line. Lengthy waiting times have an effect across the service, he says. ‘If someone is having to wait longer than a year, it’s not a service,’ he says. ‘Obviously it’s dreadful for patients, but it’s also intensely frustrating for doctors. We see our patients living in pain and they can’t get the operations they need. It also has an impact on social care.’ There is some hope. Following the death of journalist Lyra McKee in April, politicians in Northern Ireland agreed to get round the table for talks again in the hope of breaking the impasse. Doctors – and patients – will be hoping they succeed.

Why (political) inactivity is bad for your health The wellbeing of the population of Northern Ireland lags behind the rest of the UK while the political vacuum persists Measures to improve public health have been another casualty of the political impasse in Northern Ireland. While the rest of the UK has been pressing ahead with legislation on, for example, protecting children from cigarette smoke, the lack of a government at Stormont has meant that Northern Ireland is lagging behind. Assurances given by a previous health minister that Northern Ireland would follow Scotland and Wales in introducing minimum unit pricing for alcohol have not been fulfilled, in part at least because of the absence of a Government. Similarly, Northern Ireland is now the only part of the UK that does not ban smoking in cars with children. Although legislation to do this was passed in 2016, without a functioning Assembly, regulations to enact it cannot be laid. Northern Ireland is also being left behind on organ donation. While the other three countries have introduced steps to move to an ‘opt-out’ system of presumed consent, or are in the process of doing so, this is not the case in Northern Ireland. People in the region are also potentially losing out on money intended to counteract childhood obesity and increase awareness and education around nutrition. While the money from the UKwide sugar tax is supposed to be ring-fenced to tackle these things, in the absence of devolution, the proceeds go directly into the total Northern Ireland budget pot. thedoctor | July 2019 23

‘Encouraging people to slow down, be part of the environment and enjoy the beauty and be mindful of what they are seeing has huge benefit’

NATURAL BENEFITS: GP Ruth Booth with husband Graham

24 thedoctor | July 2019

If you need a prescription in Shetland, you might just be prescribed the islands themselves. Peter Blackburn reports from a nature-based scheme which could have far-reaching influence

Nature’s remedy I

n Shetland you’re either a Shetlander, or you’re from ‘the Sooth’. Dundee, Doncaster or Dover – it makes no odds. There is a distinct sense of identity and place among these hundred beguiling islands, a unique wilderness which draws people from all over the world: you’re never more than a stone’s throw away from water – the quiet and calm lochs and voes or the drama and beauty of the coast. The windswept landscape is dotted with a mix of traditional crofting cottages and Scandinavian timber lodges; and the people, who are fierce and friendly. Flung to the far north-east of the Scottish mainland, Shetland is more than 100 miles closer to Oslo than Birmingham. But, for all its isolation and sense of independence, ‘When we did doctors and wildlife the research, experts have come up the evidence for with a scheme here nature working which could have in health and positive implications wellbeing was for the rest of the UK. overwhelming’

It’s a project that looks to improve health and wellbeing using only what is freely available on our doorsteps, connecting people to nature in a bid to overcome growing mental health problems and the causes behind many longterm conditions. Nature prescribing was first dreamed up by Karen MacKelvie, a community engagement officer for RSPB Shetland, who lives and works on the islands. ‘I also work as a counsellor at Women’s Aid, and I do therapy on the beaches and I know how restorative and helpful it can be,’ says Ms MacKelvie, at her traditional white stone house, overlooking a seemingly endless, shimmering, sea loch. ‘When we did the research, the evidence for nature working in health and wellbeing was overwhelming. It’s not just about exercise outdoors, which of course helps, but the connection is even more important.’ Ms MacKelvie’s idea quickly became reality in a pilot

project last year – before being rolled out more widely after being deemed a success. The RSPB produced a leaflet now stocked in GP surgeries across the islands. It explains the potential benefits of interaction with nature: reduction of hypertension; respiratory tract and cardiovascular illnesses and anxiety; improved concentration and mood – and even increased life satisfaction and happiness. It goes on to give GPs different lengths of walks to prescribe, as well as suggestions for activities to connect with nature. A calendar with seasonal activities is published every month in the island magazine Shetland Life and the local NHS website.

‘Green prescription’ The evidence base for similar schemes is growing. A project in England from the Centre for Sustainable Healthcare, called Prescribing Green Space, found that six to eight months after receiving a ‘green prescription’ – where people thedoctor | July 2019 25

are encouraged to help plant forests and spend time in local green spaces – 63 per cent of patients were more active and 46 per cent had lost weight. And the need for efforts in these areas could not be clearer. The overall cost to the economy of physical ‘For some people inactivity in England alone is thought to it might be a better option than be £8.2bn per year – with ‘inactive’ people a box of pills’ spending 37 per cent more days in hospital and also visiting the GP more often. The Centre for Mental Health put the health and social care costs of mental health problems at £21.3bn in 2009/10. The ‘human cost’, its estimate of the negative effect on quality of life, was £53.6bn. As for implementing the approach: ‘The cost to the NHS amounts to the few minutes the GP might spend talking about this thing and how it might fit in as part of the solution, and that’s all really,’ says Mark Maudsley, a GP in Scalloway, a village on the largest of the Shetland Islands. He supports the social prescribing initiative. ‘It feels that this is a public health push. It’s not saying to somebody, here’s a eureka moment that you’re better. OPENING A DIALOGUE: GP Dylan Murphy says time pressures often influence prescribing decisions

26 thedoctor | July 2019

But you can throw it in with minimum expenditure and a bit of time and say that getting out among nature is potentially part of a solution to why you’re not feeling great – and here’s some ideas that get changed every month. ‘If more people were doing that, spending more time outdoors and noticing things that can make them feel better about the world it’s likely to make people’s lives better.’

Wellbeing boost The philosophy behind the RSPB approach is not just about fresh air and exercise – it’s about developing a relationship with the nature and wildlife being experienced. Evidence from projects in the UK suggests a relationship between connection and engagement with nature and improved health and wellbeing. It is a theory backed by society and employers in Scandinavia, where people are supported to take time away from the office and be outdoors – a concept called ‘friluftsliv’. Dr Maudsley explains: ‘It’s not just to do with exercise and fresh air, what they are picking up on is the idea of going out

and connecting. If you go out and you are paying enough attention to what is going on around you rather than just what is in your own head and what you take out there yourself, you can see things and notice the way things are happening in nature. That takes you out of yourself and you can end up feeling better about things.’ Perhaps it won’t be for all people – one sceptical patient remarked, ‘at least you didn’t ask me to talk to a horse’ when a GP had finished explaining the idea – but for those willing to have a go, it seems to be a risk-free, almost costless option in a GP’s arsenal. After all, general practice is at its best when there’s time to look at the causes of problems and options to tackle those drivers are available. ‘It’s not something you wheel out every time you see a patient with a mood disorder or someone who is isolated,’ Lerwick GP Dylan Murphy says. ‘It might come up in conversation and, as part of the discussion, you will outline various processes – psychological therapy and selfhelp. And one type of self-help, for example, is this. Sometimes it’s just a spur for someone to do something – to have it in their hands and they have a contract with themselves. ‘It’s like anything else – when you take a history

A NATURAL ALTERNATIVE: Norwick Beach, Unst

from a patient you try and put yourself in their shoes: what are things like at home, where are you from originally, what work you do, what are your hopes and aspirations. Sometimes that’s not easy for some patients and this can open up a dialogue with patients who don’t like talking.’ Dr Murphy – whose office must be a contender for the best view from a GP’s desk of anywhere in the world, looking out across the sea, ‘The cost to the which laps against the rocks just strides NHS amounts to away – adds: ‘Timethe few minutes pressured GPs can the GP might often give patients spend talking medication for mood about this thing’ disorders because it’s what is available to us. We know it’s not always the right thing. You could medicalise them or cause them harm. Doing things like this can help. ‘And I have a lot of male patients who say: “I don’t want pills doctor, and I don’t want to talk about it.” So, this is a potential way of getting to people. For some people it might be a better option than a box of pills.’

Clear-minded ON PRESCRIPTION: Scousburgh Sands, South Mainland of Shetland

It is not difficult to see why conditions are perfect for this idea in Shetland: the cliffs at Hermaness and Esha Ness, the beaches at St Ninian’s Isle and Meal, the abundant water and wildlife. Just an hour spent alone walking in the winds here is enough to wash away the worries. GP Ruth Booth agrees. She lives on the island of Fetlar, known as the ‘garden of Shetland’ but works 24-hour on-call shifts on the most northerly island, Unst, where the local GP is effectively the

ambulance, too. ‘I personally have experienced the benefit of being out in nature – both the physical wellbeing it brings but also the mental improvement for myself. This environment really contributes to that,’ Dr Booth, who also runs a retreat with her husband Graham, says. ‘Encouraging people to slow down, be part of the environment and enjoy the beauty and be mindful of what they are seeing has huge benefit.’ But there’s no reason why this project cannot be exported elsewhere. Dr Maudsley says: ‘It’s true that here you don’t have to go very far to see the sea, to find yourself among natural beauty, but there are peregrines nesting in belfries in towns across England. Nature is doing its thing all over the place.’ The timing could hardly be more perfect with the recent GP contract announcement including the setting up of primary care networks across England – with each area of around 30,000 to 50,000 people to have a social prescribing link worker, with the aim of connecting

patients to the groups and activities in their area that could positively affect their health. It seems a no-brainer to involve projects such as nature prescribing in any future vision for primary care. GP leaders are positive about the potential of social prescribing. BMA GPs committee chair Richard Vautrey has said: ‘Social prescribing has the potential to reduce GP workload by supporting patients and, where appropriate, linking them to other services in the community that can offer longer-term help.’ The nature prescribing seen in Shetland may just be the start though, if those involved have their way. In an ideal world Ms MacKelvie would like the scheme to be more formalised, perhaps through commissioning and funding from the local health body NHS Shetland, which could see activity groups set up, and coordinators employed to link patients to projects and possibilities. In Shetland, the community has always had to live off the land for what it needs, and now they are finding healing there, too. thedoctor | July 2019 27

ISTOCK

For want of a bed BMA research shows hospitals in England are regularly using thousands of ‘escalation’ beds – normally designed for emergencies or spikes in demand – as they struggle to cope with soaring activity and stagnating resources. Peter Blackburn reports

28 thedoctor | July 2019

tanding in front of the heavyweights of NHS management last month, NHS England chief executive Simon Stevens performed a policy U-turn of staggering proportions. Hospital beds have become ‘overly pressurised’, Mr Stevens told the room full of surprised observers at the annual NHS Confed conference. After years of bed cuts, talk of transformation and aggressive rhetoric around shrinking secondary care and finding vast financial savings, local areas should abandon ‘expectation of reductions’ while planning bed numbers for the next five years. As if this weren’t enough, in many areas the NHS would need ‘more bed capacity to deal with demand’, Mr Stevens added – admitting his new approach represented ‘quite a significant “gear-shift”’. The audience may have been taken aback, but a recent investigation by the BMA shows why they should not have been. The bed crisis in the country’s

129,992

144,455

treatment areas and causing unacceptable stress to the patient and their families. It is obvious in these circumstances that there are also not enough staff to cope with the number of people coming through the hospital’s doors.’

Pressure all-year round

The use of escalation beds varies significantly across the country, according to the research, with the East Midlands and, particularly hospital trusts in Nottingham and Leicester, having the highest number of escalation NHS bed beds in use. 2010 2019 numbers A Leicester consultant, who wished to remain in England anonymous, tells The Doctor that the winter bed crisis had ‘slowly and inexorably lengthened over hospitals is becoming a year-round crisis and recent years’, leading to ‘bed availability issues… can simply no longer be ignored. If Mr Stevens has almost daily even in June’, affecting patients waiting finally taken note at least it’s better later than never. for operations. ‘Every effort is made to release beds, but I Elective procedures cancelled feel the underlying issue is too few beds to cope The BMA research reveals that beds for patients who with the emergency flow which in turn then blocks have left operating theatres are being commandeered as elective surgical work,’ he says. ‘Theatre delays occur escalation beds – often leading to cancelled operations even now frequently because of bed availability for elective surgery and delays for emergency surgery, issues generally.’ with no facilities left for post-op The total number of beds in the recovery. Patients have also been put ‘The use of escalation NHS in England fell by 10 per cent on beds in other hospital facilities beds is a sign that trusts between 2010 and 2019, from 144,455 despite a lack of room in those areas. to 129,992, despite constant warnings are unable to cope The figures show that 3,428 from the BMA that reductions with demand’ escalation beds, those often would increase pressure caused by mothballed, kept in reserve or squeezed into other demographic change among the population. clinical areas, were in operation across England on At this year’s BMA annual representative meeting, 3 March. By 1 May, well clear of winter, the 80 out of BMA council chair Chaand Nagpaul questioned the 134 acute trusts which responded to the BMA reported Government’s financial support of the NHS, which has that 1,637 were still in use. led to bed cuts being deemed necessary by hospital BMA consultants committee chair Rob Harwood trusts and clinical commissioning groups. says: ‘The use of escalation beds is a sign that trusts are ‘The new money in England’s Long-Term Plan at a critical stage and are unable to cope with demand – while a welcome departure from austerity – with their current bed stock. This has a direct impact on just isn’t enough,’ he said. ‘Even with this money, patient care in numerous ways. we’ll continue to lag behind our ‘Some hospitals are forced to ‘Intense pressure on European neighbours. Why does designate their theatre recovery beds as our Government still decide beds can result in “escalation” resulting in elective surgical that our patients don’t deserve patients being placed operations being cancelled as there is the same funding as patients in in corridors’ no space for those patients, who need France or Germany?’ immediate care after their surgery. Given the parlous state of NHS trust finances ‘I have heard of other cases where beds in day– acute providers posted a deficit of £571m last procedure units are used as escalation spaces for financial year – Mr Stevens’ U-turn is likely to remain admitting patients for longer ward-style care, meaning little more than rhetoric unless it is echoed by a healthcare staff cannot continue with routine day-care change of heart in the Treasury and Number 10, with surgical cases. proper funding for increased beds and accompanying ‘Most worryingly, the intense pressure on beds can workforce planning put in place. Doctors and patients result in patients being placed on beds in corridors alike will be hoping it is another case of better late or in bits of other facilities, sometimes cramping than never. thedoctor | July 2019 29

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

A visually impaired doctor who felt bullied and harassed at work pays tribute to the BMA adviser who supported him

A doctor with a visual impairment had been provided with specialist software and adaptations to hardware as part of the reasonable workplace adjustments which had been recommended by the Access to Work service. Following closures of a number of his employer’s premises, however, the equipment was placed into storage. It led to a dispute lasting several years, while he and his BMA adviser pressed for an alternative, permanent office space. This should not have been difficult. Some other staff were expected to hotdesk under the new arrangements but it was completely impractical for this doctor to set up a new desk every day. He needed his own space. The doctor emailed and met HR repeatedly. He found his requests responded to with the implication that he should simply get on with his job – the one thing he was being prevented from doing. Sometimes he was just ignored and finally he suspected the employer was

30 thedoctor | July 2019

trying to provoke him into resignation, and felt bullied and harassed. His BMA adviser recalls some of the meetings with HR and the doctor’s line manager being ‘very difficult’. The adviser made robust representations and challenged decisions. The equipment the doctor needed was only slowly released from storage after an office space was identified. The years of struggle took a toll on the doctor’s physical health and he reluctantly opted to take early retirement. No one should have had to endure this but the doctor had nothing but praise for the professional and personal support he received over several years. He said the adviser had always been available to listen, respond to emails, and support him in meetings. ‘She has been absolutely amazing – she helped me carry on through it all.’ Some details have been changed

what’s on

July

September

26 Planning for retirement – delivered by the BMA, Cambridge, 9am to 4pm

19 Practical skills... for effective communication, London, 8.45am to 4.45pm

August

20 Planning for retirement – delivered by the BMA, Bristol, 9am to 4pm

20 Pensions taxation and retirement planning – delivered by Chase de Vere Medical, Glasgow, 7pm to 8.30pm

21 BMA Scottish conference, Glasgow, 9.30am to 5pm

05 Care of an older person masterclass, London, 8am to 5pm

27 Planning for retirement – delivered by the BMA, Leeds, 9am to 4pm

11 Planning for retirement – delivered by the BMA, London, 9am to 4pm

October

14 CESR seminars for SAS doctors, Manchester, 9am to 12.15pm

22 Pensions taxation and retirement planning – delivered by Chase de Vere Medical, Aberdeen, 7pm to 8.30pm

02 Critical appraisal workshop – Part 1, London, 9am to 4pm 04 Clinical pharmacists in general practice masterclass, London 04 Dermatology masterclass, London, 8am to 5pm

GLASGOW: Location for the BMA Scottish conference

05 Neurology masterclass, London

16 Practical skills... time management and taking control, Manchester, 9am to 5pm 22 Critical appraisal workshop – part 2, London, 9am to 4pm

04-05 BMJ Live, London

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

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