The Doctor, June 2021

The magazine for BMA members

thedoctor

Issue 32 | June 2021

Breaking point The unacceptable human cost of the NHS workforce crisis Leaving late

Can night-time commutes be made safer?

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Surgical advance The specialty’s long road to equality

GMC investigations A doctor’s widow makes the case for compassion

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thedoctor

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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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 £170 (UK) or £240 (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: 373 issue 8295

Senior staff writer Peter Blackburn (020) 7874 7398 Staff writer Tim Tonkin (020) 7383 6753 Scotland correspondent Jennifer Trueland Feature writer Seren Boyd Senior production editor Lisa Bott-Hansson Design BMA creative services Cover Ed Moss Read more from The Doctor online at bma.org.uk/thedoctor

ISSN 2631-6412

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In this issue 4-5

Briefing

GPs feel set up to fail despite a massive workload, and why the old-style CQC must not return

Welcome Chaand Nagpaul, BMA council chair Before the COVID-19 pandemic hit this country our NHS was unprepared and under-resourced. We had too few beds, too few doctors, funding strangled for more than a decade, and ageing and unsuitable facilities and equipment.

It is in this health system where, for the last 16 months, doctors have done remarkable work in responding to this public health crisis.

Yet, as I write, there are understandable fears of another surge of infections in this country and – looming large – a mounting backlog and growing feeling of unmet need which is almost too vast to even be able to comprehend.

For too long working in the NHS has been more synonymous with words like ‘brutal’ and ‘relentless’ than words like ‘care’ and ‘compassion’.

As a result, in the coming weeks the BMA will be publishing an in-depth analysis of the NHS workforce crisis – and accompanying projections of the sort of recruitment required to cope with increasing demand in the coming years.

A feature in this issue of The Doctor includes some of the elements of that report as well as powerful stories of doctors pushed to the brink – to contemplating suicide or leaving the vocation they love – by the conditions in which they have to work.

It has never been more clear that serious change is required. If the Government truly values the extraordinary work of these staff it must provide short-, medium- and long-term – and fully funded – workforce planning and supply in the spending review later this year.

We look at the relationship between GMC fitness-to-practise investigations and doctor suicides. In this feature we reveal the BMA is supporting legal action by the family of a doctor who took his own life just hours after receiving notification that he would be subject to an interim orders’ tribunal. In these cases legal representatives will argue that a hospital trust and the GMC failed in their duties of care to this doctor. For far too long those three letters – GMC – have sent shivers down the spines of doctors.

We also look at the anxieties for doctors who have to leave work in the late hours and fear for their safety, the effects COVID-19 has had on maternity services and the unconscious bias in the NHS through the experiences of a doctor told he had ‘communication issues’.

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

6-9

A price no doctor should pay

Doctors facing risky and frightening commutes in the middle of the night need support and empathy

10-11

Covid’s babies

The pandemic’s effect on access to maternity services

12-15

A lack of compassion

Viji Suresh’s husband, a consultant anaesthetist, took his own life within hours of receiving a GMC letter. The BMA is supporting her legal claim

16-21

Broken by care

Doctors are being pushed to the brink by an unprecedented workforce crisis

22-25

And you thought surgery was hard

Why managing childcare, and enabling all surgeons to reach their potential, has often been a surgical advance too far

26-27

‘Leave your baby at the door’

A junior doctor was prevented from bringing her baby with her when she was vaccinated

28-29

Your BMA and It happened to me Gaining useful experience for your ARCP, and a doctor with a heart in two places

30-31

On the ground

Fending off unfair claims about communication skills with BMA help

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briefing Current issues facing doctors

VAUTREY: GPs should be able to retain flexibility at work

UNAPPRECIATED: GPs have been made to feel they are failing despite their relentless workload

GPs asked to do the impossible GPs in England passed a motion of no confidence in the leadership of NHS England last month.

Those in positions of power at Skipton House could hardly have been surprised given it followed health leaders sending a letter instructing GPs to offer face-to-face appointments to patients, despite GPs having gone to extraordinary lengths, often at great personal risk, to keep services open for patients – including on a face-to-face basis – during the pandemic, and despite the government’s guidance requiring social distancing and infection control measures to be maintained.

The letter, which many GPs felt was critical, seemed to exacerbate media attacks on general practice and some doctors reported abuse from patients and staff in tears owing to relentless workload and a fundamental lack of appreciation.

The BMA called for an urgent meeting with secretary of state for health and social care Matt Hancock and doctors leaders were assured the Government recognises the immense pressures general practice faces.

GP representatives told Mr Hancock about the unsustainable workload pressures facing general practice, and the urgent need to support surgeries if they are to safely increase the number of face-to-face appointments while trying to care for those patients who are now part of a huge backlog.

Doctors leaders outlined that GPs

and their teams are feeling increasingly demoralised by the suggestion that they are failing their patients by following national guidance around triage and remote consulting, despite doctors working tirelessly to keep up with patient demand on top of delivering the vaccine programme.

BMA GPs committee chair Richard Vautrey said: ‘The BMA believes that GPs should feel empowered to deliver care in what they believe is the best way for their patients, and retain flexibility of access – be it in-person or remotely – rather than submitting to arbitrary targets of face-toface appointments that may not meet the diverse needs of patients, increase workload and waiting times, and ultimately diminish the quality of care we can provide.’

The COVID-19 pandemic has also left GPs in Scotland at breaking point.

A BMA Scotland survey, with 669 respondents from across the country, found that GPs and their practice staff are facing unacceptable abusive behaviour from members of the public – with almost nine out of 10 saying they or their staff have been subjected to verbal or physical abuse in the past month alone, and almost two thirds saying it is a situation which has deteriorated since the beginning of the pandemic.

As a result, around 70 per cent of GPs surveyed have said they are now more likely to take early retirement or leave the profession.

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Why we can’t have the same old CQC back again There may have been few positives from the pandemic, but the CQC’s (Care Quality Commission) temporary halting of routine inspections was certainly one of them.

The move in March last year, following an open letter to the CQC chief executive from BMA council chair Chaand Nagpaul, was a necessary step, although Dr Nagpaul was not alone in questioning why it took a pandemic to pause a system widely regarded as counterproductive and bureaucratic.

When the CQC said last year that it planned to reintroduce inspections, the BMA issued a strong warning that a return to the regime as it was would be inappropriate, given the huge amount of accumulated need that doctors would be dealing with. Last month [28 May] EXCESS BUREAUCRACY: saw the CQC launch its latest No-one missed it strategy for health and social care in England, part of which was a raft of pledges around ‘smarter regulation’.

These include applying regulatory powers in a ‘more proportionate and consistent way’, developing stronger relationships with service providers and even limiting inspection visits for occasions when there was a ‘clear need to do so’.

This apparent shift in regulatory tone, from less confrontational to more considerate, is one that has been cautiously welcomed by both doctors and the BMA. Dr Nagpaul says: ‘While this strategy is moving in the right direction, to really improve patient safety CQC must reconsider its crude rating system of inspection [and] recognise that the NHS is vastly understaffed and underresourced.

‘Ultimately, patient safety will not be assured by a reliance on episodic CQC inspections, but by a culture of learning, openness and continual quality improvement underpinned by healthcare staff being given the resources and infrastructure needed to deliver the care that patients need.’

Keep in touch with the BMA online at

When you can’t be the doctor you want to be

DISTRESSED: Doctors face obstacles at work

Doctors may not put a name to the unease they feel when they ‘cannot do the job properly’ – but they are acutely aware of the toll that moral burden is taking.

In the BMA’s recent, pan-profession survey of UK doctors, more than three-quarters of respondents (78 per cent) said the phrase ‘moral distress’ struck a chord. More than half (51 per cent) said the term ‘moral injury’ – implying more serious, lasting harm – resonated with their experiences at work.

Moral distress is defined by the BMA as institutional and resource constraints which create a sense of unease among doctors from being conflicted about the quality of care they can give.

As one doctor put it, ‘by their nature, doctors always want to do the right thing and find solutions to problems. When you cannot [do] that, due to circumstances beyond your control, it is extremely distressing’.

Of doctors who had experienced moral distress, 96 per cent of doctors who had worked before and during the pandemic said their moral distress had worsened in the past 15 months.

However, the survey makes clear these feelings predate COVID. Almost 60 per cent of those who had worked before the pandemic said they had experienced moral distress in the 12 months leading up to it.

The most commonly stated cause of moral distress was insufficient staff. Alarmingly, 62 per cent of respondents said they were planning to work fewer hours in the next year; 51 per cent said they were more likely to take early retirement in the next year.

Other significant factors included: mental fatigue, lack of time to give sufficient emotional support to patients, and the inability to provide timely treatment.

Read more online – GPs face barrage of abuse – Europe adopts BMA vulnerable patient safeguard proposal – Call for clarity as vaccination sites deny entry to dependants Read all the latest stories at bma.org.uk/news

instagram.com/thebma

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ALONE: Many doctors are forced to take risks on latenight commutes

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A price no doctor should have to pay Long shifts and varying finish times can leave doctors facing risky and frightening commutes.

They need practical help, but also more empathy from colleagues. Seren Boyd reports

C

lock-watching is as futile as it is frowned upon in regular moves to new areas – raised additional the NHS – but precisely why someone might be challenges. Without an initial support network or wide anxious about working late is not always obvious circle of friends, she tended to rent alone, which left or understood. her feeling more insecure. She used to ring her mum Extra hours at work might mean more time waiting as she walked the streets at night – until a spate of at the bus stop in the dark or standing on a deserted Brexit-related hate crimes meant she no longer felt safe station platform at 2am. speaking her mother tongue in public.

For women especially, the risks have always been Dr Costache was so tired of feeling anxious about her clear, but the highly publicised murder of Sarah Everard commute that in 2019 she decided to spend the money in London in March have brought them into sharper that she had saved up for exams on a car instead. Senior focus for many, including Cristina Costache. colleagues made it clear they did not understand her Dr Costache, a paediatric specialty trainee 3 in priorities.

Yorkshire and BMA council member, was badly shaken Negotiating hospital car parks in the dark was not

by Sarah’s death and the national always risk-free either. She cites debate it triggered. ‘It could have been instances at previous workplaces any of us,’ she says. ‘But what made where staff had been attacked or ‘Everybody thought me even more emotional was the mugged. The car park at her hospital I was slacking but I way some men were talking against is well-lit but in other jobs she and only wanted to get women being out alone at night.’ her colleagues were in the habit of She had had no way of avoiding this waiting for one another after work, and home safe’ earlier in her medical training when ensuring each got to their car safely. she was reliant on public transport.

‘I’m 47kg and tiny as a child and I try Many of her early postings required her to dress as baggy and badly as I can, to take a bus and a train in the small hours. just to not attract any attention,’ says Dr Costache. ‘I offer ‘It’s quite common to be asked to stay late and give care and safety to my patients and I feel that I should not a hand,’ says Dr Costache. ‘And I was always rushing to be exposed to risk because of the job that I do.’ leave because I didn’t want to miss the last bus or the train because the next one would be in another hour.

Stranded Everybody thought I was slacking but I only wanted to Safety means different things to different people.

GP registrar Hannah Barham-Brown does not get home safe.’ work nights and has a car. But as a wheelchair user, Being an international medical graduate – and thedoctor | June 2021 07

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BARHAMBROWN: Hit hard by Sarah Everard’s death

COSTACHE: ‘I should not be exposed to risk because of the job I do’

she still feels vulnerable.

Dr Barham-Brown, a BMA council member, is ‘I am two-and-a-half feet shorter than everyone else pleased that Sarah’s death prompted a national in my wheelchair and I can only go four miles an hour,’ reckoning that allowed women to talk more openly she says. about their safety concerns. But being reminded of the Sarah Everard’s death hit her prevalence of violence against women hard too, not least because of some has been unsettling. uncomfortable parallels between ‘I went down to London last week ‘I’m 47kg and tiny their backgrounds. Dr Barham-Brown and for the first time my mum clearly as a child and I try to is the same age as Sarah and they did not want me to go. I said, “Mum, dress as baggy and had been at the same university I lived there for years”, and she said, in the same year. She lived in the “But you’re more vulnerable now badly as I can’ Clapham Common area, where because you’re more disabled now.

Sarah disappeared, when she was a And you can’t run away.” And that was foundation 1 doctor. quite a scary moment.’

At that time, Dr Barham-Brown’s commute, mostly Fears about being attacked proved unfounded – by train, ended with a steep hill she had to negotiate in but she was, yet again, left stranded on a train at a manual wheelchair she had only been using for a year. Clapham Junction.

On one occasion, she opted to ‘hobble in on a stick’ and leave the chair at work, but had a fall en route and Safety culture arrived at work with concussion and bloody knees.

As medical director of a GP out-of-hours service in Irregular hours meant she never knew which train Birmingham and Solihull, Fay Wilson makes her doctors’ she would be taking and so could not give stations safety a top priority. sufficient notice to arrange for someone to meet her The service offers drive-through and drive-to with a ramp so she could exit the train. clinics as well as home visits, where Being left stranded in the carriage was appropriate. In 25 years, they have not uncommon. only had a handful of incidents: one ‘The trains were every 15 to 20 doctor mugged while walking to work, ‘I never knew what minutes and I never knew what time a smash-and-grab on a parked car, and time I’d finish’ I’d finish,’ she says. ‘There’s just no a home visit to a patient who greeted her doctor by throwing a brick at him. predicting that.’

With almost 500 clinical and She now has her own car but even operational personnel, precautions so there are challenges. The disabled and protocols are carefully observed. parking spaces at a recent workplace Clinics have security and CCTV. Those making home were frequently occupied by non-disabled drivers with visits are as inconspicuous as possible: the cars do not impunity – until Dr Barham-Brown, in her frustration, have logos or livery, and visiting doctors do not wear or wrote to hospital management. Eventually, a warden carry anything that would identify them as such. was assigned to guard a disabled parking space until Doctors travel with a driver who stays in the car; they she arrived.

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WILSON: A raft of safety measures at her out-of-hours service

LAST TRAIN: Many doctors face a solitary commute after a hard day’s work

lighting in car parks, better security, staff might have a chaperone too in certain cases. Timings are logged and if the doctor takes longer than expected, shuttle buses to stations: these are not going to the driver calls them. If the driver does not report in, the be budgetary priorities.

‘But there are other things like trying to roster team leader gets in touch. When previously they ran an women so they’re not leaving the hospital by outreach service for sex workers, they would contact the police if doctors failed to contact base in good time. themselves, or rostering people who get public Crucially, Dr Wilson, who is also on the BMA GPs transport to finish at the same time, or helping to committee, will not send people out if the pre-visit organise lift-share systems,’ suggests Dr Barhamassessment by phone flags up any kind of risk.

Brown. ‘These kind of things just require a ‘Not that long ago, we had a call where the caller was little thought.’ offensively racist to the doctor, but the doctor was very What made a big difference to Dr Costache were keen to be pro-patient and go anyway,’ she says. ‘But the occasions where she felt more senior colleagues he’d also heard people laughing in the background at were looking out for her and asked about her travel what was being said. This sort of abuse arrangements. means that the visiting doctor does ‘A man who lives in a safe area in ‘We don’t make a not know what they are going into. I a safe house with a car would not said we mustn’t visit. In the end they necessarily think of his colleagues’ judgement about sorted it out on the phone.’ safety because it’s not an issue for fault, we are looking Dr Wilson also warns against doctors him,’ she says. ‘It wasn’t that I wanted for a judgement endangering themselves because of colleagues to give me a lift or expected about safety’ an exaggerated sense of responsibility it, although I had one consultant who to the patient – a key lesson reinforced always did. But just asking: Are you through the mandatory training cycle. taking the bus? Are you getting home ‘You have to be sensible and not put yourself in safe? It was kindness that made the difference.’ danger because of a ministering angel complex, or Dr Barham-Brown agrees that a little empathy goes because you think you’re the only person that can a long way. Her employer moved the security keypad rescue this patient. down to seating height before she joined, without her ‘If you’re going and taking care of somebody even asking them to. who is seriously mentally ill, are you still going to be ‘The fact they took that step made me feel like I was going to be welcomed and supported,’ she says. ‘What standing tomorrow? It’s not about whether it’s the we need is for people to stop and say, “What would help patient’s fault or not that they hit people. We don’t you?” It’s about just asking the question. make a judgement about fault: we are looking for a ‘We don’t live in a world where we can plan for judgement about safety.’ everything. I don’t necessarily need people to be Thoughtful colleagues experts in keeping me safe. But I need them to be Dr Barham-Brown and Dr Costache recognise some of approachable and willing to help when I raise concerns. the practical solutions they might propose to improve As ever in the NHS, it comes down to creating that safety, especially in secondary care, are costly. Brighter culture of openness.’ bma.org.uk/thedoctor

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Maternity services have been profoundly affected by COVID, from a lack of face-to-face appointments, to decreased breastfeeding support and heightened fears for mental health. Tim Tonkin reports

Covid’s babies W

hile the treatment of illness is often seen as the raison d’être of the NHS, there is another aspect of care provided by the health service that is every bit as vital, varied and complex.

Pregnancy, childbirth and the postnatal period each present a wide range of needs that cannot be deferred and must be met by a host of support services provided across primary and secondary care sectors and the community.

As with so much else of what the NHS does, however, COVID-19 has inevitably affected the way in which expectant and new mothers access the care that they need.

Indeed, a report published

last year by the RCOG (Royal College of Obstetricians and Gynaecologists) found that there had been ‘substantial and heterogeneous’ modifications to the way in which maternity services were provided during the pandemic.

Based on responses to a survey, carried out between May and June 2020, from a total of 81 obstetric units throughout the UK, the report found that 70 per cent of units reported a reduction in antenatal appointments, while 56 per cent confirmed a reduction in postnatal appointments.

Eighty-nine per cent of units said they had used remote consultations in place of faceto-face sessions, while

59 per cent said they had had to remove access temporarily to giving birth at home or in a midwife-led unit.

Access problems There has been some recognition of the challenges created by these adaptations, with the National Insitute for Health and Care Excellence and RCOG recommending that as many antenatal appointments as possible take place face-to-face, with a minimum of six out of eight appointments to be provided in-person.

Behind the figures, however, are the very human stories and experiences of mothers and babies, and how the upheaval in the way maternity

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care has been provided has affected them.

Manchester-based specialty trainee 7 in paediatrics Jamie Gilmour gave birth to her daughter in April and had seen the changes to maternity services in her trust prior to going on maternity leave.

She says that, while she was fortunate to have had a straightforward pregnancy and birth, she is now finding access to postnatal services in her area is not always consistent or straightforward. ‘[As an expectant mother] you’re told you’re at high risk and to try and stay away from everybody for social distancing purposes, so there is almost a fear of going into hospital,’ she says.

‘When you then do need support, you’re not sure whether the service you need is either going to be there at all or available in the right way.

‘It’s very difficult for pregnant mums and people in the postnatal period to necessarily get the right support and know what’s available.’

Having worked on a paediatric ward with a tertiary neonatal unit prior to going on maternity leave herself, Dr Gilmour says accessing such services even within hospital settings has not always been straightforward.

‘We struggled to get breastfeeding support to come to the paediatric ward from the postnatal ward, never mind trying to get people to visit mums at their homes,’ she explains.

As well as redirecting services that were traditionally delivered face-to-face to online and telephone-based, bma.org.uk/thedoctor

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the clinical demands posed by the pandemic have also seen shortfalls in staff.

A survey of staff working in maternity settings conducted by the RCOG last December found that 61 per cent of those responding said members from their departments had been redeployed to other parts of the health service during the pandemic.

While the survey notes the majority of staff were returned to maternity settings between April and September, it remains unclear exactly what effects these shortages may have had on mothers and babies during this period.

Mental health concerns Another critical area linked with postnatal care is that of perinatal mental health. Like many other forms of maternity support access to, and need for, these services have been affected by the pandemic.

A report commissioned by the Maternal Mental Health Alliance published in March this year said COVID-19 has posed mental health challenges during pregnancy and early motherhood owing to a variety of issues.

Speaking at the Westminster Health Forum, national training and research coordinator for Action on Postpartum Psychosis Sally Wilson said: ‘There were gaps in some of these services already before the pandemic, but we also saw redeployment of services away from midwifery, health visiting and perinatal mental health teams.

‘We need to recognise that perinatal and maternity mental health services are essential and lifesaving. Moving forward, these services must be

prioritised and protected as we go into the future.’

Further research into what effect the pandemic has had on maternity care is also backed by Dr Gilmour, adding that she does not feel enough consideration was given to how mothers, their partners and babies would be affected by changes to services resulting from COVID-19.

While acknowledging that infection control remains a critical consideration in delivering healthcare, reliable access to PPE and universal vaccination among healthcare workers, and ever improving rates among the general public, meant that a greater return to in-person maternity care might soon be possible.

She further added that taking a standardised, national approach to policy on the access rights of birthing partners would help to eliminate the current post code lottery of different rules at different trusts.

‘I think impact [on changing maternity services] was considered purely on reducing transmission and reducing face-to-face contact,’ she says.

‘Even now on paediatric wards only one parent can go and stay with the child.

If a child is admitted with weight loss or jaundice postnatally with difficulties feeding, the mum would be admitted with the child, but she then can’t get support from her partner.

‘Now we’ve got greater availability of testing and staff are vaccinated, I do think we need to start moving back to being more face-to-face with these services.’

‘It’s very difficult for pregnant mums and people in the postnatal period to necessarily get the right support and know what’s available’

‘You do need breastfeeding counsellors or support to come and help mums on the ward’

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ADRIAN DON

VIJI SURESH: ‘He was on his own, he was alone’

Viji Suresh’s husband, a consultant anaesthetist, took his own life within hours of receiving a GMC letter.

She says he was left feeling alone and unsupported, and the BMA is supporting her legal claim against the regulator and employer.

Peter Blackburn reports

A lack of compassion ‘I ‘It is an irreplaceable loss and causes me extreme anger and disappointment’

never even dreamt or thought that this could happen in my home – and especially to my husband.

Definitely, this decision that has come out of him is not his own. He must have been shattered by seeing that letter.’

On 2 May 2018, Sridharan Suresh, a consultant anaesthetist at North Tees and Hartlepool Hospitals NHS Foundation Trust – a doctor with an ‘exceptional, unblemished’ professional record – received a letter from the GMC informing him he would be subject to an interim orders tribunal.

Dr Suresh had been under police investigation at the time following allegations of sexual touching made by a teenage patient undergoing sedation for dental extraction – although an inquest into

his death last year heard that the drugs used to sedate the patient are ‘well-known’ to produce hallucinations and heightened sexual feelings, the description the victim gave did not match Dr Suresh’s appearance and the police later closed the case with ‘insufficient evidence’.

Dr Suresh had been told by his trust he would not be referred to the GMC, but the police made a third-party referral and the trust did not inform Dr Suresh, despite knowing the action had been taken.

‘Shockwave’ The letter came as a ‘bolt from the blue’. Just hours later Dr Suresh sent an email to his wife saying he had done nothing wrong, but could go on no longer, and took his own life.

Speaking to The Doctor, Dr

Suresh’s widow, Viji Suresh, says: ‘He was on his own, he was alone, there was nobody there with him. The amount of impact it had – it was a kind of shockwave. His mind was not in the right place.

‘For me it is an irreplaceable loss and causes me extreme anger and disappointment.’

Mrs Suresh’s medico-legal adviser Rajendra Chaudhary says: ‘I didn’t know Dr Suresh but when I see that letter myself it hits me how this would have panned out in his mind. Doctors see the GMC as a very cold, unsympathetic organisation, and that they have no concern whatsoever about doctors’ wellbeing. You feel you become guilty before you have been tried.’

GMC figures show that in 2019 there were 8,654 fitness-to-practise enquiries – the majority from members

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of the public. Of those 1,389 extended to a full investigation, 602 to a provisional inquiry and 365 ended in a referral to a responsible officer. The significant majority, 6,298, were closed prior to those stages at ‘initial triage’.

And it is clear that the effect of each and every one of these processes can be huge.

A West Midlands GP, who asked to remain anonymous, told The Doctor the stress of even the initial, six-week in his case, inquiry ahead of a potential investigation had a huge impact – and led to him taking medication to block obsessional thoughts and emotions.

He says: ‘It affected every grain of me in terms of what I did in the workplace. I had repetitive, intrusive thoughts and anxiety and it just wouldn’t go away. I constantly worried about everything else that happened, other patients I had seen and I was constantly looking back and analysing things I had done. On top of that I worried about losing my job and becoming destitute and all those sorts of things.’

He adds: ‘I ask myself – “would I have had the resilience to persevere knowing how long this process would take?”

I don’t think I would have had the armoury to cope with that at that point.’

The effects of these processes should not be a surprise to the regulator, either. It has even investigated the link between doctor suicide and fitness-to-practise investigations itself, before.

In 2014 the GMC commissioned an independent review from Sarndrah Horsfall, which identified 28 suicide – or suspected

suicide – cases among doctors under investigation between 2005 and 2013. Manchester University professor of psychiatry Louis Appleby was subsequently tasked with analysing the impact of GMC investigations on doctors and coming up with proposals to lessen those impacts. He said at the time that ‘suicide is not confined to those who are known to be mentally ill – it can be those who are thought to be coping that are most at risk – so reducing risk is a task for the system as a whole’.

Heavy-handed response Speaking to The Doctor, Professor Appleby says doctors under investigation can feel trapped, humiliated and unjustly treated – three ingredients for a recipe of great concern. He adds: ‘Sometimes the response in the system can seem disproportionate when doctors start to see not just a threat to their livelihoods and professional standing but something much more profound about who they are.’

The GMC says it made a number of changes following the review, including only carrying out formal investigations ‘where necessary’, ‘coordinating’ approaches so doctors under investigation has a single point of contact, ‘improving’ communications with doctors, and establishing a specialist team to handle cases where doctors are unwell.

All of these changes were made prior to the death of Dr Suresh and he was not identified as vulnerable. It seems the GMC would likely need something as clear cut as an obvious diagnosis of mental ill health in order to trigger any

particular concern or extra layer of compassion.

Professor Appleby says: ‘The gap that leaves – an important gap – is that sometimes people who feel that sense of humiliation or being unjustly treated might not have a mental disorder.

That is, to some extent, a natural reaction of the highstandard, perfectionist, professional challenged about the work they do and in which their identity is wrapped up. It’s very important we don’t just see suicide risk as just in those people who have got a specific mental disorder. It also applies to other people who may not be depressed in a clinical sense but are becoming a risk because of these factors and these reactions to the process.’

As Dr Chaudhary says: ‘I personally feel it was quite foreseeable that there was a high risk of self-harm at this point – particularly for someone facing those allegations already.’

The BMA is supporting Dr Suresh’s family in a claim for damages and other relief brought under the Human Rights Act 1998, the law of negligence under the provisions of the Fatal Accidents Act 1976 and under the Law Reform (Miscellaneous Provisions) Act 1934.

A letter before action will be sent to the GMC outlining the details of the case. It says the GMC should have known there was a real and immediate risk of suicide, and that there were system failures after the GMC failed to take any steps to liaise with Dr Suresh’s employer or the police to assess his vulnerabilities, despite Dr Suresh telling his trust how the investigations were affecting

‘Doctors see the GMC as a very cold, unsympathetic organisation’

‘Sometimes the response in the system can seem disproportionate’

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DEVASTATION: Dr Suresh took his own life after GMC contact

‘I am going to keep campaigning until this changes’

him and his family.

The letter outlines that the GMC’s communication with Dr Suresh on 2 May 2018 was impersonal despite the GMC suggesting it has improved these processes. It also says the GMC failed to conduct a risk assessment.

BMA council chair Chaand Nagpaul says: ‘Those three letters – GMC – send a shiver down any doctor’s spine. For as long as I have known every doctor lives in fear of a letter through their letterbox from the GMC. When doctors see such a letter, what flashes through their minds is they see their careers ending, they fear adverse publicity, they fear suspension from their employers, they fear for their livelihoods, they fear the shame and they fear their side not being heard.’

In his report, Professor Appleby also recommends ‘systematic recording’ of the cause of death of doctors under investigation but the GMC told The Doctor it did not introduce this new method until January 2018. As such there was no systematic monitoring, and are no figures available, for the period from the report concluding to January 2018.

The GMC has been collecting the figures since but has not yet published them. In April, in a response to a Freedom of Information request from The Doctor requesting the figures the GMC said: ‘We are now working towards publication of data concerning suicide of doctors under investigation or monitoring for 2018 to 2020 later this year.’ That would represent a wait of at least 30 months for the figures from

calendar year 2018.

A GMC spokesperson said new safeguards were being put in place including a phone call with the first email contact and that the regulator was seeking legislative reform which it hoped would ‘reduce the impact of investigations on doctors’. They said: ‘We are deeply saddened by the tragic case of Dr Suresh and the devastation this has brought his family. It’s so important we keep listening, learning and improving our processes, and we have made a number of changes since the inquest.’

The GMC may believe it has taken the necessary action to create a compassionate process but the majority of its changes were made prior to the death of Dr Suresh.

Humane approach Doctors leaders believe it is time for another look at the systems which cause such fear and distress for frontline staff. At the heart of any reform should be the tragic case of Dr Suresh – and the principle that doctors be treated with the same respect, dignity and compassion they are expected to provide to patients.

Dr Nagpaul says: ‘Knowing this is what the impact

of notification of a GMC investigation can have it really is vital that every effort is made to make sure this information is communicated in as humane a manner as possible and also recognising the natural justice that no one is guilty at the onset of an investigation. Investigation is not a notification of guilt.’

For Mrs Suresh, it has already been a three-year battle for action – and has included a gruelling inquest and now another legal process.

Mrs Suresh says she will not stop until she believes the institutions which hold sway over the lives of doctors are more accountable to frontline staff and operate with compassion at their core. She says: ‘The GMC is an organisation that terrifies doctors. I am going to keep campaigning until this changes.’ Speaking about her husband, Mrs Suresh says: ‘He was a very polite, kind and softhearted person. He is a person who everybody would trust to the core and he had a lot of friends and respect from the community, families around us and colleagues.’

If one thing is clear, it is that one more tragedy like this would be one too many.

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Action against employer The BMA is also supporting legal action against North Tees and Hartlepool NHS Foundation Trust.

A letter before action which will be sent to the trust suggests Dr Suresh’s employers owed him a duty of care and breached that by wrongly informing Dr Suresh that he would not be referred to the GMC, failing to update Dr Suresh or their medical director when the police made a referral to the GMC and failing to take steps to protect Dr Suresh’s mental health in light of those developments.

The letter says the trust could have put appropriate measures in place to provide further support to Dr Suresh, including a more interventionist approach where counselling and occupational health could have been arranged.

The letter will say the trust’s failings contributed to Dr Suresh’s decision to take his own life.

BMA council chair Chaand Nagpaul (pictured above) says all employers should be ‘acutely aware of the impact of an investigation by the GMC – and the communication of that investigation – can have on a doctor.’

He says: ‘There should be systems to ensure that the mental wellbeing of a doctor is safeguarded, the right support given, any work adjustment allowed for and that they have colleagues they can speak to and trust and have the ability to share their fears and feelings in a confidential space rather. Without this employers risk adding to the isolation that being notified of an investigation can create due to the worry and the shame of that being more widely known. Employers must put in place systems to support the mental health of doctors, any adjustments they need and a safe space to speak confidentially about anything they need.’

A North Tees and Hartlepool NHS Foundation Trust spokesperson commented: ‘We remain saddened by the loss of a highly valued colleague in such distressing circumstances for his family, friends and colleagues within the trust.’

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Fitness-to-practise reform Earlier this year the Department of Health and Social Care announced a public consultation around the regulation of healthcare professionals.

The BMA will support proposals for a three-stage process for the fitness-to-practise reforms, which will provide for an ‘accepted outcomes’ process which may avoid registrants being considered by panels where they accept the facts and action necessary.

However, doctors leaders will call for timelines for each stage of the process to give doctors some certainty and avoid drawn out cases, as well as that health must stay as a grounds for action rather than being subsumed under ‘lack of competence’.

The BMA will also call for significant doctor representation in GMC decision making, which is not currently an assurance in the proposals.

thedoctor | June 2021 15

07/06/2021 11:22

ED MOSS

MULLINS: ‘You fear something bad is going to happen and that you will be blamed’

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Broken by care There was a workforce crisis before COVID, but doctors are now facing unacceptable, unsustainable pressures that are driving many to consider leaving the NHS. Peter Blackburn speaks to members of a profession under siege, and considers what the Government needs to do to make things better

‘I

was having a lot of suicidal thoughts. I actually ended up ringing the Samaritans at one point. The impact on my life was huge: I wasn’t able to connect with my kids, I was drinking too much, not spending time with family, not sleeping and constantly ruminating over negative thoughts.’

Seventeen years as a consultant psychiatrist working in acute services – trying to make early interventions in the lives of patients with psychosis – had taken its toll on Simon Mullins.

The early days in the profession had been largely positive. The mid and late-00s seemed to bring a focus on mental health services – new teams were set up and rolled out across the country and the required resources followed.

Lofty demands, targets and standards came from central Government and NHS leaders but for Dr Mullins this was all welcome pressure to succeed while the money to make improvements and meet expectations was in place.

However, a decade of austerity and demographic changes followed and produced soaring demand from patients and families: the disenfranchised, asylum seekers, greater numbers from left behind impoverished and ethnic

minority communities and people with overwhelming, and often multiple, complex trauma.

And these are not patients easily healed – these are people who are losing touch with the reality most usually experience.

Austerity politics ensured resources did not follow the demand – and the relentless need. And for South Yorkshire consultant psychiatrist Dr Mullins and many peers across the country, day-to-day life became a ‘battle’ – a constant reminder that you are ‘letting patients down’.

‘If somebody is in a crisis – the early stages of psychosis – there are a lot of risks: they aren’t coping, they hear voices, they have paranoia and their reality is driving them to self-harm or making them very vulnerable.

‘You want to respond quickly but there wouldn’t be a bed to admit them to, you would be waiting an increasingly long time for a Mental Health Act assessment, there is nowhere to admit them, crisis teams are overwhelmed, other support wouldn’t be in place and social care was decimated.

‘You were left with a huge concern for a fellow human being – someone who is very distressed and also quite risky. You fear something bad is going to happen and that you will be blamed somehow.’ thedoctor | June 2021 17

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Looking for a way out – stark survey findings

The BMA’s April COVID tracker survey found that the number of UK doctors who were considering early retirement more than doubled in less than 12 months, with 32% of respondents considering leaving the NHS early (compared with 14% last June)

ANDREW MOLODYNSKI Consultant psychiatrist, Oxford

‘My service gets more than twice as many patients referred as it did back then and we have only had limited extra resources. we are all much busier as a result. Work starts earlier and finishes later and I frequently will do catchup work at weekends.

The thresholds for taking on patients are significantly higher and there are longer waits for all kinds of support and especially for talking treatments – it’s heartbreaking sometimes.’

Half of respondents to the latest tracker survey said they planned to work fewer hours, 25% said they are ‘more likely’ to take a career break, with a further 21% considering leaving the NHS altogether for another career

40% of respondents said they don’t even have a place at work where they can safely relax with colleagues, but knew that they would find it beneficial if they did

to a new job role working in a less acute part of psychiatry services.

Dr Mullins’ story: a dedicated clinician with great empathy for those he seeks to help, broken by the rigours of his job will be deeply upsetting for many. Perhaps even more tragic is the fact that he is one of many left in a similar position – of those some are considering, or in the process of leaving, the NHS, some suffer in silence and others may perhaps not yet know how close to burnout they are.

BMA research has revealed the scale of the crisis in NHS workforce which has pushed frontline staff ‘There is nowhere such as Dr Mullins to Job vacancies the limit: prior to the Survival mode is no to admit them, COVID-19 pandemic reasonable landscape crisis teams are there were at least in which to expect overwhelmed’ 8,338 doctor vacancies doctors to work – – 6.3 per cent of all and no reasonable medical posts; since landscape in which September 2015 the to expect patients overall number of fully qualified FTE to get better. For Dr Mullins it meant (full-time equivalent) GPs has dropped taking on more and more stress, even by 1,307 or 4.4 per cent; the number of turning to that demand to work harder and feel the stress as a ‘perverse coping GP partners has also dropped by 4,685 or 22 per cent. As of March 2020 – even mechanism’. But the difficulties were before the onset of the pandemic – staff too great. Vulnerabilities grew and habits became unhealthy and Dr Mullins vacancies were 7.8 per cent of all NHS posts, some 88,000 job roles not filled. eventually found himself reaching out Data regarding doctors working in to Samaritans, a practitioner health secondary care suggests numbers are programme, and others in order to find increasing – but there is no evidence as a way out of his pain.

In January this year two months away to whether it is keeping up with demand and doctors leaders ‘strongly suspect’ from work were required and Dr Mullins it is not. was eventually able to find his way back

That culture of blame extends from worries on the ward every day all the way to the fear of inquests when the – perhaps inevitable – worst has happened and where system pressures may not be taken into account.

‘You feel like you are being left to carry something impossible. And that is really draining emotionally – especially when you are compassionate like most of my colleagues are. You just get full up – you can’t cope with caring any more.

‘Once the demands are completely outstripping the minimum resource you are just in survival mode.’

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COOMBE: ‘On the last night shift I worked we hit a five-hour wait to be seen’

moving to locum work in order to fund the education to do that. They said: ‘I have a lot of years ahead of me and I am very conscious of the fact that I will not be able to keep this up for another 20 years.’

They added: ‘When I started out emergency medicine was all I wanted to do but it has changed beyond recognition from when I entered the specialty. I can’t spend the rest of my career worrying about the level of risk in Unsustainable the queue of patients on the corridor.

One emergency medicine consultant ‘Staff are absolutely knackered spoke to The Doctor wanting to explain and absolutely on the strain of working their knees. People in this environment. are exhausted from They felt under such ‘You feel like you COVID. It has been pressure from their hard and scary and trust and NHS England are being left to stressful and now it is that they did not want carry something out of the frying pan to have their gender impossible’ and into the fire. We or region of work now have patients published, let alone queuing in corridors their name. again – those horrific They said: ‘I’m scenes from winter 2019.’ actively seeking work outside the NHS These are pressures felt across the and have already registered my CV in profession - whether in public health, expression of interest to one company.

If the opportunity comes up, I will leave, medicine in the community, among hospital doctors or in primary care.

100 per cent. It does make me sad.

East London GP Selvaseelan Working in a system where the same Selvarajah qualified as a GP in 2009 standard of care is given to patients and has seen significant increases in whether they live in a palace or a park workload, while staffing levels have not is brilliant and I love the clinical side increased in that time. He says: ‘Some of my job, but the current workload, of my colleagues are burned out. I the pressures and the stress are not have managed to keep myself going sustainable.’ by taking on different roles but it has Among the consultant’s options been extremely challenging and I can are leaving clinical practice entirely, or

SELVARAJAH: ‘Some of my colleagues are burned out’

One thing that is certain is that the strain is clearly showing in the profession. One in five doctors responding to an April BMA survey have said they will leave their career in the NHS altogether after the pandemic and one in two said they are currently suffering from depression, anxiety, stress, burnout, emotional distress or another mental health condition.

JEEVES WIJESURIYA

GP registrar, London

‘We have a finite workforce, and the teams have felt the physical and emotional toll of the pandemic on staff and patients who have great need. As volume of need and patient numbers increase we have a beleaguered workforce trying to manage more without the additional resources or numbers needed.

‘This has a knock-on impact on our practice as you would expect when stretching a workforce thinner and asking them to do more.

This takes a toll on people personally as well as at work.’

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Rising pressures and the workforce crisis With just 2.95 doctors per 1,000 people, the UK has the second-lowest doctorto-patient ratio in Europe.

Not a single area in England meets the OECD average of 3.7 doctors per 1,000 people

2.95 doctors per 1000 people

SHOBHNA SHAH

Anaesthesiologist, London

‘BAME staff need to feel welcome – that is the first thing. If we can allow ourselves to be kinder and more compassionate and provide more wellbeing support that would be better. When staff come here they don’t know where to shop, where to eat, where to follow their faith, they need to be guided. Mentorship is required. Providing these sorts of support would really help retain staff.’

Sources: BMA analysis of NHS Digital workforce statistics and OECD data, NHS Digital general practice workforce statistics and NHS Digital hospital episode statistics for admitted patient care and outpatient data

see many of my colleagues not pushing European neighbours. This was a health through with this in the long term. It’s service with a baseline infrastructure not just the patients, it is the paperwork that was not prepared for what was and the negative press. There is low the unforeseen global calamity of morale in the profession.’ coronavirus. And the situation has Dr Selvarajah is a GP trainer and adds significantly worsened since. that trainees are often choosing to do much fewer hours of clinical work due to Training suffers the increased demand and stress – often The BMA estimates that, between April 2020 and March 2021, there were taking on alternative roles like clinical 3.37 million fewer elective procedures lead work for the rest of their hours. and 21.4 million fewer outpatient And paediatrics specialty trainee 6 attendances. Across the NHS doctors Emma Coombe, who works in the west are seeing that unmet need flood of England, says the workforce crisis is to services and are having an impact on being urged to get available services and on with addressing a facilities. She says: ‘In monumental backlog. the last three or four ‘Patients are Dr Selvarajah adds: years I have come to waiting months, ‘Patients are waiting shifts and been told months, they are in there is one paediatric they are in pain’ pain and there is only intensive care bed in so much that can be the country and it is in done at any one time.

Scotland or something I feel for my colleagues to that effect.’

– they have been inundated.’

Dr Coombe adds: ‘On the last night Away from the public face of the shift I worked we hit a five-hour wait NHS, this workforce crisis has serious to be seen. It’s very frustrating to see implications for staff of the future, children cared for in an environment as well as those of the present – with that doesn’t suit their needs or their a hollowed-out workforce expected families’ needs.’ to do more and more just to keep And that strain is becoming service provision running, let alone increasingly evident for the public making time for training or quality trying to access healthcare too. improvement.

The NHS entered 2020 already Dr Coombe says: ‘My training is overstretched with record waits for longer than it needs to be because I operations, cancer treatments and GP am doing things that don’t need to be appointments and with fewer hospital done by a doctor of my level – tasks beds and critical care capacity than our

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07/06/2021 11:36

that add nothing to training. The rota gaps also mean I have had inadequate access to training in outpatient clinics.

It is an accepted fact that consultants now, newer consultants, will need more training and guidance because they haven’t got the experience in their pre CCT training.’

managing the huge backlog of patients who did not receive the care they needed because of the pandemic.

Yet the GP workforce has not grown since 2015 when then health secretary Jeremy Hunt promised an extra 5,000 GPs. The BMA is calling for long-term investment in, and ‘There needs to be development of, Government general practice. consideration of The association is action needed how many beds our This might already also urging the NHS’s country needs’ feel like crisis point chief people officer to so many doctors Prerana Issar and across the NHS – but the Government to without Government take note ahead of intervention this is a situation which is the summer 2021 iteration of the NHS destined to worsen.

People Plan – with urgent requirement Life expectancy has steadily increased for comprehensive occupational since the creation of the NHS in 1948, health services for NHS staff, time the population is expected to grow by off to recover from the pandemic around 9 per cent over the next 25 years response and flexible working options and, most crucially, one in four adults all highlighted as being required in the will be aged 65 or over by 2043 – an updated plan. increase of 3.6 million people or 30 per Doctors leaders say the NHS People cent. As people reach 65-years-old and Plan should also look to address beyond the average annual cost of their discrimination and poor working culture, healthcare – and thus the demand they making effective use of the full range of place on services – rapidly increases. staff skills and experience to maximise As such, the BMA is calling for a education for all and, above all, recruiting multi-year settlement enough people, for NHS workforce retaining staff already supply that matches in the NHS and making patient demand over it easy and worthwhile ‘We are massively the next one to five, for others to return. understaffed across five to 10 and 10 to The emergency the whole NHS’ 20 years in the 2021 medicine consultant spending review.

– who wishes not to Doctors leaders say be identified – adds: that settlement should ‘I think there needs include a resolution to punitive doctor to be consideration of how many beds pension taxation issues, comprehensive our country needs and with that comes workforce monitoring, projection and staff. We are massively understaffed planning work, expansion of medical across the whole NHS. I quite often education and training places, expansion hear numbers about the thousands of of the medical educator and research doctors or nurses we are short – and let workforce, increase in the occupational me tell you we feel that. We feel those health medicine consultant workforce gaps every single shift. There needs to be and an expansion of the public health investment into training and recruitment consultant workforce. and most importantly retention. We have GP practices in England are a huge problem of staff walking away delivering more than a million from the career. People hit a limit and appointments each day, as well as they leave.’ bma.org.uk/thedoctor

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BRETT METELERKAMP Acting consultant in old age psychiatry, Kent

‘Over the last eight years our referral rates have more than doubled. The number of referrals in some years has been three times what it was eight years ago but there has been no additional increase in workforce – we have seen no increase in the number of nurses and the number of doctors.’

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07/06/2021 07:43

PAUL HERRMANN

And you thought surgery was hard...

Managing childcare, and enabling male and female surgeons to reach their potential, has all too often been a surgical advance beyond the NHS. Jennifer Trueland speaks to surgical couples who have managed it, and asks what needs to change

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FINDING A BALANCE: Euan Green, Sandhir Kandola and baby Dilan

I

t was 6pm in the operating theatre and Anjali* had been due to finish work at five.

She knew she had to pick up her son from the childminder before 6.30pm – but, because of her training rotation, she was a 45-minute drive away. She spoke to her consultant and asked if she could go – an hour later than she was supposed to. His response wasn’t encouraging.

‘He said to me that this simply wasn’t compatible with a career in surgery,’ she says.

‘My husband was on-call, there was nobody else to collect my child. I had already stayed an hour after I was supposed to be staying, and I knew I’d be rushing in any case. What was I to do?’

Anjali isn’t alone. How to balance work and family life is a conundrum that faces many doctors – male as well as female – and there is some evidence that specialties such as surgery make it even tougher.

According to Mend the Gap, the independent review into gender pay gaps in England, surgery is ‘deeply segregated’ as a specialty, with women found in lower proportions, and those who are there being on the whole younger and more junior. It also quotes survey data that suggests that surgical specialties are less supportive of less than full-time working – just 10 per cent of surgeons reported ever having worked LTFT compared with almost half (47.7 per cent) of GPs, for example.

One disturbing finding outlined in the review was that 29 per cent of women doctors said their partner’s career was a barrier to their own career progression, in comparison to 15 per cent of men. Possible reasons for one career taking precedence include the wide geographical spread of some training posts, but childcare is also a factor, and the reason why in so many cases it’s the woman’s career that takes the back seat.

Lack of support This is not the case with Anjali, whose husband was also training to be a surgeon but decided instead to switch specialty.

‘We had so many problems with childcare that he decided to quit surgery and retrain as a GP so that our child would reliably have a parent to hand, because we were finding it very difficult to do wraparound care,’ she says. thedoctor | June 2021 23

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MCKEOWN: Decisions made for benefit of families

‘We found that hospitals simply didn’t appreciate that you have childcare issues’

‘Childcare isn’t just a female issue, it’s an issue for everyone’

‘We found that hospitals – whether it was in a training or other post – simply didn’t appreciate that you have childcare issues. We’re both from different countries, and we have no social support in the UK, so all childcare issues come down to him and me.

And when he was working in hospital, they were calling him before he was due to be in asking him where he was, and he couldn’t leave on time to pick our child up from nursery.’

He was the one who made the decision to change specialty, she stresses. ‘At first I told him I’d prefer he didn’t do it, and he still misses operating to this day. So it was a sacrifice, but it was one he was prepared to make for our family.

‘I think that in modern terms childcare isn’t just a female issue, it’s an issue for everyone. I don’t think I’d be able to do my career if I didn’t have a really supportive husband who was able to or willing to change track.’

There have been repeated initiatives to try to encourage more women to take up surgical specialties, not least the Royal College of Surgeons Women in Surgery initiative. But given that this project marks its 30th birthday this September, and the ratio of male to female consultants remains at eight to one (although the number of female consultants has risen by 10 per cent in that time) it’s fair to say that more needs to be done.

Financial basis According to Helena McKeown, chair of the BMA’s representative body, who helped set up the BMA’s network of elected women, childcare remains a vexed issue for doctors who are parents, particularly those in mixed-

PAUL HERRMANN

FATHER AND SON: ‘My job’s not more important than hers’

sex medical couples. Steps such as enhanced shared parental leave (available to junior and SAS doctors and some GPs but not to consultants) help, but as it is, women’s careers are still often bearing the brunt.

‘If you’re a couple working out how to maximise your income and have the best lifestyle for your family, you might well prioritise the career that’s bringing in most money,’ she says. ‘It’s still the case that women will often marry a man who is two or three years older, so he’ll be further ahead in his career, and then – because nature dictates it that way – women will have some time having a baby and then on maternity leave, so they may become even more behind.

So when you’re making that decision as a couple for the benefit of your family, you’re going to prioritise the higher income.’

Of course, it isn’t all about the money – and some couples, even those where both partners are surgeons, have opted to take a financial hit so that they can keep both their careers on track. Although he is a consultant and therefore isn’t entitled to an extended period of paid parental leave, urological surgeon Euan Green opted to stay at home with baby Dilan for three months.

‘My wife is a surgeon as well, and we decided to split it, so she had nine months leave and I had three with some overlap.

My wife suggested it and the more we looked at it, it made sense – after all, my job’s not more important than hers, and he’s my son as well.’

Mutual understanding His colleagues were mostly supportive, he says, but in money terms it wasn’t a

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CHILDCARE: Part of the solution

‘You might well prioritise the career that’s bringing in the most money’’

‘For me to take that time off needed some fairly serious financial planning’

straightforward decision. ‘I think I got one week of statutory paternity pay [for the three months] which is peanuts in terms of what my salary is and the cost of a mortgage and raising a child. For me to take that time off needed some fairly serious financial planning.’

Now that both are back to work, there remains a pay gap between Mr Green and his wife, Sandhir Kandola, who is an ST8 in vascular surgery at Manchester Royal Infirmary and about to take up her first consultant post.

The pay gap is due to a number of factors, including seniority because Miss Kandola took time out to do a PhD and also switched specialty during training which meant she took longer to reach consultant level. But it is also down to working hours – she will be at 80 per cent on 10 PAs, while he will remain full time at 12. This is his preferred option from a financial point of view, but also for other reasons, he says.

‘I’ve thought about it, but it’s a question financially of how things stack up because I’ve outgoings that necessitate money coming in. But the other thing is that if I cut down the number of sessions I work, inevitably it will be a lot of the non-clinical work that goes, and that’s something I’m really interested in.

It would be difficult to fit that in.’

Although she is working fewer hours and earning less, Miss Kandola is adamant that she is making no compromises with her career.

Having chosen vascular surgery, she is aware that in terms of unpredictability and high on-call demands it’s one of the toughest of sub-specialties, and it’s still one where there are relatively few women.

‘I’m the 12th consultant appointed to this

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department, and the other 11 are all men,’ she says. ‘A few of them have children and we all have to run our childcare to the wire. It’s going to be tough when I’m on-call – but it’s the same for all of us.’

Although some things such as childcare might be easier with a partner from another specialty, there are advantages to being part of a surgical couple, she says.

‘We have a mutual understanding of our jobs that I think some non-surgeons would struggle with,’ she says.

She believes that she and her husband learned a lot when he was on parental leave and she was back at work. ‘It taught me what it was like to be the one who comes home, tired from a long day at work, and then relieving the person who’s also had a long day with our baby,’ she says.

Miss Kandola clearly has an eye to the future – her department is going through a period of change and she can see a lot of potential for her skills. But she doesn’t believe it needs to be right away. ‘I’m happy to wait until the right time. My mum had to stay at home with me and my brother because we moved to Italy and the EU didn’t recognise her qualifications (she was a pharmacist).

‘When we came back to the UK, I was 12 and she would have been approaching 40. She bought a pharmacy shop to own and run, and then bought some more, and ended up with a small chain. Eventually my dad gave up his job for a large company and worked for her instead.

‘The years she spent at home with my brother and me didn’t hurt her ambition, and didn’t hurt her career in the end. She still achieved what she wanted to do.’ *‘Anjali’ is a pseudonym

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GETTY

A junior doctor was prevented from bringing her baby with her when she was vaccinated.

Following BMA action, new guidance should protect others from discrimination.

Jennifer Trueland reports

‘Leave your baby at the door’

D

octors leaders have welcomed guidance to ensure people are not turned away from vaccination centres because they attend with dependent children – and have called for it to be publicised more widely.

The BMA sought clarification after a junior doctor on maternity leave was refused entry at a hospital vaccination site because she was carrying her three-monthold baby. Senior doctors have warned that the issue will only become more pressing as younger people – who are more likely to have young children – are called for vaccination.

The junior doctor had attended the appointment for her second vaccine dose

in the north west of England with the baby asleep in a sling, dressed so that her arm could be exposed without disturbing the baby, explains Latifa Patel, a paediatric trainee in the region and deputy chair of the BMA representative body.

‘She was stopped at the door by a woman who told her she couldn’t enter the tent with her baby because no children were allowed,’ Dr Patel tells The Doctor.

‘She had no carer support and her husband, who is also a doctor, was at work, couldn’t get time off at short notice.

Plus, the centre closed at 4.30pm.

‘She was told that she could stand in the queue with her baby, but that she would have to hand the child to someone

else before she went inside – and that she could be inside without her baby for 25 minutes.

‘She was shocked, surprised and very upset – her husband rang later and asked about their breastfeeding policy, and they said they didn’t have one.

‘This is happening at a time when we want to get as many people vaccinated as possible, and also at a time when people in their 40s, 30s and 20s will start to receive invitations for vaccination – why should it be that an adult who requires support can bring someone with them, but parents who don’t have childcare support, or who are exclusively breastfeeding, can’t bring their babies with them?’

‘She was told she couldn’t enter with her baby’

‘She was shocked, surprised and very upset’

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RIBEE: ‘Everybody was pleased to see him’

Guidance issued The doctor contacted Dr Patel, who raised it on her behalf with the BMA. ‘[BMA GPs committee chair] Richard Vautrey, along with others in the GPC England team, has been in regular dialogue with the vaccination team of NHS England and NHS Improvement to address many of the issues highlighted by GPs and vaccination centres and, as a result, they have released guidance making it clear that parents with dependent children should not be turned away,’ Dr Patel adds.

‘In addition, following our intervention, the centre manager called the doctor the next day and apologised.

They arranged another appointment and said her baby was welcome and that she could breastfeed on site if necessary.’

Dr Patel says it was discriminatory to breastfeeding parents not to allow babies to attend appointments.

‘This doctor had to travel for about half an hour to get to the hospital, spend around 25 minutes inside, plus whatever time she had to spend in the queue, then drive back for another half hour. She’s exclusively breastfeeding – that’s a long time to leave your baby hungry.’

Reasonable adjustments The NHSEI guidance recognises that recognises that parents may need to bring dependent children to vaccination appointments.

‘Colleagues are reminded that reasonable adjustments can be made for people in such circumstances, and every effort should be made bma.org.uk/thedoctor

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to ensure that individuals can receive their vaccine at the appointed time,’ the guidance says, adding that denying treatment or an intervention for any reason must be a clinical decision, and made by the most senior clinician on duty at the time.

‘As cohorts move to younger populations, it is more likely that adjustments will need to be made to ensure no one is disadvantaged because they have dependants with them.’

Dr Patel says the NHSEI guidance should be widely publicised – and adds that she personally knows of other cases where breastfeeding mothers had been denied the vaccine.

‘Another doctor in a similar situation went with her baby – again, asleep – and as she tried to enter the centre, they wouldn’t let her in. She felt intimidated and cried and said there was no way she could do anything different because she didn’t have any carers for her child. Again, her husband couldn’t get time off work at short notice, and the centre closed at 4.30pm. The centre has since apologised to her since Richard Vautrey raised it with NHSEI. ‘If we want people to be vaccinated – and we do – then we have to stop discriminating against parents with children.’

Dr Patel says any BMA member who has experienced anything similar should contact the union.

‘The BMA is always there for you, and we also have a number for anyone requiring emergency COVID-related support [0300 123 1233].

As this situation shows, we can act quickly – and effectively.’

A child-friendly experience While some women have been turned away from vaccination centres for bringing their babies, Helen Ribee’s experience was the complete opposite.

Attending her appointment with threeweek-old Thomas, Dr Ribee, a specialty doctor in emergency medicine, says she and her baby couldn’t have been better treated or more welcome.

She had arranged the appointments for her own vaccination and that of her husband, a specialty trainee in anaesthetics, at the same centre in Stafford.

‘I had scheduled the appointment for a day that my daughter was in nursery, but Thomas was three weeks old, and he was really too small to leave with anybody.

‘As it turns out, everybody was really pleased to see him. I think a lot of the volunteers were retired older people who perhaps hadn’t seen their grandchildren for a while, and everybody was really nice to him.’

She asked if she and her husband could go to the same vaccinator and he held Thomas while she was having her jab and vice versa.

‘I didn’t even imagine there would be a problem with taking Thomas – realistically for a lot of people it’s the only option. What about single parents, or people whose partners work long hours or shifts? And for doctors like me on maternity leave, it’s really important that we are vaccinated before we return to work. As it turns out, our experience was very good, but I’m glad that NHS England has clarified its guidance, as it’s vital that everybody gets vaccinated and nobody should be put off taking up their appointment.’ thedoctor | June 2021 27

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Your BMA The ARCP need not to be so daunting with all the support and opportunities the BMA has to offer It is that time of year again. For many doctors in training, such as me, the ARCP (annual review of competency progression) process will be occupying thoughts and – no doubt – causing some stress.

This year I have something of a reprieve as I am on maternity leave, but I can identify with those emotions.

And I know how serious this can be as a process which determines whether you can immediately progress in your training, face delays or be at risk of losing your training post.

Each year I set out to give myself lots of time and I think this year will be different – I’ll prepare as I go along, get my evidence ready on a weekly basis so it isn’t a last-minute panic. For whatever reason – not least because we’re all busy and the hours we work, let alone the stresses involved, are longer than many vocations – it never works that way. Although I’ve been the same all the way through my education and career whether it is GCSEs, A-levels or medical school, so perhaps that is just me.

One thing that has always helped me, however, is having a plethora of leadership and management experiences to call on for the ARCP through my roles and responsibilities with the BMA. Did you know that your BMA can support you in some leadership roles – and there are all sorts of options so you can tailor your experiences to your needs? Whether it’s being a representative locally at your trust or hospital or representing your colleagues nationally in a committee position.

My journey started with both of those things. I was both an elected BMA medical students committee member nationally, and also had a local role with the Liverpool medical students society. I was able to make progress locally which had an immediate impact, using the resources and knowledge from my national position. This included medical student welfare, access to support and preparing for foundation training.

Nationally, I was involved in reshaping the UK Foundation Programme Application System, improving welfare and financial support for medical students. I was also involved in the equality, diversity and inclusion group at the BMA. When I graduated I became the junior doctor local negotiating committee representative at my trust.

I worked with a staff, associate specialist and specialty doctor representative and a consultant representative and we sat with the management at the hospital and discussed the issues affecting doctors’ working lives.

We were really well supported by our BMA industrial relations officer.

One of my proudest moments was when we reshaped the junior doctors’ mess. I came across my hospital mess as a foundation one doctor. It was awful.

The furniture was broken, the toaster didn’t work, the fridge was horrible and to cap it all off we had a rodent problem. It was clear to me that this was no way to treat junior doctors.

We sat down as a team – the LNC, the mess committee and the trust’s medical director – outlining the issues and managed to secure a brand-new mess with new furniture, reclining chairs, and all the kitchen equipment we needed. To some these might seem like trivial issues but a clean, safe and comfortable space to relax and recover is vital for doctors.

We actually went further than that and negotiated restrooms. It meant any doctor or staff member who felt they were too tired to drive could ask the estates team for a key and it was a free place to have the sleep you needed – whether that was just a nap for an hour or a full night of rest.

It made a huge difference to junior doctors. Even if you didn’t use the spaces you knew the trust – your employer – cared enough to invest in you.

These have all been invaluable experiences over the years. As a junior doctor you often play a leadership role at work anyway, but these are roles and responsibilities that can give you so much more. When it comes to your ARCP, not only can you tick off those competencies with ease but you have also developed useful skills as well making tangible differences.

If you are working on the dreaded ARCP – I wish you all the very best. If you would like to know more about getting involved with the work of your BMA, say hello to me on Twitter @DrLatifaPatel – my DMs are always open.

Latifa Patel is acting chair of the BMA representative body

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it happened to me

GETTY

Doctors’ experiences in their working lives

MUMBAI: COVID has kept families apart

DAVE: ‘Where do the boundaries lie?’

A heart in two places When I was growing up in India, there was a song on everyone’s lips. By Pankaj Udhas, its title translated as ‘A letter has arrived’, and it was about the sense of yearning and grief expressed by a father whose son goes abroad to work.

Twenty-five years after arriving in the UK, the sentiments hit me with full force.

I think of the resigned acceptance of fear and loneliness in a newly arrived doctor’s voice, who was very ill with COVID-19 but had no food in the house. Alone in the UK, she remembered a taxi driver from her part of the world whom she asked to deliver food to her doorstep.

I think of the international medical student who had to remain anxious and isolated in his flat, terrified of leaving for fear of breaking a rule inadvertently, being stopped by the police and his student visa being rescinded.

And I think of our friend, desperate to visit his terminally ill father. Held back by cancelled flights and travel restrictions, he finally managed to make his trip, only for his father to die while he was quarantining in a hotel after landing. I cannot imagine being bereaved and grieving in that place of soulless isolation.

I wanted to visit my own father in February, when he was hospitalised, but the time required for quarantine meant that I would not be able to spend any time with my family, and nor could I take a period of extended leave from work.

My father’s voice was a mixture of sorrow, part yearning and part acceptance. I could imagine him sitting rocking in his chair, straining to hear me, looking out of the sitting room window in the house in Mumbai where he has lived alone since my mother passed away.

The terrible situation that India now faces has only intensified the feelings of helplessness and yearning. There is a massive co-ordinated effort across the Indian diaspora to do what they can to help.

But things can be different. Nitin Shrotri, an NHS consultant urologist from Kent, made a case on the BMA website for parents of international NHS workers to be given indefinite leave to remain in the UK, reflecting on his own parents being given leave after a great deal of effort and lobbying. A powerful blog in the BMJ calls for the Government to review the unnecessarily stringent rules on the adult dependant relative visa, and citing evidence that the issue caused significant stress to doctors, with 85 per cent having considered relocating to their country of origin or another country where they would feel more supported.

The Pankaj Udhas song continues ‘Oh bird, break free of your cage and return’. But where do the boundaries lie for me and others between love and duty to my work as a doctor, to the NHS which is overburdened right now, and to the love for my family, in my motherland? The choices we make around migration are largely ours, but they can never be fully undone. We can never un-know what it is to be caught in a dualism that gives and takes in equal measure.

Ananta Dave is a consultant child and adolescent psychiatrist and president of the British Indian Psychiatric Association.

This is an edited version of a longer article which can be seen at https://bit.ly/3bXHEM1 thedoctor | June 2021 29

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

A doctor who faced persistent claims that his communications skills were not good enough began to suspect that discrimination was the reason ‘I used to be very vocal and speak out on issues that I thought could be changed to improve patient safety or staff working conditions,’ says Purab Singh.* ‘Now it’s the case that, even though I might want to say something, I worry that it might cause problems or maybe I might upset the wrong people.’

When Dr Singh first came to the UK from India to work in the NHS, he did so full of confidence and belief in both his clinical and language skills, and with an eagerness to help patients and further develop his knowledge and experience.

However, his experiences as a registrar at his first NHS workplace, during which he says he faced numerous accusations of having poor communication skills, have shaken that confidence and even changed the way he approaches his job.

Dr Singh’s problems first began after he had raised concerns about how notes on patients were being recorded differently by separate health professionals. Following this he says his educational supervisor called him over and suggested that it was in fact he who had the difficulty in communicating.

‘As far as I was concerned, as an international medical graduate you have to demonstrate your proficiency in English before you even take

a medical exam to prove your clinical skills,’ Dr Singh says.

‘I felt that it was a way just to silence me, but took it in my stride during my appraisal and said that I was ready to do a communication skills course just to show that I was continuing to try and improve my communication.’

He progressed through his second year without any further feedback being raised about his communication skills, up until the very end of his final post when his clinical supervisor told him he had ‘communication issues’.

When he pressed for details

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and specifics, he says he was met with vague examples and hearsay, and then felt as if he was being pressured into accepting something that he did not agree with.

After his appraisal was completed in his absence, he complained to his deanery and notified the BMA, with the former accepting that his appraisal should not have been completed in absentia, and Dr Singh progressed to his third year. Unfortunately, criticisms of his communication style persisted, and he began to feel he was being singled out and picked on.

He was told by his clinical supervisor that a clinic letter he had written had been too brief and therefore an example of bad communication.

‘I said, “Did the GP complain about this letter? Did the patient?”, she said no,’ Dr Singh explains.

‘It felt like she was going through all my correspondence in order to find something that could be considered a problem.’

It was at this time he began to suspect that racial discrimination or unconscious bias might behind the claims of poor communication, particularly after seeing how outspoken doctors from EU backgrounds, including some without English as their first language, did not appear to face similar accusations.

‘They were very outspoken in team meetings, but nobody accused them of communication issues,’ Dr Singh recalls.

‘It felt like I was expected not to be outspoken but submissive, so I felt like there

was racial stereotyping there.’

It was at that time that he decided to raise a complaint about bullying and racial discrimination, and to begin exploring the possibility of being transferred to a different trust. During this dispute Dr Singh tragically learned that one of his parents back in India was terminally ill, something that added further mental strain to an already difficult situation.

Matters escalated when he was asked, with less than 24 hours’ notice, to attend a meeting at which representatives from his trust’s HR would be present.

After pointing out that he had not received enough notice to arrange for a BMA adviser to accompany him, he declined to attend the meeting, a decision for which he was subsequently threatened with disciplinary action.

With BMA help, and support in raising his concerns and endeavouring to resolve matters constructively, he was able to move to a new trust and eventually obtain his CCT, and when there, learned that his former one had begun an internal review into his complaints.

‘Within days of my parent passing away, the employer bombarded me with multiple questions about the internal review,’ he says.

‘They asked me to respond in writing despite being aware that I was arranging a funeral abroad while suffering from an accident which had fractured my hand.’

But Dr Singh chose not to participate in this process after discovering that the person

chairing the investigation was someone against whom he had raised a grievance for bullying and discrimination.

He also discovered that his most recent appraisal had not been approved by his previous employer, something that he knew would hinder his progression at his new place of work. It was this that led to him to take his former trust to an employment tribunal.

Eventually Dr Singh reached an agreement with his former employer in which he would withdraw his case provided that members of senior management at the trust committed to undertaking training in unconscious bias, a request that they eventually acceded to.

While he never sought financial compensation he says he also did not receive any apology from his former employer.

While admitting that his experience has been a damaging and traumatic one for him, especially for his mental and emotional health, Dr Singh says that he has no regrets about fighting his case, which he hopes will help to highlight the issue of racism within the health service.

‘The reason I went through all this was so that nobody else has to undergo the same kind of treatment,’ says Dr Singh.

‘I wanted to reinforce the point that being vocal is not automatically a communication issue.’

The BMA will fully support members with similar concerns about their treatment and advise and help them to use the appropriate routes. *Names have been changed.

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