The magazine for BMA members
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Issue 34 | August 2021
No one left behind Taking the vaccine to the fringes of society Support us
Doctors speak out after suffering violence at work
Climate conscious
Global warming and its effect on mental health
Striking gold
The Olympian who trained as a doctor – and in five different sports
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In this issue 3 At a glance Key issues to be tackled at this year’s BMA annual representative meeting
4-7 Vaccines for all The extraordinary efforts by doctors to take COVID-19 jabs to the most neglected corners of society
8-9 Climate and the mind How the impact of climate change on mental health has been overlooked
10-13 At the sharp end Doctors give their personal accounts of suffering violence and aggression
14-15 Step up to boost health The social prescribing advocates hoping to get people moving after the COVID shut down
16-17 A man of principle A tribute to Kailash Chand, a passionate advocate for better patient care
18-19 Doing the double The Olympian who has combined athletics with a career in medicine
20-21 Unequal outcomes NICE tries to improve the maternity experience for women from ethnic minorities – but is it the right approach?
22-23 Your BMA and On the ground Representative body chair Latifa Patel on doctors’ wellbeing and navigating an unwell doctor’s route back to work 02
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Welcome Chaand Nagpaul, BMA council chair I would like to begin by paying tribute to my friend and colleague Professor Kailash Chand OBE who suddenly and unexpectedly passed away last month aged 73. Kailash was a pillar of our profession, driven by conviction and principles, who gave so much of himself to others. He was a staunch advocate for the NHS who worked tirelessly for the BMA, serving as honorary vice president and formerly deputy council chair, and was an inspiration to so many. We share tributes, memories and reflections from those who knew and loved him in this issue of The Doctor. He will be sorely missed. The community vaccination programme has been a great success in the UK – particularly thanks to the wonderful work of GPs and volunteers across the country. However, some patients and communities who struggle to access healthcare have been left behind. A feature in the August edition of the magazine looks at the brilliant work of doctors trying to fight health inequalities and improve access to healthcare and the COVID-19 vaccine. This pandemic has exposed and exacerbated the dreadful inequalities in our society and many lessons which could help us to build a better future can be learned from the experiences of the doctors who know these communities best. In last month’s magazine we told the heart-breaking stories of the violence and aggression faced by doctors working on the front line in the NHS. Many of us have felt these experiences worsen during the COVID-19 pandemic and in this issue of The Doctor three more doctors share their experiences of abuse and how it has affected them and their work. These are issues on which the BMA has long campaigned – and progress has been made – but the Government and NHS leaders must do more to protect frontline staff. Also in this issue we have an interview with Steph Cook – a GP in Sussex who won Olympic gold in modern pentathlon at Sydney 2000, as well as the European and World Championships the following year. It is fascinating to read about Steph’s relationship with her two loves: sport and medicine. Elsewhere, we have a feature looking at a doctor-led scheme aiming to get whole towns and cities active and a report on new maternity guidance from the National Institute for Health and Care Excellence, which has been criticised for failing to address existing inequalities in maternity-care outcomes experienced by women from ethnic minority backgrounds. Read the latest news and features online at bma.org.uk/thedoctor Keep in touch with the BMA online at twitter.com/TheBMA
instagram.com/thebma
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AT A GLANCE
ARM2021
The annual representative meeting, the BMA’s main policy-making body, will be meeting next month. Every year, around 500 doctors and medical students from across the UK consider and debate matters of interest to the medical profession. This year’s event will be virtual, and take place on 13 and 14 September. To view the ARM agenda, or to follow this year’s conference online, visit bma.org.uk/arm Here is a brief flavour of some of the motions on this year’s agenda – it should be said there are many more, and not all are reached in the limited time available: A COVID public inquiry Urging an immediate inquiry into the pandemic, including a full review of all aspects of the NHS and the Government’s response, the motion also asks for any inquiry to consider whether ministers’ actions should be investigated for potential criminal negligence.
Investment in long COVID research and treatment Calls for greater investment in the research and treatment of long COVID, and for the BMA to lobby for the condition to be recognised as an occupationally acquired disease among doctors.
Overseas dependents
The environment and climate change
In recognition of the enormous contributions made by overseas staff, this motion says the BMA should lobby the Home Office to make it easier for international medical staff to bring older and dependent parents to the UK.
That the BMA should lobby the NHS, and NHS supply chain, to support efforts to trial reusable and recyclable personal protective equipment, improve access to recycling facilities in clinical areas and campaign for a complete end to fossil fuel use in the NHS by 2030.
Tackling the mountain of unmet need
Pensions
Calls for the private sector to be part of recovery plans for elective care, as well as additional financial investment from the Government and the suspension of all target-driven bureaucracy that distracts from patient care.
Warnings that punitive rules around pension taxation on doctors have not been properly addressed and that policy fails to remedy the medical workforce crisis in the NHS.
Assisted dying
Medical student sex workers
Along with an open session encouraging debate, this year’s ARM will see calls for the BMA to move to a position of neutrality on assisted dying including physician-assisted dying.
Calls on the BMA to press the GMC and medical schools to not expel or otherwise penalise medical students engaging in sex work to support their studies, and instead provide specialised support to students who find themselves in this situation.
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NEIL TURNER
WORTHLEY: Vaccinated vulnerable homeless patients as a kind of ‘underground movement’
The COVID vaccination programme has been a huge success, but what about the homeless, asylum seekers, and others who find it hard to access services? Peter Blackburn reports on the extraordinary efforts of doctors to take the vaccine to the neglected corners of society
Vaccines for all
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‘W
e felt this was something that we simply could not afford not to do.’ When the Government announced the largest vaccination plan in British history – and an accompanying rigid, largely age-based, criteria for delivering jabs – Brighton GP Tim Worthley and his colleagues knew they had to make decisions that would push the limits, but would protect the most vulnerable people in their communities. Dr Worthley, a GP at Arch Health, a GP surgery for people experiencing homelessness or living in temporary accommodation, used his relationships as a primary care network clinical director to source vaccines and his team set about meeting people where they were staying and giving the street homeless, and other groups like travellers, access to jabs with a mobile unit which they drove around the city. During a four-month period the team have given nearly 900 first jabs and more than 650 second doses. That work has been important because these are people particularly vulnerable to this disease: In the UK the life expectancy is 45 for men and 43 for women who are homeless, homeless patients in their 30s and 40s often have the health patterns and morbidities of people decades older, and people live in cramped accommodation or vulnerability on the streets. Advanced nurse practitioner at Arch, Hannah Bishop, says: ‘It’s been really good. This has enabled us to be much more opportunistic and accessible for a group of people who are extremely vulnerable.’ Clearly the project has been successful, but the conditions in which Dr Worthley and his team had to work were dispiriting. ‘The frustrating thing is that we had to do what we were doing on the sly – almost like an underground movement,’ he says. The team had to underwrite the costs of an expensive process as a small organisation, be particularly careful with their communications, fearing the ‘wrath of national bodies’ and come up with their own business proposal and hire staff. Until commissioners and local authorities formally supported the project Arch was operating at ‘significant financial risk’. Dr Worthley hopes to reach up to 2,000 patients in total and new strategies, including ‘intensive work’ with local housing officers to get better access to those in emergency
accommodation and planning co-delivery of an ambitious and complicated flu and booster covid programme through the autumn, are being developed.
IN THE FIELD: The Arch Health vaccination team in the community
Most vulnerable Two hundred miles north in Oldham, GP and local councillor Zahid Chauhan OBE felt compelled to make similar decisions. In his role as the local authority’s cabinet member for health and social care Dr Chauhan decided to vaccinate ‘hundreds’ of the homeless at soup kitchens and shelters. Dr Chauhan believes his patients were the first homeless people in the world to be given COVID-19 vaccines. He says: ‘I believe as a clinician it is our responsibility to challenge policies which impact on people’s lives. If you don’t vaccinate homeless people they are a source of the spread of infection and they are at increased risk of dying. You also create extra problems for the health service.’ While homeless patients in Oldham and Brighton have strong advocates, this is not the case everywhere. In many parts of the country the people who find health services the most difficult to access – homeless people, undocumented migrants, asylum seekers, travellers or a wide range of other groups – lack those voices of support. Doctors are concerned the UK’s vaccination programmes risk missing these people and is undermined by a society and a health system which labels them as ‘hardto-reach’ rather than simply reaching out.
‘It is our responsibility to challenge policies which impact people’s lives’
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CHRIS PATTERSON
SHEIK: Relationships need to be established with people on the fringes of society
Access problems James Matheson, chair of the Royal College of GPs’ health inequalities group, says: ‘These people aren’t hard to reach – they are the people you step over in the street on your way to work.’ The reasons for difficulty in accessing health services are incredibly complex. Those living in the UK with a lack of immigration documentation often fear being reported and raided due to the politics of the ‘hostile environment’, across the country outreach services are patchy and underresourced, and even the very structure of funding of services means providing care for complex patients can be costly. There are also pressures caused by austerity politics and many doctors are concerned the brutal impact of trauma is not understood. As Dr Worthley says, many people are ‘let down by the state from the moment of birth onwards’. In many parts of the country barriers to healthcare remain problematic, and this becomes an even greater problem when vaccination so often seems to rely on GP registration. Research by the Bureau of Investigative Journalism last month found less than a quarter of GP practices would be willing to register a patient without ID or proof of address. GP trainee Kitty Worthing has been researching the problem, including interviewing primary care staff, and says there are three main issues: Time-consuming NHS digital infrastructure demanding information about patients, primary care staff not feeling supported should they be embroiled in an issue like identity fraud and a degree of xenophobia and racism. There are organisations trying to drive change. The BMA supports the Safe Surgeries initiative, which is a ‘toolkit’ developed by DOTW (Doctors of the World) – a charity which seeks
to help reduce the barriers to healthcare for vulnerable people and undocumented migrants. The toolkit aims to make practices aware of the guidance and rules – that no patient should be turned away regardless of whether they have a proof of ID, address or immigration status.
KASARANENI: ‘Nobody should [face] barriers when they are trying to access vaccinations’
Tackling distrust Krishna Kasaraneni, a member of the BMA GPs committee executive team, says: ‘Nobody should have barriers in front of them when they are trying to access vaccinations in the current climate. Everybody is entitled to free GP services at the point of need. Irrespective of their immigration status they should be able to access vaccination as well as the wider primary care services available to them.’ Fatima Sheik is a GP in south-east London and also works for DOTW. Dr Sheik has two roles with DOTW; one aiming to promote vaccine confidence and the other being involved in outreach offering the vaccine in asylum seeker hotels and in a mobile clinic van. The latter has included offering the COVID-19 vaccine from the mobile clinic. She says: ‘In this population there is often such a lack of trust in both healthcare professionals and the system in general. Often we would go to a place and only one person would be keen to take the vaccine. We are seeing in some circumstances people who feel very distressed. In one location someone said, “I don’t like people with a lanyard” and escorted me out. I think that is quite understandable. Really the vaccine should be being delivered by people who are already known to and trusted by patients. Engaging communities and building real trust is of vital importance.’ Senior doctors told The Doctor they privately
‘They are the people you step over in the street on your way to work’
‘There is often such a lack of trust in both healthcare professionals and the system in general’
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PAUL HERRMANN
MATHESON: Inequality worsened by COVID
petitioned Public Health England and NHS England to expedite vaccination to people often excluded from healthcare who were at greater risk of infection and death. They said those pleas were ignored in the guidance published by the JCVI – despite official PHE documents making a strong case for prioritising people in these groups. One doctor described the process as ‘strange and unpleasant’. In addition, The Doctor understands that some staff who took part in group sessions sharing success stories of outreach with the COVID-19 vaccine felt such fear of hostility from decision makers that they asked for their names and places of work to be removed from the minutes of meetings. And one GP practice received a letter praising their outreach work during the same week that they received one which they felt threatened them to ‘get in line’ with the set national guidelines. Dr Matheson says: ‘We were worried from the start the vaccination process was going to worsen inequalities from COVID-19 and that appears to have been the case.’
Ease of use When it comes to health inequalities and access to healthcare the vaccination programme seems to have doubled down on existing problems: Those with the worst health are largely left to become unhealthier and those with the least access are frozen out further. So what needs to change? ‘It’s really about a fundamental change in thinking,’ Dr Matheson says. ‘We have some brilliant health services set up but they are all set up for the convenience of the people delivering them rather than those accessing them.’ Dr Worthley says he could describe a ‘utopia’ but instead outlines simple but fundamental bma.org.uk/thedoctor
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changes required: Accommodation fit for human habitation where people don’t have to ‘fight for the right to exist’, proper resourcing for complex patients through the funding and integration of primary care, mental health, community services and outreach, and these sorts of services spread across the country – not just in the pockets where people have the energy to fight daily battles for these groups of patients. And for Dr Worthing, when it comes to undocumented migrants, there are two major changes required. Firstly, the NHS needs a clear firewall in place to stop government access to patient data. Without that the majority of patients will never feel secure in accessing care. And, secondly, an end to any sense that the health system is hostile. ‘You can’t ask people to take an exceptional risk to allow them to access healthcare,’ she says. Perhaps that oft-repeated maxim – ‘the true measure of any society can be found in how it treats its most vulnerable members’ – is something the NHS and this Government should take to heart. As Dr Worthley says: ‘It’s a horrible feeling to think that people are placed in temporary or emergency accommodation or are hiding away somewhere sleeping rough and they are frightened, not knowing who to get health advice from, who to get the vaccine from, and not knowing whether to trust the vaccine. ‘It’s deeply sad. It’s not a personal choice people are making to hide away or be distrustful or isolated – it’s a consequence of what they have experienced in their life to this date. It’s incredibly frustrating and saddening that as a society we still have not recognised the importance of righting those wrongs and improving these people’s lives.’
CHAUHAN: His homeless patients were perhaps the first in the world to receive the COVID vaccination
‘It’s not a personal choice people are making to hide away or be distrustful or isolated’
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GETTY
A fire takes hold near Bundaberg, Queensland, Australia
Climate and the mind The effects of climate change on mental health have been overlooked, but they may be linked to increased admissions and risk of suicide. Tim Tonkin reports
C
limate change is today widely recognised by governments, health systems and medical professionals as a one of this century’s biggest challenges to human health, with the BMA itself labelling climate change as a ‘global health emergency’. Much of the focus on the health implications of climate change has been given to the effect CO2 emissions and rising temperatures and sea levels will have on physical health. A report by Imperial College London, however, has sought to highlight the existing data on the effect of environmental change on mental health, the reality of which, it claims, is frequently overlooked by
governments and health planners. For example, the report notes the evidence demonstrating a link between higher temperatures and an increase in suicide rates. It also observes that increases in temperature translate to a greater risk of hospitalisation for those diagnosed with bipolar disorder, schizophrenia and dementia.
Anxiety and depression Detrimental effects on mental health can also be as a byproduct of changes in climate, such as the stress that might result from the loss of a home to flooding or forced migration
owing to drought. Indeed, being concerned for the environment and ruminating on the possible consequences of climate change can itself contribute to people experiencing, and potentially seeking treatment for, anxiety and depression. ‘The multiple pathways by which climate change impacts mental health is not completely straightforward,’ warns the report’s lead author Emma Lawrance. ‘Climate change as a health emergency is becoming more and more broadly known and it is one of the levers for climate action when we understand the effect it will have on human health.
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‘[However] mental health in general has historically not received parity of esteem with physical health. We also see this difference in the attention and emphasis placed around climate change’s impacts on physical versus mental health in [climate change] policy and the wider public discourse, even though they are so intricately linked. ‘The paper is part of this step towards understanding, better quantifying and better accounting for these costs.’ A Mental Health Innovations Fellow at the Institute of Global Health Innovation based at Imperial College London, Dr Lawrance says that while many doctors now recognise the grave risks to physical health posed by climate change, this awareness and dialogue needed to be expanded to encompass mental health. For example, while the risks to physical health by higher temperatures are likely to be well known to doctors and other healthcare professionals, the interaction between heat and mental health is perhaps not as well understood. Indeed, the report notes that an increase in temperature by just one degree Celsius can correspond to a roughly one per cent rise in people taking their own lives. ‘There are certain medications, including antipsychotics and some types of antidepressants, which for some people change their body’s ability to regulate temperature,’ Dr Lawrance warns. ‘That heat seems to be related to more psychiatric hospitalisations or an increased risk of suicide, and those links aren’t necessarily well known, bma.org.uk/thedoctor
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from what we can tell, within the medical community. ‘This means that first aid responders, community groups and emergency responders need to be equipped with that knowledge and the expertise to screen for these effects to know how to respond to them.’ Sussex-based psychiatry fellow Dan Hadley says many of the report’s findings chimed with his own experiences when reflecting on climate change’s role in mental health. Undertaking an academic post that is part clinical psychiatry and part teaching, he says that while climate’s role in health was more acknowledged, he wants to see concrete steps taken in medical training to educate about its role in mental health. ‘I think that climate change and health in general is becoming more recognised, but I think mental health is still an area where people don’t make that connection,’ he says. ‘Having taken part in a teaching programme about climate change and mental health, I would say that for most of the people it was something that they hadn’t really thought about before. ‘There’s a really big gap in [general] physical health outcomes for people with severe mental illness, and that definitely interacts with climate change. I worry that that gap is going to widen as we see more effects of climate change.’
Increased burden Dr Hadley says more research and awareness of research is key to raising awareness of climate change and mental health among doctors, adding
that making climate change and mental health a part of medical training programmes would also be critical in this. He also believes that future workforce planning must start to reflect the likely increased burden in mental health posed by climate change, through increased recruitment of psychologists and having response plans in place. Part of the challenge, Dr Lawrance says, is the absence of sufficient and effective research metrics for gauging climate change’s effect on mental health, while the other is raising awareness and discussion amongst the medical profession. She adds that by advocating for policies aimed at reducing carbon emissions such as improvements in housing and the protection of public green spaces, doctors could serve an important role in countering the effects of climate change on mental and physical health. ‘All of us are grappling with this threat to our future and the collective future,’ states Dr Lawrance. ‘Understanding and accounting for climate change’s effects on mental health, both the negative effect of inaction and the positive effect of action, is something I would strongly encourage the medical community to speak out on.’
HADLEY: Many people have yet to make a connection between climate change and mental health
‘Heat seems to be related to more psychiatric hospitalisations or an increased risk of suicide, and those links aren’t necessarily well known’
‘There’s a really big gap in [general] physical health outcomes for people with severe mental illness, and that definitely interacts with climate change’
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SIMON GRANT
At the sharp end Three doctors give their personal experiences of patient aggression and violence. While they seek to understand the causes of hostility, they argue it should never be ‘part of the job’ – and support from colleagues is vital. Interviews by Seren Boyd 10 thedoctor | August 2021
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‘People can’t abuse NHS staff like this’
Having been attacked in his surgery by a patient, GP Nazrul Hossain took legal action. He thinks the complaints process is weighted unfairly
‘I
n our LMC [local medical complaints, but none of the white committee] in London, we’re doctors. getting alerts three or four times a ‘Sadly, we’re in a very weak position week of physically aggressive behaviour as doctors: the complaints system, towards colleagues at the moment. It for example, is very much weighed in is bad now but I had previously raised it favour of patients. There is absolutely with my local MP in 2019. nothing about staff protection, staff ‘Three years ago, a patient hit me on morale or staff emotional welfare in the the head with a hard, wooden baton. He complaints’ guidelines and protocols. had come in effing and swearing twice If I have made a clinical mistake, then before, and I hadn’t told him off, so he I’m quite happy to pay a fine. But if I am had become emboldened. I called the found not guilty of that complaint, I staff in as witnesses and we called the want an apology from the patient, and police. My head was painful for four or I want them to pay investigation costs. five days: there was And I may prosecute some bone thickening them for harassment of the forehead. But in the small claims there is an advantage court. ‘We’re in a very to having a thick skull ‘I’m reasonably weak position in this job. robust, but some as doctors’ ‘The police gave of my colleagues him a warning, but I get very upset, wasn’t satisfied. Two understandably, when MPs I mentioned there’s a complaint it to agreed it was not acceptable or physical threat. This is one reason behaviour. So, I sent a letter to the why some doctors go back to India or patient threatening legal action for Australia, and why there’s a workforce common assault. crisis: they’re annoyed with this ‘I got £700 from him about a country’s system. month later, after he sought legal ‘It helps when there’s media advice. The patient was more than coverage when people are prosecuted 80 years old, so I didn’t want to be for assaulting NHS staff: that sets a too harsh. But I think it’s important to legal precedent. I hope my experience send a clear message. does, too. I’m pleased they’ve put ‘I do view this as a racist attack. How video cameras on ambulance staff, and many white doctors has he hit on the I’ve suggested we should use video head? In my last practice, where this cameras in our consultation rooms, happened, some of the Asian doctors too. The message needs to get out that and the black doctors were getting people can’t abuse NHS staff like this.’ thedoctor | August 2021 11
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‘You’re there for the patient but we do need to support one another too’
Shaan Sahota is a foundation year 2 working in cardio-geriatrics at a London hospital, having spent part of her FY1 working in critical care with COVID patients. Dr Sahota argues that abusive behaviour from patients is easier to bear when colleagues acknowledge it.
‘I
had a patient once who was caring for patients, making them feel slightly delirious and probably heard. There was no practice for actually dying, and she told me, “Get away, asserting a boundary with a patient get me a white doctor!” Because she who’s being completely out of order, was so unwell, I found it easier to think, and caring for your colleague. “OK, you’re the person who’s hurt right ‘When the nurse who had something now.” But I’d understand if someone thrown at her told us what had else couldn’t see it that way. happened, the senior doctor said, “Oh, ‘In the last few months, I’ve seen two no, is he OK?” All his training has been nurses attacked: one geared towards what had something thrown the patient needs. Of at her, the other one course you’re there for ‘It’s really important was punched. the patient, but we do ‘There’s so much need to support one that someone frustration at the another too. And we’re acknowledges moment from families not doing that. what’s happened’ not being allowed in ‘It’s really important hospital and about that someone what’s happened to acknowledges what’s non-COVID healthcare. happened, that there Families are dumping their anger on is some measure of justice. What I’ve whoever they can get on the phone. You found really hard is when people try to need to do a lot of deep breathing. brush over it. It’s quite embarrassing ‘This week, we’ve had quite a racist when patients are rude to you. You patient and I’ve heard a few people say, think, “Did I do something wrong?” “I can’t treat that patient any more. She It can make you feel inadequate and said the ‘N’ word.” That’s devastating to angry and confused. hear. But we can’t all respond like that, ‘So, it’s really cathartic when so you decide you’d better go and treat someone helps you process it, and them. You’re not going to punish or draws it into the collective, and says, judge them but I probably enjoy caring “Hey, I saw that and it wasn’t right. Are for them a bit less. you OK?” It’s the response of the people ‘I don’t think we were prepared for around me that makes me feel either this in training. So much of it focused on protected or really alone.’
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‘I ‘Do my non-medical friends have to deal with things like this?’
Anna Christina Morawski is a core trainee 2 in general psychiatry in London. Despite regular incidents of aggression in psychiatry, she has felt safer on psychiatric wards than in other departments during training, because of robust preparedness and a strong sense of teamwork.
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’ve been held by patients in happened. Do my non-medical friends violent ways, or I’ve witnessed have to deal with things like this?” them throwing tea at someone’s ‘In most scenarios people just put face or pulling lanyards. People their feelings to the side and get the touching my hair. I’ve had swearing and job done. But I wouldn’t be human if I threats to the point of desensitisation. said that it doesn’t have an effect on Sometimes these are psychiatric the energy and the disposition and the presentations: focus that you can sometimes it’s just provide, not only to ‘Patients are in antisocial behaviour, your patients, but also or frustration. to colleagues, friends defensive mode and ‘COVID has and family. they might say or definitely added ‘I definitely feel a do things that stress because people lot safer in psychiatry they don’t mean’ weren’t allowed to in the sense that receive visitors, and whenever somebody our patients are is physically admitted for months sometimes. aggressive, they’re restrained, And they weren’t allowed to go on de-escalated and, if necessary, offered home leave or to smoke either. All oral medication to help them calm their support groups in the community down. had to stop during COVID too. ‘At worst, they might be injected ‘Our patients definitely tend to be and moved to seclusion. Having a bit more agitated but that’s because worked in A&E, I know that if within psychiatry, we have the legal somebody is being aggressive, you power to temporarily strip them of just have to cry for help and hope that their freedom to prevent them from security comes on time. causing harm to themselves or others. ‘We need security checks and So they’re in defensive mode and they safety alarms (which we do carry in might say or do things psychiatry), and they don’t mean. we need training in Many times I’ve had to communication skills ‘In psychiatry... remind myself they’re – acknowledging how there’s always that unwell. the patient is feeling feeling somebody ‘During my first CT is key. We also need job in psychiatry, I had to develop cultural has your back’ a lady who basically competencies. told me to “eff off” Telling someone to every single day for “calm down” is quite about five months because I had to disrespectful in some cultures. Also, take her bloods. Then, at the end of the in other cultures, people engage by five months, we did a review where I touching each other, but some people asked her again, “Is it OK, if I take your might see that as aggressive. blood?” And for the first time, she said, ‘More than anything, we need “Yes, doctor, that’s fine.” Sometimes that feeling of teamwork, not just if you just stick with it, and you give between doctors, but also including people time, they’ll stop. the occupational therapist, physios, ‘When I was in medicine, I got kicked nurses, everyone. Psychiatry has been in the head by an elderly patient, on unique for me in the sense that every purpose. It was the middle of the night, single time I’ve had an issue with a so we just moved on. But I remember patient, my consultant has stepped in: sitting at home later and thinking, “I’m there’s always that feeling somebody on my third night shift, I just got kicked has your back, rather than you feeling and I’m expected to act like nothing abandoned.’ thedoctor | August 2021 13
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ED MOSS
DOUGLAS: ‘People can improve their mental health through becoming more physically active’
Step up to boost health A GP who started by going out for walks with his patients is now behind a citywide game involving 60,000 people. Peter Blackburn speaks to doctors who see physical activity as as way of tackling the negative mental health effects of lockdown
‘F
ive years ago, I was still that tree-hugging doctor doing strange
things.’ Reading GP William Bird is reflecting on how much has changed. In 1996 Dr Bird became known for ‘health walks’ which initially saw him encouraging patients from his diabetic clinic to get out and about – using social motivation as the driving force and improving physical and mental health. And just two years later Dr Bird brought ‘green gyms’ to the world – encouraging patients to get to work in the great outdoors on commons and in nature reserves. Those health walks now number 3,500 weekly and there are more than 100 green gyms across the country – but Dr Bird’s latest brainwave might well encourage many more people to get active in their local communities. Recently, more than 60,000 Sheffield residents have been playing a game which
encourages them to spend time out of their house, getting to know their local area, engaging with other people and – crucially – becoming more active. The game is simple: ‘Beat Boxes’ – electronic buzzers – are placed across the city and participants are given cards which beep when placed on them and make a record of the distance travelled to the box. Dr Bird is clear the introduction of technology is part of what makes the project successful. The game gives increasing amounts of points to players and teams to reward walking or cycling to spots further from home. ‘The reason for the success is we take it to them,’ Dr Bird says. ‘We don’t even need them to go to a leisure centre or even a park to start with. We put the Beat Boxes right in the heart of the housing estate.’ He adds: ‘They don’t have to have a phone or download an app and children love the practicality of touching
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something and it beeping back. We use kids as the energy but then they get their parents, grandparents and aunts and uncles involved. We are still looking at mostly young families but over 10 per cent – and 10 per cent of 60,000 is still 6,000 – are over the age of 50. So, we do get the grandparents and the neighbours and the community groups involved as well.’
Activity on prescription The importance of the idea – particularly in the context of a pandemic where health inequalities have widened and young and old have been left so isolated – could hardly be more clear. And, even prior to COVID-19 many areas of the country have been very much left behind when it comes to wellbeing and health. Dr Bird says: ‘In the really deprived communities most of them don’t even go out of their estate. We had children in Eastbourne who lived half an hour from the sea who had never been to the sea and they were six years old and had lived there all their life.’ It is a project Dr Bird, and colleagues, have been working on for some time – with the initial idea coming in 2010. For a long time the majority of the work was done with schools but of late Beat the Street has become a more ambitious idea with doctors aiming to involve much wider parts of the community. And, in Sheffield, where leading doctors are making efforts to involve physical activity in much of their work, patients are even being prescribed the game. Sheffield GP Andy Douglas says: ‘My colleagues and I have been speaking to lots bma.org.uk/thedoctor
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of patients who since the pandemic have experienced the effects of lockdown: isolation, inactivity, financial difficulties, and stress. These conditions have led to a huge surge in the number of people feeling down and depressed. One of the most effective ways people can improve their mental health is through becoming more physically active. ‘That’s where Beat the Street ticks a lot of boxes. I have heard from people playing that it has got them out of the house, finding areas near them that they had never explored before; often finding themselves chatting with new people over a Beat Box.’ And Sheffield’s director of public health, Greg Fell, adds: ‘Noticeably, there are more people walking, cycling and rolling around the game area in family or friendship groups, and it’s great to see physical activity move up the agenda in this way.’
Broadening horizons The schemes, which have also recently run in lots of areas
across the country, seem to be a success beyond just the numbers of people involved, too. A recent location for the game, Lanarkshire in Scotland, found a 20 per cent increase in the proportion of children meeting the chief medical officer’s physical activity guideline of 30 minutes of activity a day. An evaluation also found 7 per cent of adults reported a decrease in inactivity and 5 per cent more travelled in an active manner. Dr Bird is hopeful those numbers can increase further, too. He says: ‘We aren’t teaching people to do a new sport as such, we are just widening their world. When the Beat Boxes go the whole idea is the habit continues: the world is bigger, they’ve met lots of people and they’ve got their confidence.’ Given the experience and excellence of the doctors involved who would bet against the worlds of many more people being widened – and, perhaps, the health of a nation being tangibly improved.
BIRD: ‘We put the Beat Boxes right in the heart of the housing estate’
‘The effects of lockdown have led to a huge surge in the number of people feeling down and depressed’
‘There are more people walking, cycling and rolling around the game area in family or friendship groups’
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A MAN OF PRINCIPLE Kailash Chand, who has died suddenly, was a passionate campaigner for the NHS and a great friend to many doctors. By Jennifer Trueland
B
feelings of many when he said he was ‘reeling’ from the y any definition, Kailash Chand OBE was a news. The BMA tweeted that ‘his was a life of service to towering figure. his patients and his fellow doctors and all at the BMA will His titles, honours and public achievements miss him deeply’. are many. He was honorary vice president of the BMA, Dr Chand was born in India, the eldest of five children. had been the first Asian elected as deputy chair of the A talented cricketer, he attended organisation, he was a fellow of the Punjabi University on a sporting Royal College of GPs, and had played scholarship, graduating in 1974. But an almost impossibly active role in already the passion that would lead local and national medical politics. He ‘His was a life to a career of campaigning for better was also a prolific writer. of service to health services was apparent. To his friends, family, colleagues – his patients’ ‘In India, he was quite a political and patients – he was all these things, activist, and was a student leader when but he was also someone they loved. he was at university – he would lead ‘I had a unique, privileged marches, that sort of thing,’ says relationship with my dad,’ says his son, Dr Malhotra. ‘He was actually jailed twice, for calling Aseem Malhotra, a consultant cardiologist, author and out government corruption.’ campaigner. ‘He wasn’t just an amazing father, he was my best friend. We would speak at least three times a day, sometimes more.’ Political involvement Dr Chand moved to the UK in 1978 and worked as a GP Deeply missed in Ashton-under-Lyne, Greater Manchester. His wife, Kailash Chand Malhotra died suddenly on Monday Anisha Malhotra, worked in the same practice. 26 July, aged 73. Almost immediately, there was an He quickly became involved in medical politics and outpouring of tributes on social media. Former Labour was a central figure in many of the major events to hit leader Jeremy Corbyn thanked him for ‘a life of care’. the profession and the health service. For example, he Greater Manchester’s mayor Andy Burnham echoed the was behind a petition to drop the bill that would become 16 thedoctor | August 2021
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CHAND AND NAGPAUL: Great friends
‘WE JUST CLICKED’: Dr Chand and Dr Wrigley
CLOSE BOND: Aseem Malhotra with his father
unbelievable capacity for pouring oil over troubled the Health and Social Care Act 2012 – garnering so waters – he really could bring people together and many signatures that it was debated in Parliament. make things work.’ According to BMA council chair Chaand Nagpaul, Cristina Costache first met Dr Chand around three Dr Chand was an inspirational figure who was fearless years ago, when she was a new member of BMA council. in speaking out about what he believed in. ‘I was a foundation doctor 2 when I joined council ‘We became instant allies and then we became and it was daunting from a junior point of view and as an friends,’ says Dr Nagpaul. ‘We shared so much – I loved immigrant doctor. But from the beginning, he was one his sense of conviction, his sense of what was right, of the most welcoming and supportive people I’ve met. his willingness to speak out about what he thought I felt he understood some of the things was right, regardless of political hue. I was going through. He will be very Kailash always put his principles and much missed, not only by his very close values above anything else.’ ‘He always put friends but by all those other people It was Dr Chand who persuaded Dr his principles and whose lives he touched.’ Nagpaul to stand as chair of the BMA values above GPs committee and later as chair of council. ‘He gave me the confidence Going the extra mile everything else’ and the belief to do it, and he was Professor JS Bamrah, chair of the BAPIO always there to provide guidance.’ (British Association of Physicians of Indian Origin) and deputy chair of the Bringing people together BMA’s board of science, attended the same medical Seeing an ethnic minority doctor progress in the BMA school (a few years apart) as Dr Chand in India and both meant a lot to Dr Chand, he adds. ‘I’ve felt that I owed came to Greater Manchester. Dr Chand was very proud it to Kailash to speak out and address race inequalities to be an Indian doctor practising in Britain, says Prof in the NHS, in part driven by the fact that Kailash and Bamrah. But he adds: ‘He had experienced racism and his peers had faced so many unfair hurdles when they was very passionate about expressing the racism he’d came to the UK several decades ago.’ experienced so that people who are of foreign origin Dame Clare Gerada met Dr Chand when she was could understand that it’s okay to speak out and that it’s chair of the RCGP. He supported her when she spoke not right to be abused in a racist way. out against the 2012 English health reforms, and they ‘My first memory of him is that he was a very good became close friends. ‘Over the years I’ve grown to doctor – he would always go the extra mile for patients, love him,’ she says simply. ‘Kailash had this capacity to always do his best. But he was also very passionate about make me feel like his daughter; he had this unbelievable the NHS – I tweeted that if they did a PM they would find capacity to make us all feel special. He also had an engraved on his heart these three letters: NHS.’ bma.org.uk/thedoctor
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JANE STOCKDALE
COOK: Juggling medicine and sport had its demands
On her way to an Olympic gold medal, Steph Cook managed to balance a medical career with training in five different sports. As Britain once again triumphs in modern pentathlon, she tells Seren Boyd how she managed it
Doing the double ‘At lunchtime, I’d do a session at the cross-country club, and then go back up the hill for my 2pm tutorial’
I
JANE STOCKDALE
t’s about this time of year that Steph Cook senses a familiar agitation, a flutter of nervous excitement. These days she’s a Sussex GP with two sportsmad sons, but there’s still that irrepressible urge to ride and to run, even before surgery. She’s also the Steph Cook who won Olympic gold in modern pentathlon at Sydney 2000, as well as the European and World Championships the following year. Watching the Olympics has become less nerve-wracking with the years, but she’s still on edge. ‘You feel very close to it still, almost responsible for what’s happening, because you want the legacy of the medals we won to carry on,’ says Dr Cook. ‘And I know exactly what they’re going through.’ One of the most remarkable things about Dr Cook is not just that she dominated the ultimate sporting challenge: modern pentathlon involves swimming, fencing, riding, shooting and running, all on the same day. It’s also the fact she combined her medical training with taking her sport to elite level. And then, having achieved everything there was to achieve, she put competitive sport behind her and returned to medicine.
Training in lunch breaks She chose medicine before sport chose her – and she’s remained loyal to that first love. She volunteered with an ambulance service
in Jerusalem before starting her pre-clinical medicine degree at Cambridge. She had been sporty at school ‘but no one would have picked me out as a future Olympian’. She took up rowing and did athletics at Cambridge but it was when she started her clinical training at Oxford in 1994 that she saw a poster in the porter’s lodge about modern pentathlon. It offered a chance to get back to riding that she had loved as a child, and a more flexible training schedule. But it encompassed five sports, two of which – fencing and shooting – she would have to start from scratch. ‘At lunchtime, I’d cycle down the hill from the John Radcliffe Hospital, and do a session with the cross-country club, and then go back up the hill for my 2pm tutorial, all a bit hot and sweaty. I just had to juggle. Shooting was easier to pick up but fencing is very technical and it’s much harder to reach that higher level in a short space of time.’ But soon she was representing her university not just in modern pentathlon, but also in fencing, athletics and cross-country. In 1997, she was selected for the British team at the European Championships in Russia. But the competition clashed with her clinical finals, and the university would not budge on exam dates. So, she missed Russia and the World Championships, because the same British team went to both. One day, her coach sat her down and
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Decision time What followed was a very tough year. ‘For six months in Poole, I was taken completely away from all my training facilities. I joined a fencing club, and a swimming club, and used to go running before work. I was shooting, dry-firing, in my room, just trying to keep everything going as best I could. I think everybody thought I was a bit mad, but they were very understanding and very supportive. ‘I never let it affect my work: when I went away to competitions, I took it as leave. I remember doing loads of nightshifts on the trot, just so that I could go out to a World Cup competition in Poland, then just sleeping and sleeping, trying to catch up on sleep before competing.’ A chat with consultant surgeon Mark Whiteley ‘over a ruptured AAA [abdominal aortic aneurysm] in the middle of the night’ towards the end of her house job in surgery in Oxford led to him funding a vascular research post for her in Guildford for 15 months. Then, when Bath University became the national training centre for modern pentathlon, she moved to Bath in 1999 and gave herself fully to sport. ‘My commitment to medicine was always there but I realised the opportunity for sport was at that time,’ says Dr Cook. ‘My training was going well: I was competing successfully in internationals. Had I taken time away from sport, I couldn’t have gone back to it.’ In the event, she took 20 months out of medicine – and timed it perfectly. She claimed Olympic gold at Sydney, snatching victory from Emily deRiel in the final, cross-country running event, despite the American starting with a 49-second advantage. In 2001, at the World Championships in Somerset, she added three gold medals to her Olympic and European titles. Then at 29, Dr Cook announced her retirement. She was reigning Olympic, World and European champion, she had become something of a celebrity, and she’d been bma.org.uk/thedoctor
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awarded the MBE for services for sport. A few weeks after the World Championships, she began a surgical rotation in Bath. Before that, however, she flew out to Gujarat, India, to visit the work of medical charity Merlin six months on from the January 2001 earthquake. Those ten days visiting devastated communities and tending patients in makeshift clinics confirmed to her she’d made the right choice. ‘It was really important to put things into perspective and see what’s really important,’ she says.
JANE STOCKDALE
challenged her: ‘What’s your plan?’ ‘Because I missed that opportunity to go to a major sporting championship, I didn’t really know how good I could be. I wanted to do my house jobs so I decided to keep my training going through it all. It was really difficult to know whether I was doing the right thing, but I felt I had unfinished business with pentathlon.’
The right track When Dr Cook and her husband, an equine vet, started their family, they made some big life decisions. They moved to his native Sussex and Dr Cook, having completed her surgical specialist training, and embarked on a career in ENT, retrained as a GP. She found she loved the breadth, diversity and flexibility of general practice – and has stayed there ever since. She’s no longer wrestling with the What ifs? Others have continued her legacy. Team GB’s medal success in women’s modern pentathlon at Sydney – the first time the women’s event was included in the games – has continued at almost every Olympics since then, with Kate French winning gold in Tokyo this month. Her fellow Brit Joe Choong won gold in the men’s event. Dr Cook has never regretted medicine, even in a tough year when her practice has merged with three others. ‘Sports taught me a lot in terms of always trying to have a really positive approach, focusing on the things that are within your control, and finding that balance. It’s definitely made me more resilient. ‘But I have never had any intention of walking away from medicine. I sometimes resent the hours that I spent doing it, when it’s keeping me away from my family, but I still love the job. ‘Competing at an elite level in sport, you have to be really quite selfish in some ways, whereas medicine is completely the opposite. All you’re doing is for other people, not yourself. Medicine, as a profession, gives you an immense amount of satisfaction: it’s an incredibly privileged job to be able to do.’
‘I have never had any intention of walking away from medicine... I still love the job’
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Unequal outcomes Women from minority ethnic groups are more likely to die during pregnancy than their white counterparts, but a NICE recommendation which seeks to address this and other disparities has proved controversial. Tim Tonkin reports
L ‘We don’t really understand why black and Asian women are overrepresented’
ast month saw the close of a consultation on proposed NICE guidelines for healthcare staff on inducing labour. Among the recommendations included within the draft, under a section concerned with the prevention of prolonged pregnancy, NICE calls on staff to consider inducing birth from 39 weeks in ‘otherwise uncomplicated singleton pregnancies’ in Black and Asian women. This proposed recommendation, made on the basis that women
from these backgrounds are among those at ‘higher risk of complications associated with continued pregnancy’, was condemned by many health professionals, primarily for apparently encouraging decisions on healthcare to be based on a patient’s race. The recommendation was further criticised, however, for the fact that such a blanket approach would do little to adequately address the many existing inequalities in maternity care outcomes experienced by many women from ethnic minority backgrounds.
A report looking at reducing inequalities in outcomes of maternity care published in December last year by Public Health England stated that Black and Asian women are respectively five times and twice as likely to die during pregnancy than white women.
Higher mortality The report also found that women from ethnic minority backgrounds experienced poorer outcomes in other aspects of pregnancy and childbirth including neonatal mortality rates, pre-term birth
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and perinatal mental health. ‘It’s important to recognise where this guidance came from and the fact that we know Black and Asian women are overrepresented in the group that unfortunately suffer still births and early neonatal death,’ says consultant in obstetrics and gynaecology Christine Ekechi. ‘We also know that induction of labour before 40 weeks could try and capture that proportion of stillbirths that occur in the later stages of pregnancy and produce a better outcome [but] the point is we don’t really understand why Black and Asian women are overrepresented in these statistics.’ Understanding the causes behind poorer outcomes in maternity care for Black and Asian women is complex and, according to PHE’s report, multifactorial and in need of further research. The latter warns however that applying a ‘one-size-fitsall’ approach to maternity care combined with insufficient training and awareness of cultural sensitivities among staff can contribute to inequalities in healthcare outcomes and structural racism, and ‘personalised care is the key to safe care’.
whole group of women based on the colour of their skin, what we do is remove choice for those women meaning they would be unable to have a home birth or water birth for example,’ she says. ‘That then further erodes the trust between a group of women and the healthcare system that we already know has issues. We also potentially expose those women to further intervention that may have implications for future pregnancies.’ ‘We hear over and over again [from] Black, Asian and other ethnic minority women that they are not spoken to with the care that places them at the centre of their health journey, that their voices are not heard and that when they present with concerns about themselves or their baby, they feel that they are dismissed. ‘This will definitely impact on the [maternity] outcomes, it’s not necessarily going to be the sole cause, but it’s definitely going to be a contributing factor. It’s important to acknowledge that and to think about how we can continually have the discussion about how we can be open and engage with these women.
Trust at risk
Responding to the draft guidance, the BMA says that disparities in maternal care and health are complex and more than ‘skin deep’, adding that further research and ensuring that women of all races are supported in making informed choices during pregnancy, are key to understanding and addressing inequalities. It says: ‘We share the concerns of leading healthcare
Dr Ekechi, who is the RCOG (Royal College of Obstetricians and Gynaecologists) co-chair for racial equality, says that while attempting to address inequalities in maternity care outcomes is laudable, basing recommendations on race is not only reductive but risks further undermining patient care. ‘If we were to induce a bma.org.uk/thedoctor
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Informed choices
organisations surrounding inducing labour for women from Black, Asian, and minority ethnic backgrounds at 39 weeks. Disparities in maternal outcomes are more than skin deep. ‘Treating women from Black, Asian, and minority ethnic backgrounds as a homogenous group veils the distinct care needs of the women in each of these groups. It is vital that all women are empowered to make informed choices and advocate for themselves throughout their pregnancies. ‘This approach to care also risks perpetuating narratives that disparities in health outcomes are a result of biological racial differences, without taking into consideration structural inequalities. The BMA supports the call for further research into the underlying causes of disparities in maternal outcomes, so that healthcare providers can best support women during their pregnancies and after childbirth.’
EKECHI: Basing recommendations on race risks further undermining care
‘Disparities in maternal outcomes are more than skin deep’
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MATT THOMAS
Your BMA The pressure on doctors to be ever-present at work despite how they are feeling is a risk to their well-being, says BMA representative body acting chair Latifa Patel The recent #TipsForNewDocs on social media has got me reflecting on how we have all been hard-wired to worry about attendance – and to believe, wholeheartedly, that 100 per cent attendance is important. It has led me to wonder what the effects of that might be for our careers, our well-being and ultimately our NHS. For me, it goes all the way back to primary school. I think back to year three where we had reports which included the amount of authorised and unauthorised attendance we had during the year. For many it was a matter of pride or came with a feeling of shame. In my career as a paediatric respiratory trainee, one thing I see is those children for whom 100 per cent attendance is not possible. We see children with acute and chronic respiratory disease which makes it an impossible achievement and for those children and their families it is difficult. They can’t have that certificate at the end of the year – they can’t achieve that 100 per cent attendance and whatever reward it may sometimes come with. That’s not right. I think it’s a feeling we are programmed to keep with us. I remember as a medical student and then a newly qualified doctor still feeling like being ever-present was so important. And it sticks with many of us throughout our working lives too. In our career – perhaps more than most others – there’s a feeling that we have to be there. The patients need us, our colleagues need us, 5.45 million patients on the waiting list for treatment in England alone, we are reminded constantly. The truth, perhaps, is that while we often talk about demand on the NHS it would be more reasonable to talk about demand on the staff working in the NHS. The demand on us. For many of us working in the NHS is being part of a team. We spend so much time with our colleagues and we share moments of great emotion – of joy and of sadness. We often feel we need to keep up that 100 per cent attendance because our teams need us. One memory sticks out to me. I was working as a house officer on an adult respiratory ward. A healthcare assistant found out that I hadn’t had a lunch break and it was now approaching 5pm. When she approached me
@drlatifapatel with tea and toast I told her I simply didn’t have time. Her response is something I’ll remember forever, I think. She said: ‘If you keel over now, this service will just have to carry on without you. It won’t stop.’ Right there I realised two things – she was right. If someone in the NHS ever offers you a break and some tea and toast you take it. There is a very serious point here. We face so many pressures in our working lives – and this idea of 100 per cent attendance is a strong element of those. It is in-built and it becomes ever more powerful as we throw ourselves into our work. But it can be dangerous, too. Our jobs are difficult and have become increasingly so during the course of this pandemic. We have to look after ourselves and each other. I would like you to know that if you are finding it difficult – if any of these feelings resonate with you – the BMA has many provisions and services which could help. As your trade union and professional body we recognise just how important it is we invest in the well-being of our members and the wider profession. All doctors and medical students, members and non-members and their partners and dependants have access to our confidential services because we know how important this is. We provide 24/7 access to free counselling and peer support services. There is always someone to talk to – 0330 123 1245. In recent months we have run surveys featuring unprecedented numbers of contributions from doctors to help us understand what people are experiencing and how they need to be supported or represented by us. But I would also like to ask you if there is more we can do. Is there anything we could be doing to help you? If there is anything – no matter how small or insignificant it may seem – please get in touch. I want to know, I want to understand and I want to help. You can contact me via DM on Twitter: @DrLatifaPatel, my DMs are always open or via email at RBChair@bma.org.uk
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on the ground Highlighting practical help given to BMA members in difficulty
How the BMA helped a doctor who was experiencing delays in her planned return to work A doctor wanted to return to work. She had been unwell for some time, but occupational health had recommended some adjustments to make her return more manageable. The plan included a phased return to work, a reduced number of sessions worked, and no on-call duties. It also required some workplace changes to ensure there was nothing that could trigger her health condition, or involved her being left alone, in case her condition flared up. She contacted the BMA because everything was happening very slowly, if at all. The employer had needed to discuss the doctor’s return to work with appropriate staff, and ensure that all the necessary equipment and recommendations could be put in place, and it had sought advice from a specialist. But the doctor was becoming frustrated and upset, and her health was deteriorating. She was a single parent, prohibited
from driving because of her condition, and worried about her finances, all of which were compounding her anxiety. The doctor in this case praised the employment adviser for her knowledge and experience, and it is easy to see why. The BMA employment adviser contacted and chased up the necessary staff, represented the doctor in meetings, and gave her advice on her employment rights and pension. The employer – credit where it’s due – was supportive when the member went back to work. But even with the right support now in place, the overall stress of the health, work and personal situation were taking a toll on her health. The BMA had been involved throughout, in regular contact with the doctor and employee, and about a year after she returned to work, it became evident to all that ill-health retirement would be the best option for the doctor. The
BMA supported the member through this entire period. Anyone who has been through this process will confirm that it can be a long-winded and sometimes bureaucratic process. In this case, the necessary occupational health assessment was slow in arriving, and the BMA adviser took the matter higher up in the organisation to accelerate the process. The ill-health retirement was approved, which was an immense relief for the doctor. She was given three months’ notice on full pay (her sick pay had been exhausted) and all the holiday pay she was owed. For the BMA adviser, there was the privilege of attending a meeting with the member where senior staff thanked her for her long contribution to the NHS. The member left with dignity, feeling valued. And she said to the BMA adviser, ‘I couldn’t have done it without you’. thedoctor | August 2021 23
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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 July 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 July be obtained from the publishers on written request.
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The Doctor is a supplement of The BMJ. Vol: 374 issue no: 8303 ISSN 2631-6412
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