The magazine for BMA members
thedoctor
Issue 31 | May 2021
Online but off limits Supporting patients left behind by the digital divide
Kept apart
Harsh rules on hospital visits isolate vulnerable patients
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Childcare needed Available, affordable – or the NHS will keep losing doctors
Public health
Reorganised – but can it now be revitalised?
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thedoctor
The Doctor BMA House Tavistock Square London WC1H 9JP Tel: (020) 7387 4499
Editor Neil Hallows (020) 7383 6321 Chief sub-editor Chris Patterson Senior staff writer Peter Blackburn (020) 7874 7398
thedoctor@bma.org.uk
Staff writer Tim Tonkin (020) 7383 6753
Call a BMA adviser
Scotland correspondent Jennifer Trueland
0300 123 1233 @TheDrMagazine @theBMA The Doctor is published by the British Medical Association. The views expressed in it are not necessarily those of the BMA. It is available on subscription at £160 (UK) or £225 (non-UK) a year from the subscriptions department. All rights reserved. Except as permitted under current legislation, no part of this work may be photocopied, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical or otherwise without the written permission of the editor. Printed by YM Chantry. A copy may be obtained from the publishers on written request.
Feature writer Seren Boyd Senior production editor Lisa Bott-Hansson Design BMA creative services Cover photograph Matt Thomas
Read more from The Doctor online at bma.org.uk/thedoctor
The Doctor is a supplement of The BMJ. Vol: 373 issue no: 8291 ISSN 2631-6412
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In this issue 4-5
Briefing BMA support for India, GP numbers not keeping up with demand, and why doctors don’t always look after themselves
Welcome Chaand Nagpaul, BMA council chair The COVID-19 pandemic has been all-consuming for many of us – with our daily working lives focused on responding to this public health crisis for more than a year. But, away from the pandemic, there are very serious and significant changes afoot in the health systems in which we work, and in this issue of The Doctor we shine a light on reforms which may result in significant changes. The Government has published a white paper which outlines its plans for system-wide reforms of the health service. The proposals are intended to remove competition from the NHS and mandate a move towards integration and collaboration – an indication that, as we have said for so many years now, the 2012 Health and Social Care Act was not fit for purpose. Doctors are tired of reforms and reorganisations. We have seen so many over recent years and decades. On most occasions the sweeping changes drain resources from the health service, set us back several years and see doctors leaving in droves, while having little effect on the daily realities GPs, hospital doctors and public health specialists experience. In some cases they simply place further obstacles in the way of providing the best care for patients. And in public health, the Government has announced the formation of two new bodies – the UK Health Security Agency and the Office for Health Promotion. If these reforms are to have any positive effect for doctors, the NHS and patients, genuine clinical engagement will now be crucial. In this issue of the magazine we look at the digital divides created by enforced reliance on technology during the pandemic. While technology brings many benefits there are concerns some groups of patients are pushed away from services, and it will be vital these issues are explored in depth to ensure no parts of society are left behind. The May issue of the magazine includes a feature looking at childcare for doctors, with so many doctors leaving the profession because issues around childcare often force a choice between working and being parents. We also look at the rights of families and carers to see patients during the pandemic.
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Bridging the digital divide The challenges and unexpected benefits of online consulting
12-15
Finding good care is not child’s play How affordable and available childcare would help retain doctors and narrow the gender pay gap
16-19
Down with the wall Barriers are set to be broken between primary and secondary care in England
20-23
How the cards will fall The shake-up to public health must combat health inequalities and address a long-term funding deficit
24-28 Kept apart Do limits on visiting loved ones strike the right balance between safety and compassion?
29 On the ground The BMA wins back hundreds of thousands of pounds for doctors
30 It happened to me Fighting deadly diseases, like father, like son
31 Your BMA Raising key issues on the world stage
Read the latest news and features online at bma.org.uk/thedoctor bma.org.uk/thedoctor
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briefing Current issues facing doctors
WRIGLEY: ‘We don’t tend to look after ourselves very well’
DAVE: The idea of physician health has been swept under the carpet
INDIA: COVID patients overcrowd a hospital
Doctors neglect their own health ‘Doctors, and most healthcare workers, are not very good patients.’ This observation by BMA council deputy chair David Wrigley sets the context for how important it is for doctors to talk about how they maintain their own health while dealing with unprecedented pressures. He was speaking at last month’s International Conference on Physician Health, a biennial event organised by the British, American and Canadian medical associations and this time hosted virtually by the BMA. He added: ‘We don’t tend to look after ourselves very well, we battle on and go to work when we’re unwell. ‘When I was at medical school many years ago there was no mention at all about the mental health and wellbeing of doctors and students. We have to learn from this past year and help our colleagues, doctors and nurses, who are suffering.’ This was a view shared by Royal College of Psychiatrists dean-elect Professor Subodh Dave, who spoke at a session on what has been learned from the pandemic, and how this knowledge can improve physician health services in the future. ‘COVID has really shone a spotlight on a problem that has existed for some time,’ he said. ‘I think for a long time the whole idea of physician health and wellbeing has been
swept under the carpet, and certainly that is reflected in our training. ‘For me the big turning point has been having an open conversation about our wellbeing and our mental health. It is really important and needs to be embedded in our curriculum during our training and needs to happen more routinely in our workplaces.’ One of the recurring themes discussed over the conference’s five days was that with immense change having been foisted on the world by the pandemic, members of the medical profession need to themselves embrace change, particularly in how they viewed themselves and each other. For King’s Fund senior fellow Professor Michael West, the key to improving the wellbeing of doctors was to ensure that compassion was at the centre of medical leadership and practice. ‘I think it’s the compassion of health and care staff that has enabled us to cope during this period. Tragically some of them have given their lives in service of patients. Stress levels, vacancies and intentions to quit in many countries are at the highest levels ever amongst health and social care staff and leader empathy [in addressing this] is fundamental.’ And a compassionate culture, he argued, began with those in it having the ‘courage to be selfcompassionate’.
BMA shows solidarity with India As the struggle against COVID-19 remains the focus of countries around the world, it is sometimes easy to view the pandemic as a series of individual battles rather than a single, global one. In the UK the apparent success of the vaccination rollout and the ‘circuitbreaking’ effect of the last national lockdown has, since late January, seen the number of deaths from COVID continue to fall. While the tide appears to be turning in this country, in many other parts of the world the fight to control the virus’s spread and save lives is faltering to a horrifying and tragic extent. With more than 20 million reported infections and close to 250,000 deaths, the effect of the pandemic in India is threatening to overwhelm the country’s health services and plunge it into a humanitarian crisis. In response, the BMA has made grants totalling £25,000 to organisations working to support doctors and healthcare workers in India by providing them with desperately needed supplies of oxygen and ventilators, with the association’s council chair Chaand Nagpaul pressuring the UK Government and world leaders to do more. The organisations receiving the money are the Disasters Emergency Committee, the British Association of Physicians of Indian
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GETTY IMAGES NEWS
Origin, the British International Doctors Association and APNA NHS, a staff network of leaders from a south Asian heritage who work in the NHS. ‘The recent scenes in India resulting from the COVID surge afflicting the country have been truly shocking and heart-wrenching,’ Dr Nagpaul said in a recent message to BMA members. ‘I have been contacted by many doctors expressing anxiety about the deteriorating situation and I know that every member of the BMA will be concerned about the impact this is having on their colleagues as well as what it means for the people of India.’ With the NHS staffed by tens of thousands of doctors of Indian origin, the unfolding tragedy in India feels incredibly close to home, and serves as a reminder that the fight against the virus cannot be limited to individual countries. As a result, the association has pledged its continued support to the president and general secretary of the Indian Medical Association, as part of efforts to provide ongoing help and support in dealing with the COVID crisis. ‘There has never been a more important time for us to stand in solidarity with and offer practical support to our colleagues around the world,’ said Dr Nagpaul.
Keep in touch with the BMA online at bma.org.uk/thedoctor
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A pledge on GP numbers which needs to be kept During the political campaigning in the run-up to the 2015 general election, the then health secretary Jeremy Hunt promised to deliver 5,000 more GPs for the NHS by 2020/21. Today’s Conservative Government has pledged to find 6,000 more GPs by 2024. The first of those promises never materialised. GP workforce data released last week shows that despite a headcount increase of 1,261 individual fully qualified GPs in England between March 2020 to March 2021, the net gain of full-time equivalent fully qualified GPs was just 111. These damning figures cast serious doubt on the credibility of the latest promises made by the Government, and they don’t just mean expansion of services – or any sort of progress – is impossible, but ultimately that the workforce is not growing fast enough to cope with future demand. BMA GPs committee executive team workforce lead Krishna Kasaraneni said: ‘According to a recent BMA survey, more than half of respondents working in a primary care setting said they plan to work fewer hours in the next year, with a further 36 per cent deciding to leave the health service altogether and take early retirement. ‘We know that much of this is linked to personal wellbeing – doctors across the NHS have been pushed to their limits this past year, with many struggling to get the respite they need following the demands of the pandemic. ‘For some, this has led to them becoming unwell and feeling disillusioned with a job they once loved. ‘Almost 50 per cent of respondents to our recent COVID-19 tracker
instagram.com/thebma
KASARANENI: Doctors struggle to find respite
survey told us they suffer from depression, anxiety, stress, burnout, emotional distress or another mental health condition.’ Jeremy Hunt’s promise was never fulfilled. As, in Dr Kasaraneni’s words, the future of the NHS hangs in the balance, the new promise must be kept.
Read more online – BMA rushes to help India fight COVID – Doctors gather to reflect on effects of COVID – Doctors urged to engage with honesty proposal – Help to influence junior doctors’ careers for the better – Reflecting on Ramadan, faith, and workplace support for doctors Read all the latest stories at bma.org.uk/news
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The rapid switch to telemedicine has made it hard for some patients to access services. Doctors tell Seren Boyd how they have helped people overcome the digital barriers, and how online consulting can bring some unexpected benefits
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hen GP Aaminah Verity’s London practice moved to digital triage in April 2020, something unexpected happened to the appointments diary. North Lewisham, the area they serve, has high levels of social deprivation, including a large migrant and homeless population. There is also a university nearby. ‘Suddenly, we were only seeing 20- and 30-year-olds with skin conditions, lumps and bumps, urine infections and thrush,’ says Dr Verity. ‘We’re used to lots of vulnerable users coming in, in extremis, with, “I’ve got severe chest pain,” or “I’ve just arrived from Africa with malaria”. ‘We were actively reaching out to some of our most vulnerable and complex patients but [as for] them reaching out, they just dropped off. We realised they were struggling to get in through the system.’ The shift towards virtual consultations was already under way pre-pandemic, as part of the NHS Long Term Plan. But COVID switched the rationale abruptly.
SARAH TURTON
Bridging the digital divide
‘Patients were struggling to get through the system’
VERITY: Some vulnerable patients were suddenly not consulting
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MATT THOMAS
PATEL: ‘I saw when people were video consulting from a cramped corner’
‘For the street homeless person, the places where they’d normally access the internet were shut’
Debate about the relative pros and cons of remote consulting became academic: face-toface appointments were now a potential risk for patient and doctor. ‘Digital first,’ came the cry: telemedicine became the default. A year on, the benefits and challenges of this ‘digital-first’ approach are crystallising. There are concerns the new virtual NHS is inadvertently shutting out certain groups of patients. As the varied experiences of three doctors show, understanding the root causes of this digital divide is central to bridging the gap.
Stop signs at the door The move to telemedicine was meant to happen differently. Before COVID, NHS guidance and limited academic research on remote consulting urged caution: take it slow, bring colleagues on board, be flexible to ensure no one is left out. Dr Verity, concerned about her vulnerable patients vanishing, began to suspect the problem was not just the eConsult platform and the NHS App. The sudden-onset, emergency messaging was also putting up barriers. ‘People in the tower blocks of Deptford, who don’t have good internet access, they’d watch
the TV news and see the advice “Stay at home” and they thought that meant “Don’t go to the doctor either”,’ says Dr Verity. ‘For the street homeless person, the day centre, the library, the places where they’d normally access the internet, they were all shut. Then they walk up to their practice, see the STOP sign on the door and think, “they must be shut as well”.’ There are other factors that make remote consultations with vulnerable patients unsatisfactory, even if they can access eConsult, says Dr Verity. ‘With vulnerable patients who struggle to prioritise their health, it’s so important to make every encounter count. They can take a picture of a sore finger so you diagnose an infection remotely, but you’ve lost all the other opportunities to engage with other health needs. You can diagnose a UTI, but not see if someone is suffering from domestic violence. Long-term holistic care does not work with these app-based systems.’ This experience has led Dr Verity to undertake a quality improvement project, with GP academic Victoria Tzortziou Brown, into the effect of total triage and remote-by-default consulting on vulnerable groups across her primary care network in North Lewisham, with
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WOODS: Virtual consulting is a huge benefit for those in remote areas
‘You can diagnose a UTI, but not see if someone is suffering from domestic violence’
funding from Health Education England. Their study identified a range of potential solutions, including: clear and consistent messaging; a dedicated freephone number for vulnerable patients; a triage system that prioritises their needs; and face-to-face, longer appointments. They are now working on an academic research project replicating this method and building the findings into a toolkit to improve access at all practices, for NHS England. Unless every practice is committed to caring for everyone, Dr Verity fears primary care may diverge into practices that focus on e-consulting and those who ‘specialise’ in caring for those with complex needs. ‘It’s not right that one or two practices take on all that burden of work,’ she says.
New insights Latifa Patel, a paediatric respiratory trainee based in the north-west of England, agrees that the only way to ensure that people do not fall through the net is to be intentional about preventing this. Her work shifted entirely to virtual consulting from home during her pregnancy last year. Dr Patel, BMA representative body deputy chair, was given a hospital laptop, a
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second screen and a headset – and a long waiting list to work through with colleagues, on the Attend Anywhere platform. Generally, the shift to digital technologies has brought significant benefits for patient and clinician, she feels. Her hospital serves a huge catchment: not having to attend in person has meant huge savings in time and money for patients. A hospital visit usually meant an early start, time off work and school, long journeys and costly car park fees. Having a glimpse into patients’ home environment has been hugely instructive for the doctor. ‘I saw those multi-generational homes, I saw when people were video consulting from a cramped corner, I saw the damp in the living room of a child with asthma,’ says Dr Patel. ‘I met children of single-parent families and siblings with multiple health and social care needs. These details weren’t in any of their records, as they hadn’t been communicated previously. They’d missed appointments because of this – but now they were able to attend.’ Early on, Dr Patel adapted her approach for patients likely to notch up Did Not Attends or Not Brought to Clinic. She knew who they were: the people with poor English who don’t answer ‘No caller ID’ calls, the Pay-As-You-Go thedoctor | May 2021 09
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‘We need to make sure we are not worsening inequalities by assuming older adults can’t use these services’
PARKIN: Unequal society must be considered
‘I saw the damp in the living room of a child with asthma’
phone users who change their number often, the people who don’t have enough data to wait online if the clinic overruns. ‘Normally, it’s three strikes and they’re out,’ says Dr Patel. ‘But with those patients I actively rang again and again. I’d always leave a message to say who I was and say I’d call back in five minutes. I’d ring them again at 6pm because I’d know that Mum who didn’t speak English wouldn’t be on her own, or those key-worker parents who worked throughout the pandemic would be home by then.’ She would also write to them and their GP offering ways to get in touch with the team. She would send appointment letters by post, in case patient phone details were out of date, and left cases open rather than discharging them automatically in the case of no reply. But, for some, there was no alternative. The lack of online translation services in the first few months was a huge problem for those who struggled with English. They had no option but to attend in person, during a pandemic. ‘So the health disparities just got bigger,’ says Dr Patel. She is also concerned for those with poor literacy or learning difficulties unable to digest information in digital formats. ‘How do we make it better?,’ asks Dr Patel. ‘We think of the most disadvantaged and we
make that our acceptable level. We go above and beyond to make sure we’ve covered everyone. When the parent doesn’t answer the phone, we give them the benefit of the doubt because it is the child that matters.’
Access for all Digital exclusion in the narrow sense of people lacking digital skills, the right tech and connectivity remains a pressing issue. 10 per cent of the adult UK population were classed as ‘internet non-users’ and an estimated 10.7 million people had limited or zero basic digital skills in the latest Office for National Statistics figures (2019). The causes are complex, although poverty is central. But, according to James Woods, a consultant geriatrician in Fife, we should not make assumptions about who these excluded groups are or dismiss digital options for older people. Assigned to remote consulting from home for five months last year because he was shielding, Dr Woods has spent long hours with older patients on the Near Me video consulting platform. For him, it’s a ‘helpful additional tool’ in outpatient assessment. As he explained in a recent Royal College of Physicians of Edinburgh webinar, virtual consulting has huge benefits for older
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76%
of respondents aged over 75 were supportive of video consulting.
10% Sources: Near Me, ONS
of the adult UK population were classed as ‘internet non-users’
patients, especially in remote rural areas – and for the environment. Research by the Scottish Government’s Technology Enabled Care programme found that, on average, a Near Me consultation saves a round trip of 28 miles in Scotland.
Group call
‘We have an unequal society with unequal access to technology’
Timely conversations with the patient in deciding treatment options are vital to geriatric medicine, Dr Woods points out, and they are easier to arrange digitally. The ability to involve others in a virtual call, from specialist nurses to occupational therapists, is a huge benefit too. Enthusiasm for digital pathways is high, he says, citing a public engagement survey by Near Me in September in which 76 per cent of respondents aged over 75 were supportive of video consulting. ‘Like much in geriatric medicine, we need to be enabling rather than disabling,’ says Dr Woods, ‘and we need to make sure we are not worsening inequalities further by just assuming that older adults can’t or won’t use these services.’ However, telemedicine works best with a belt-and-braces approach, for now. So, for example, in Dr Woods’ health board, once a patient requests an appointment via Near Me, the appointments team will check if a virtual consultation is appropriate, and confirmation letters are posted.
Addressing inequalities David Parkin, a BMA senior policy adviser on NHS IT, believes the challenges thrown up in these early days of the digital boom are not insurmountable. ‘We need to make a distinction between the inherent problems in remote consulting – the fact you can’t physically examine someone, for example – and problems that are determined by external factors, like the fact that we have bma.org.uk/thedoctor
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an unequal society with unequal access to technology,’ he says. ‘A lot of those external factors can be addressed with the right funding and political will.’ He argues that technology can be used to tackle some of the underlying inequalities illuminated by the sudden shift to digital. For example, greater access to VDIs (virtual desktop infrastructures) in primary and secondary care – something the BMA has been lobbying NHSX for – and a willingness within the profession to continue with at least some level of remote working could help address disparities in historically underserved areas with a higher proportion of patients per doctor. VDIs allow a doctor to stream on a laptop all the information they would see on a computer at work and would allow them theoretically to work entirely remotely. Likewise, Dr Woods suggests that existing technological solutions – such as Highland Hubs which have good audio-visual equipment and healthcare professionals on site to facilitate e-consulting – could be replicated elsewhere.
Future impact These are still early days and the longerterm effect of going digital is hard to predict. A determinant of its success or failure will be the effect on clinical outcomes, something into which the BMA is looking to commission research. A motion passed at the 2020 annual representative meeting called on the BMA board of science to examine the evidence base on the use of digital consulting and when it is appropriate. But, argues Dr Verity, we need to address the digital divide while health inequalities are high on the political agenda and before new systems become too deeply embedded. ‘The old appointments system was insane: things are so much better now and most patients are seeing the right people,’ she says. ‘But for the vulnerable minority who actually really need access to healthcare, the ones who are going to die young, who are going to have significant morbidity, I worry about them a lot.’ A BMA patient liaison group symposium on 18 May will address the subject of ‘Equitable access to digital health and social care services’, with speaker Helen Milner OBE of the Good Things Foundation thedoctor | May 2021 11
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Affordable and available childcare would make a vital contribution in retaining doctors and levelling the gender pay gap. Jennifer Trueland reports
Finding good care is not child’s play
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MCKEOWN: ‘Look to the Scandinavian model and have heavily subsidised childcare’
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oncerns about childcare brought Helena McKeown into medical politics – and now she is chair of the BMA representative body, it is still an issue which drives her. As a GP and single parent, she struggled to keep her own career on track, and knows that many other parents, particularly women, face the same problem today. ‘I think we’re very foolish as a society not to sort this out,’ she says. ‘We’ve got some of the most expensive childcare in Europe and a desperate shortage of doctors. It makes no sense that we can’t get it heavily subsidised or a tax concession. It doesn’t make economic sense and it doesn’t help doctors to have a well-rounded life.’ Late last year, the UK Government published its report into the medical gender pay gap. Mend the Gap found that, despite growing numbers of women entering the profession, there remains a ‘significant and substantial’ gender pay gap, out of line with other professions, and significantly wider than for other healthcare groups. The report cites support with childcare – or the lack of it – as a crucial factor in individuals’ ability to remain and thrive in a medical career. It also points out that women’s disproportionate responsibility for caring (whether for children or older relatives) bma.org.uk/the doctor
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makes ‘a major contribution to the pay gap between men and women’.
Prohibitive costs For Dr McKeown, it all sounded depressingly familiar. Although her interest in the topic was sparked by her personal experience, talking to doctors around the country has convinced her that, while some progress has been made, there remains much to do. ‘I was a new GP partner when I became a single parent,’ she explains. ‘That was in 1998, when we still did our own on-call, prior to the 2004 GP contract which allowed us to opt out. ‘My children were under five, and when you added up the fees for pre-school, nursery, wraparound care, care in the school holidays and care overnight when I was on-call, it was almost as much as I was earning; I nearly gave up general practice.’ Responsibility for childcare is shared more equally between parents than it was in the 1990s, she says, but the cost is still prohibitively high. ‘I think there’s been a culture change – it’s more common for dads to be very involved with their children, including when their children are sick. For example, my experience is that it’s much more common now for male GPs to work less than full time and to spend one
‘[My childcare] was almost as much I was earning; I nearly gave up general practice’
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HERBERT: ‘It’s so important members of staff are supported’
‘I had been naïve – I had assumed hospitals had nurseries attached to the premises’
or two days with their children, being the one who looks after them at home. It’s become accepted – even encouraged – now. But childcare is still very expensive. I would look to the Scandinavian model and have heavily subsidised childcare. I think it’s good for the economy not to lose doctors’ working hours and I also think it’s humane for people who are parents. It would let parents continue in their profession, and be parents, rather than making it a choice between one or the other. As tax payers, we spend so much money to train doctors to be experts, but then we lose so many GPs in their late 30s – they leave the profession. That’s a terrible waste to the individual and a terrible waste to the economy.’
COVID’s new pressures The BMA has set up an implementation group for the medical gender pay gap report and its first meeting will be held soon. Childcare will very much be on the agenda, says Dr McKeown. ‘What’s important is that we’ve got doctors from all branches of the profession, and I want to have some input from dads as well, because this isn’t just a mums’ issue or a woman’s issue; it’s important for everyone.’ According to the Mend the Gap report, some employers have taken the step of employing a care coordinator to assist staff with caring responsibilities for children and, in some cases, for older relatives. While these posts are far from universal, and their impact can be variable, they have been a huge boon for some doctors. Myra Herbert is a paediatric emergency medicine consultant at Sunderland Royal Hospital, part of South Tyneside and Sunderland NHS Foundation Trust. She is also a single mother to a five-year-old. She confesses
that until she had a child herself, she hadn’t particularly thought about the need for a care coordinator – but since then, she has found her services invaluable, particularly during the pandemic. ‘I had seen the coordinator’s name on trust emails, but I didn’t really pay much attention until I was on maternity leave. I had been naïve – I had assumed that all hospitals had nurseries attached to the premises – but it was only when I looked into it that I realised that wasn’t the case. I contacted the coordinator and she was really helpful, sending me details of nurseries, and also giving me information about childcare vouchers and other advice too.’ This support came into its own when COVID hit, bringing with it pressures on health services and changes to the availability of childcare. ‘My childcare arrangement was all working very well until lockdown,’ explains Dr Herbert. ‘That was a very emotional time. At first the Government said that nobody could look after your children, I couldn’t have a friend in the house – so what was I to do?’
Working ‘crazy hours’ Dr Herbert was fortunate in that her mother, who usually lives in London, was staying with her at the start of lockdown and didn’t go home – meaning there was someone at home with her son overnight to cover on-call. But additional childcare was needed to cover the evenings when Dr Herbert was at work. ‘The nursery was open so the daytime was no problem. I was also able to coordinate with a colleague who needed time off during the day for home-schooling, so she did my late shifts and I took on a lot of daytime hours, then returned to hospital after my son was in bed –
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which was OK, as Grandma was in the house. But I was working crazy hours, and was really struggling with the whole thing.’ She called the care coordinator ‘in despair’, she says, because she simply couldn’t put in the required time at work with the childcare she had in place. At that point, the trust had said it would cover the cost of extra childcare for staff and the coordinator managed to arrange for home care for her son from workers he was already familiar with from his nurseries. ‘I spoke to the coordinator when I was really struggling and she said, “hang on, let me make a few calls”,’ says Dr Herbert. ‘When she said that some of the nursery staff were happy to come and babysit, I just cried. It really, really helped me at that time.’
Flexible working The availability of a care coordinator is something that her employer mentions upfront when advertising job vacancies, and it has proved popular, says Kath Griffin, the trust’s director of human resources and organisational development. ‘As an employer, we know the pressure that staff can be put under when they suddenly lose childcare or unexpectedly become a carer for a loved one,’ she says. ‘Our care coordinator bma.org.uk/thedoctor
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can support staff by helping them to identify alternative childcare, as well as helping carers to access additional levels of support like flexible working and in some cases, additional time off. ‘Our staff are the most important part of our organisation and we know that juggling work commitments with caring responsibilities can be stressful and demanding. That’s why it’s so important that we make sure these members of staff are supported.’ Despite the availability of this support, however, Dr Herbert believes that she might well have changed tack in her career in paediatric emergency medicine had she become a parent before she was a consultant. ‘I love my job, but if I’d had my child earlier in my career, when I was a junior doctor or middle grade, I probably would have changed course a bit, if the truth be told. I might have looked at general paediatrics because it would have been easier for childcare – they do on-call, but it’s from home. Obviously, you still have to have someone in the house because you might be called in, but I would be able to be at home with my child rather than on-site all the time. ‘I’m very lucky – I have a job that I love, which is a blessing that not everybody has. But I’m a mum as well, and it’s important to get that balance.’
‘I want input from dads as well, because this isn’t just a mums’ issue’
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Down with the wall?
Barriers are set to be broken between primary and secondary care, and an end is promised to the waste and fragmentation caused by competitive tendering. But there is much the Government needs to do if its new blueprint is to succeed – especially with the threat of the private sector still looming. Peter Blackburn reports
‘T
here’s a long way to go but I think this is a better starting point than some of the others.’ Birmingham GP Gavin Ralston has – like so many colleagues across the profession – seen NHS reshuffles and reforms too numerous to count. Whether it is primary care trusts, strategic health authorities, or CCGs (clinical commissioning groups), the health service has
been expecting and preparing for reforms, going through the uncertainty and confusion of sweeping change, or getting used to new systems and structures for what seems like much of the last three decades. But there is always hope that the next reorganisation might be the one that sticks – the one that is given the time to solve the issues that obstruct doctors daily and get in the way of integrated
‘Nobody has been able to break the siloes because everyone is protective of resources’
patient pathways. Dr Ralston, chair of Birmingham local medical committee, says: ‘It’s an awful lot of work away, but it is that starting point. The purchaserprovider split was always difficult, CCGs didn’t always have power to influence things and the system became very bureaucratic and difficult. Hopefully this is a better ethos and might be more likely to be successful.’
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At the heart of these latest proposals for NHS reform in England are the removal of competition from the NHS – and the accompanying wasted time and resource managing the internal market – and a mandated move toward integration and collaboration. Ultimately, the white paper seems to be a final acceptance that the 2012 Health and Social Care Act was not, and is not, fit for purpose. These are moves that many doctors will welcome.
Pooling resources Doncaster GP and LMC chief executive Dean Eggitt says: ‘We are siloed and nobody has been able to break those siloes because everyone is protective of pots and resources. No matter what system we have had everyone has been protective and that means patient pathways haven’t changed. The white paper gives us a genuine opportunity to do that – to force us to come together to ease the patient pathway. We pool resources for the good of patients.’ BMA consultants committee chair Rob Harwood is hoping for ‘early wins’ from these processes – and identifies improved interoperability between general practice and secondary care as priorities, hoping to see consultants being able to order investigations and drugs from inside the hospital to be delivered outside the hospital, without arguments about who pays the bill. The Government’s proposals include establishing ICSs (integrated care systems) bma.org.uk/thedoctor
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in statute and transferring the commissioning duties of CCGs to them. The proposals require an ICS board and an ICS health and care partnership board to be set up and enable the setting up of joint committees between NHS bodies and providers. The white paper proposes to repeal section 75 of the Health and Social Care Act 2012, which means NHS commissioners will no longer be compelled to put services out to competitive tender and places a new ‘duty to collaborate’ on all NHS bodies. It is a project that Greater Manchester’s health and social care partnership primary care lead Tracey Vell describes to The Doctor as ‘radically permissive’.
Private threat persists BMA council chair Chaand Nagpaul, who has long campaigned for the repeal of the 2012 act, supports the white paper’s proposal to end the waste and fragmentation in the NHS caused from being forced to put contracts out to competitive tender and the NHS even being sued in some instances when it attempted to keep services in-house. However, he remains concerned that this could also result in contracts placed with the private sector without scrutiny, saying: ‘We want the existing arrangements to be replaced with a coordinated system where the NHS becomes the preferred provider. We want the NHS to be a state-owned, staterun health service and our concerns are that the white paper, while it addresses our wish to end competitive tendering, leaves open the
RALSTON: ‘The system became very bureaucratic and difficult’
‘We want the NHS to be a stateowned, state-run health service’
door for direct procurement from the independent or private sector without regard to the need for the NHS to be supported and funded properly and which could be undermined.’ There are other outstanding worries, too. Foundation trusts have ‘insular’ institutional powers – and the BMA has lobbied NHS England to alter their financial responsibilities to allow for a genuinely and legally collaborative approach across each system. The GP contractor model still needs protecting, particularly if doctors are to be recruited and retained. There are also outstanding concerns about the lack of focus on social care, the fortunes of which cannot be extricated from those of the health service. And, above all else, as is often the case following a decade of austerity, funding could well undermine these plans – particularly with a mountainous backlog of work after the COVID-19 pandemic. The role of the private sector also remains a significant concern. Dr Harwood says: ‘The biggest threat to hospital secondary care would have to be around external providers. I fear we will not budget enough overall, will buy in additional capacity and then won’t have enough to invest thedoctor | May 2021 17
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in the capacity we need in secondary care overall. We then may have wasted the funding we could have used to develop long-term solutions.’
Uneven change Away from the immediate concerns – what is the picture, and the view from doctors, around the country? Some areas will be ahead of others in this process. Research by The Doctor reveals differences in how STP (sustainability and transformation partnership) or ICS process have been carried out across the country. In some areas, such as Greater Manchester, Sussex, Norfolk and Bristol, North Somerset and South Gloucestershire, programme delivery teams with up to 139 staff roles, have been created to drive the process so far. And in other areas the work on this integration process, which has been ongoing since STPs were first announced in 2015, no jobs have been created and staff from existing organisations have taken on responsibilities for drawing up plans and creating new structures and pathways. The research also found that some parts of the country – including Sussex, South Yorkshire and Bassetlaw, Somerset and Norfolk and Waveney, had spent millions of pounds on private consultancy firms – seemingly in a race to position themselves as the most ‘integration-ready’ local health systems. Dr Eggitt – who works in the South Yorkshire and Bassetlaw footprint – says: ‘I know the approach is… first to the post wins. There has been
EGGITT: A chance to ease patient pathways
a race and a rush to establish the ICS and to establish it as successful. I think the spend on consultancy is a speculative spend to try and win that race. The knowledge is if you win that race you will be invested in.’
Care variation Some areas have been building these relationships for years and have had a head start as a result. Retired GP Jane Lothian – medical secretary for Northumberland LMC – says: ‘Our local trust is headed by Sir Jim Mackey (former head of NHS Improvement) and for at least 20 years they have had an active policy of involving primary care. There are lots of joint forums where we all meet professionally and politically and we also work closely with our CCG as well.’ Aside from other questions about use of precious resource, the research raises questions about the variation in working environments and systems around the country for doctors – and potential postcode lotteries for patients
‘The biggest threat to hospital secondary care would have to be around external providers’
if areas are less well developed than others. Also included in the proposals are the formal merger of NHS England and NHS Improvement, increasing the health secretary’s abilities to direct NHS England and NHS Improvement, intervene in reconfiguration disputes and amend or abolish arm’s length bodies. The health secretary will also be required to publish a report each Parliament on workforce planning. And the reforms include the establishment of the Health Service Safety Investigations Body in statute, which will be tasked with encouraging the spread of a ‘culture of learning’ in the NHS and raise the possibility of the extension of professional regulation to NHS managers and senior leaders. Dr Nagpaul says: ‘There needs to be a balance. The BMA has always felt the secretary of state should be accountable for the NHS – to ensure it provides comprehensive, equitable services with the resources it
HARWOOD: ‘I fear we will not budget enough overall’
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needs for safe and high-quality care. However, what we do not approve of is politically motivated policies and we believe that the interests of the patients need to be protected from political whim.’ Arguably the most important point of all is that if these reforms are to be successful, clinical engagement, consultation and involvement will be crucial. There is a long way to go, with some doctors being given ad hoc roles without the necessary time or resources to carry out the work.
Representation fears In addition, Dr Nagpaul says it is vital LMCs, local negotiating committees and public health are properly represented on ICSs, so they do not become talking shops, remote from local realities. Greater Manchester’s health and social care partnership – already years down the slow road to integration – might provide something of a blueprint for clinical engagement, at least as far as GPs are concerned. Dr Vell tells The Doctor she is part of a primary care board and a general practice board which feed into the ICS’s top level of leadership – and voices with clinical expertise as well as professional and management expertise are heard through forums with representatives from primary care. In Liverpool, LMC secretary Rob Barnett says he has been met with a ‘shrug of the shoulders’ from ICS leaders when he has asked about what new structures will look like, but that current models for primary care representation bma.org.uk/thedoctor
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‘One of the things CCGs did deliver in many areas was a strengthening of GP leadership’ are likely to mean one person has to be a voice for GPs, practice staff, nurses, pharmacists and optometrists among others. Without adequate representation, he questions how it will work. In other areas the profession is split. Dr Eggitt says grassroots GPs feel there has been a ‘severe lack of engagement’ to date and many feel ‘alienated’, but that doctors who have worked with the new structures feel otherwise. He says ICSs should look to create forums which can capture the views of GPs who aren’t familiar faces in leadership positions or are newer to the profession.
Clinical leadership BMA GPs committee chair Richard Vautrey says clinical engagement – including that of LMCs – is of paramount importance and that as much work as possible should VAUTREY: ‘We need to ensure GPs and practice staff in local areas are empowered’
be done at a local level, with the ICS remaining for strategic decisions. He says: ‘The main concern is about clinical leadership both at a regional level at the ICS and probably more importantly at a local level at what people might term an integrated care provider. ‘One of the things CCGs did deliver in many areas was a strengthening of GP leadership and involvement in the commissioning process. We need to ensure GPs and practice staff in local areas are empowered to take leadership roles working with colleagues in their local place to ensure decisions are made with them so they have a real input into patient pathways.’ Dr Vell advises ensuring clinical engagement in areas with more ‘immature’ relationships and systems: ‘The white paper is allowing a voice for GP and a voice for secondary care – doctors need to know that and to engineer their space. If they don’t have relationships now they need to get into those doors. Get trusted leaders through the door.’ The proposals put forward broad philosophies without the detail to explain how they become reality. This is a welcome direction of travel – a commitment to the sort of integration and collaboration that could solve so many of the problems faced by doctors in their daily work. But, as things stand, the potentially undermining factors are many. The talk is positive and full of questions with some genuine concerns. But the reality is talk is cheap – there is much more work to do. thedoctor | May 2021 19
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ANDREW BAINBRIDGE
How the cards will fall A shake-up of public health in England during a pandemic was always going to be disruptive, but it is now essential the opportunity is taken to combat long-term health inequalities and years of underfunding for the specialty. Peter Blackburn reports 20 thedoctor | May 2021
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ANDREW BAINBRIDGE MATT SAYWELL
JARVIS: ‘It takes around three years for any new organisations to settle down’
‘I
think you have all the right questions – but I am Serious disruption afraid I don’t have the answers.’ Some of the broad concerns are quite clear given the Speaking to The Doctor, a senior national timeline and the context. BMA public health medicine public health leader – identity protected to allow committee co-chair Richard Jarvis says: ‘We are still in a freedom to speak – is a little lost for words when it pandemic. We hope it is coming to an end but fear there comes to the big questions: what opportunities or may be another wave in August and September, just as concerns might new public health structures bring? the new organisations will be trying to set themselves up. Is a focus on public health and health inequalities There is a danger that we create something that is useful owing to the pandemic likely to be supported with in pandemics just as we are coming out of this one but proper resources and political will from ministers? we fail to create something which is useful in dealing What can be done to safeguard an exhausted with other aspects of public health.’ workforce, tired of reorganisations and likely to lose The North West consultant in public health adds: precious staff through early retirement? ‘In public health we tend to have a reorganisation in It comes as Public Health England is being England every five to 10 years and this one is pretty disbanded and replaced with two new organisations – much bang on time. In some ways that can be good as the UK Health Security Agency and the Department of it presents opportunities to do things better but each Health and Social Care, Office for Health Promotion. time there is a reorganisation it disrupts the working of It has been a controversial process. Public health the public health system as a whole and it takes around staff have seen many reorganisations, notably in three years for any new organisations to settle down, 2012/13 which resulted in fragmentation of the mature and get to work.’ profession and services, cuts Dr Jarvis’s message to funding and decreased ‘Each time there is a reorganisation is simple: ‘We don’t give professional autonomy and reorganisations long enough it disrupts the working of the freedom to speak up. And the to settle down, it causes huge public health system’ midst of a pandemic seems, disruption and expense each to many, like a particularly odd time to be putting new time it happens and we never seem to learn from the systems and structures in place. perceived failings and strengths of the old system and At the time of writing, most PHE staff have not build those lessons into the new ones.’ been made aware what their new roles will be and It may not be totally welcome, but a reorganisation is where we are. So where are things likely to go from here? where these will sit in new structures, what their terms and conditions will be and for most, there has been Uncertainty is the overriding feeling for many, but the precious little, if any engagement or consultation. The senior source within PHE made it clear this is not owing to any lack of effort from senior leaders. Government timeline suggests the ‘future destination of all services and functions’ should be decided during ‘Everyone is working very hard to design the new the spring, a ‘formal staff consultation’ and ‘ongoing arrangements and to capitalise on the current focus design work’ for both new organisations will take place on public health, health inequalities and prevention,’ during the summer. It says staff transfers will follow they say. ‘It’s very early days for any new arrangements, most and both new bodies should be fully operational in the autumn of this year. of these have not come into being yet.’ bma.org.uk/thedoctor
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GETTY
The source outlines one particularly important area of priority: ‘I am especially keen that we think about how to secure the public health workforce we need for the future, as everything else will depend on doing that successfully. ‘Quite a few senior staff are planning to retire this year, or have already done so, which is always a challenge with major organisational transition events like these.’
the lessons of the pandemic are to be learned, including ensuring there is no further fragmentation of services, that there is vertical and horizontal integration between public health functions, as well as with the NHS and other agencies and that staff can operate across the public health system. Chief among the concerns will be that the focus and spotlight on public health and inequalities, as a result of the pandemic and the disproportionate effect Learning from past mistakes on people from more deprived geographical areas The coming days and weeks feel like very significant and socio-economic circumstances and from some ethnic minority backgrounds, is followed up by genuine moments for a profession which has felt systematically political will for levelling up to be more than just a slogan overstretched and undervalued for some time. – and for that commitment to be followed by proper The early signs seem quite mixed. On the one resources and priority. hand many doctors have Dr Toff says: ‘It’s really reacted positively to both ‘It’s really important we seize important we seize this organisations being given this moment of opportunity to do moment of opportunity to do clinical leaders – former something about inequalities’ something about inequalities. deputy chief medical officer The establishment of a cross-government committee to Jenny Harries is chief executive of the UKHSA and address these issues is very welcome. You need to impact chief medical officer for England Chris Whitty will lead the Office for Health Promotion. However, concerns the wider determinants of health – putting health in all policies – and properly resource local public health and have been raised about the terminology used in both organisation titles – and what that terminology might say local government to do this effectively. ‘These are problems which already existed and about future directions of travel. have been highlighted during the last year – most starkly ‘Health promotion’ is a term which has not been through worse illness and more deaths from COVID but used widely for some time in public health and there crucially from people’s different ability to self-isolate and is a feeling it ignores the reality that many of the most significant drivers of people’s health outcomes are not in disproportionate loss of income and homes.’ their own life choices but owing to the circumstances in She adds: ‘On the workforce side, the pandemic which they live. has demonstrated the importance of maintaining and For BMA public health medicine committee properly funding full capacity of public health services co-chairs Dr Jarvis and Penelope Toff there are a range of across all areas. priorities if mistakes from previous reorganisations and ‘It’s also shown us at every level how important it is to 22 thedoctor | May 2021
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address those health inequalities – it has shown us how much people have suffered because of the disparities with which we went into the pandemic and how those have worsened since.’
A national necessity
terms of employment and resulting siloing of expertise, in barriers to essential data-sharing and people’s ability to collaborate for the benefit of the population.’
Engagement fears
It is concerning those close to the corridors of power, It is an important moment of opportunity that too. The source within PHE says: ‘We have to avoid organisations and experts across the system can see. fragmentation of the public health workforce if at all A statement from the Association of Directors possible because public health remains by its nature a of Public Health said: ‘This is a crucial opportunity cross cutting function, whatever the role of individual to build and properly resource a new public health bodies and organisations.’ system which is able to drive forward the lessons from Staff consultation and engagement on the shape COVID-19, by tackling health inequalities.’ and direction of the plans has been minimal thus far. And Jo Bibby, director of health at the Health A genuine period of engagement and consultation is Foundation, adds: ‘A strong not only the right and proper public health system isn’t a ‘This is a crucial opportunity to build process to follow but also a requirement for the new luxury – beyond the obvious and properly resource a new public benefit to the individual, organisations to be designed health system’ good health brings with it in such a way that they can huge economic and social benefits that are vital to the make best use of existing expertise and have a positive country’s prosperity. effect on the population’s health. ‘The Government has pledged to increase healthy On top of that, proper conversations around life expectancy and narrow the gap between the richest establishing standard NHS-equivalent contracts for and poorest, but it has a mountain to climb to reverse staff, regardless of employer, are required, as well as the current trends.’ other measures to ensure their ability to move around The potential for further fragmentation of services the system and the UK. will also be a concern. Public health system reforms and It is also vital that health improvement and healthcare public health functions, as well as health budget cuts had already left many staff in public health feeling isolated – and during the pandemic, these protection, are given appropriate care and thought problems were crystallised, as local directors of public during this process. health spent months denied full access to test and Resources will be important. Prior to the pandemic, trace data about their own populations, which was key the budget for public health services sat at around to responding effectively to the pandemic. £400m and in 2020/21, the public health grant to Dr Toff says: ‘After the last reorganisation we ended local authorities has been cut by 24 per cent relative up with fragmentation of the public health system to 2015/16. between those working in different functions of the The COVID-19 crisis has shown the folly of cuts to specialty and also in terms of its connections to the public health budgets and the damage of repeated NHS and other agencies. reorganisations. As Dr Jarvis says, this time round the ‘That was reflected in inconsistencies in workforce lessons of the past must be learned. bma.org.uk/thedoctor
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GETTY IMAGES
‘I experienced complete isolation in my cubicle’
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Kept APART A harsh consequence of COVID has been the restriction on visiting, separating patients from loved ones. Two doctors tell Tim Tonkin about their own hospital stays and ask whether the balance between safety and compassion is right
O
ne of the cruellest symptoms of the pandemic has been the physical separation and isolation of those infected by the virus from their family and friends, the very people whose love and support is most needed during times of ill health. However strong the infection-control arguments are, there is increasing concern about the blanket nature with which many of these restrictions have been applied and how, in some cases, hospitals have failed to take into account the important role access has for patients’ wellbeing, and to doctors’ ability to provide care. The BMA patient liaison group is deeply supportive of the need to uphold infectioncontrol measures. It has, however, voiced concern that the restrictive COVID policies have ‘resulted in a number of family-care givers and long-standing carers, partners in maternity settings, and parents of babies in neonatal units being excluded’. The group is calling for an end to this blanket approach and is urging trusts to view the rights and needs of these discrete groups as distinct from general visitor policy, and for more data on the effect of these policies to be uncovered.
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Separation anxiety
Despite his wife’s It is a position shared by dependence on him as her professor emeritus of husband and carer, with a child health and former lasting power of attorney BMA president Sir Al to speak for her needs the Aynsley-Green, whose own consultant leading her care experiences as a patient and explained that, owing to carer during the pandemic infection control measures, have led him to speak out it was his trust’s policy for on the issue. patients to be separated from Sir Al, who is the full-time family before admission to carer of his disabled wife, was hospital for treatment. unexpectedly hospitalised ‘He told me in our very first with COVID in March last year conversation that the trust after collapsing at his home, policy in his hospital was that AYNSLEYthe severity of his symptoms meaning his patients would be left at the entrance to the family was told that he might not return home. GREEN: Unable hospital to be taken into ward and subjected to see family He remained on the COVID isolation ward for to surgery unsupported by their carers,’ Sir Al even online almost a week. says. During this time, he says he received ‘He [the consultant] proved to be entirely excellent and compassionate care from all the empathetic and understood my outrage doctors and healthcare staff he encountered [at] being told that I would have to leave my while they gallantly reconfigured their wards incredibly vulnerable and entirely dependent to cope with the pandemic. wife at the entrance to the hospital.’ ‘I saw at first-hand what it was like to be a Encouraging presence patient seriously ill with COVID. He says the consultant and the patient liaison ‘I experienced complete isolation in my nurse understood his concerns and promised cubicle with nurses wearing full PPE [personal to do everything they could to enable Sir Al to protective equipment] and my not being able to see or communicate with my family. be admitted with his wife. After isolating themselves for two I couldn’t even see them on an iPhone weeks ahead of his wife’s surgery date and because my cubicle didn’t have internet undergoing testing for COVID-19, Sir Al was connectivity.’ ultimately allowed, exceptionally he was During his stay in hospital, Sir Al’s wife, told, to accompany his who has a severe cognitive wife, despite not knowing disability with an expressive ‘It seems like this section of whether he would actually aphasia, was not able to be permitted to do so until communicate with her medical care has been neglected’ arriving at the ward on the husband or understand day of the surgery. why he had suddenly been Wearing PPE, his presence with his wife removed from their home, something Sir proved to be of great help to the ward in Al says led to her developing an intense keeping her calm, encouraging post-op separation anxiety. drinking and allowing her home earlier Sir Al fortunately made a full recovery, but than otherwise. in the weeks following his discharge his wife’s The separation of patients from their health deteriorated, requiring investigations carers is not the only example of the reductive under anaesthesia and ultimately being told nature of some trusts’ blanket policies on that she would have to undergo major surgery restricting access. for cancer. 26 thedoctor | May 2021
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PATEL: My antenatal and midwifery appointments were all on my own
During the course of last year, many pregnant women found themselves having to attend scans and hospital appointments alone, and in some cases give birth without their partners, owing to infection-control policies limiting access. It is an issue which BMA representative body deputy chair Latifa Patel, who herself gave birth during lockdown, feels has huge implications for the welfare of parents and babies and yet has not received adequate attention during the pandemic. When Dr Patel was first admitted to hospital while in labour, her husband was not allowed to come with her to the assessment unit. ‘It was only after the assessment and decision that I would be admitted had been made that my husband was allowed to enter the ward and join me. It ‘I can understand why these seems like this section they need to be evidenceof medical care has been based. We’re over a year into risk assessments were made, neglected and no real the pandemic now so we but I also feel you need to thought has been put into it.’ really need to consider how strike a balance’ While Dr Patel’s husband these risks are managed was ultimately able to attend the birth of their and what is important and how we balance daughter, she remains acutely aware that this the mental, physical and emotional needs has not been the experience of all families of parents and children, and also a balance during COVID-19. between ensuring we don’t spread the virus. She adds that for any ‘That joined up thinking just didn’t happen 24-hour period partners were only allowed to [in 2020] it was just easier to say “stop at the visit for a pre-booked two-hour slot. door, you’re not allowed any further”.’ ‘Despite the guidance from NHS England An emotional bridge the hospital’s local policy remained that no Leading a team of staff during the height one was allowed to accompany pregnant of the pandemic, consultant geriatrician women for any of their appointments. Cerys Morgan has experienced first-hand the ‘We were fortunate in that we had an challenges presented by restricted access uncomplicated pregnancy and did not receive to patients. any bad news at my appointments but had Based at St Mary’s Hospital in London, she there been it would have been quite a lonely says the absence of family members visiting place to be.’ and supporting patients was not something Dr Patel believes that rather than leaving she was used to, adding that PPE and infection decisions on access up to the discretion of control measures had affected her preferred individual trusts, a national policy should be face-to-face style of communication. implemented in the NHS. With her trust benefiting from a donation ‘As a doctor, I can understand why these of iPads from a charity, she and her colleagues risk assessments were made, but I also feel were able to use these to good effect in you need to strike a balance,’ she explains. helping patients and families communicate, ‘Risk assessments need to be reviewed and bma.org.uk/thedoctor
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but such technological Value carers solutions had limitations, As the vaccine roll-out across particularly for older the UK continues, Dr Morgan people affected by hearing or says she hopes greater levels sight loss. of immunisation within the She adds that being the population will encourage bridge between separated trusts to consider relaxation families and patients is of their regulations around also a hard thing for staff to access to patients. bear mentally. Dr Morgan adds that her ‘From an emotional point trust now allows all patients of view, seeing someone die to receive one visitor for an without their family present hour a day, while the passport and having to give all that system for carers remained information over the phone in place. has had a huge impact on people,’ she says. She accepts, however, that there MORGAN: Better to have an NHS‘As a geriatrician we try to really encourage will continue to be an emphasis on wide policy for families to come in, particularly patients protecting patients and staff from carer visits with dementia. Right at the beginning of potential infection, and that balancing the pandemic there were times when I was access with health and safety will continue having to tell family members who really to challenge hospitals and other services wanted to come in that, unfortunately, the such as care homes. public health guidance at the time would For his part, Sir Al says he fully understands not allow that to happen, even though for the need to minimise risk of infection to staff that patient it would have been a better thing and patients and agrees that non-essential for them.’ visitation should be restricted. Carers, he Fortunately, Dr Morgan says that her trust, argues, are not ‘visitors’ and should be Imperial College Healthcare, amended its seen to be valued members of the team supporting the patient. policies at an early stage to allow those who He rejects utterly what he were carers to patients access to them in hospital. labels as the ‘one-size-fits‘It’s time for an open, ‘Right at the beginning of all’ policy still being applied today not only to carers but the pandemic the policies honest debate’ were very strict as to who also to pregnant people being could come in and out of the given devastating news of hospital. I think that my trust was one of the fetal abnormality unsupported, giving birth first to introduce carers’ passports,’ she says. separated from partners, and even parents of seriously ill new-born babies denied access to ‘Our dementia specialist team is a brilliant advocate for our patients in my trust and they their sick babies. very quickly turned it around so that if there This, he says, is ‘unspeakable cruelty’, denying the basic principles of compassion, was someone who was a main carer, they should be allowed to come in. flexibility and the best interests and human ‘I have heard that other places have rights of patients. had quite strict policies, but I do think that ‘I’m really concerned that what we have witnessed as a result of COVID will become people are now becoming a bit more lenient and that things are changing quite quickly. It embedded because of future policies, not would have been better, I think, for there to least because COVID is not going to go away. have been one policy across the whole of ‘It is time for an open, honest debate and the NHS.’ for doctors and nurses to speak out.’ 28 thedoctor | May 2021
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on the ground Highlighting practical help given to BMA members in difficulty
The BMA won back £300,000 for doctors who were denied pay for annual leave, in a case that raises questions about when people are truly self-employed
T
he BMA won thousands of pounds in back pay for GPs after spotting they had not been paid for annual leave. The case, which goes to the heart of when doctors are self-employed or have legal rights as ‘workers’, came to light when there was a change in the provider of OOH (out-of-hours) services, from an NHS community trust to a social enterprise. The trust had expected the GPs to transfer under TUPE legislation with the same conditions under the social enterprise, and it had talked about making them employees to ensure this, but had not progressed the work, and the transfer did not place. However, while in contact with the GPs, the BMA staff member came to a discovery which was to have considerable financial implications. One of the sessional GPs had not been able to provide many sessions last year because she had contracted COVID-19. She sought advice as to whether she would be entitled to any COVID-related pay, and the issue of annual leave payments arose. The BMA staff member checked her payslip and established there had been no annual leave provision. She raised it with the trust, assuming – correctly – that if one GP had not received it, then the others would not have done either. She needed persistence but is not the type to give up easily. And this was a trust which could have saved itself trouble by giving proper contracts to all GPs who worked for it and making a transfer possible to the new provider. The key here was whether the GPs were self-employed contractors, or whether they were ‘workers’, in a legal sense. It is an area of law where there are still grey areas. Hundreds of thousands of people have been deemed to be self-employed, but as a convenient fiction where they lacked most rights and benefits. Now, the self-employed have to meet a
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number of definitions, such as whether they can hire someone else to do the work, are in business and can make a loss or profit, and work to a fixed price no matter how long the job takes to finish. Following these definitions, it is clear these doctors were ‘workers’ rather than contractors. For some who relish the freedom of being self-employed, this has been a headache. But for many, it has meant being given the rights that others take for granted – statutory rest breaks, protection against discrimination, and a maximum working week or the ability to opt out if they choose. Without wishing to throw in too many definitions, there is a third category – employee – into which most NHS hospital doctors would fit. They have the same rights as ‘workers’, but have additional benefits such as sick pay, and maternity, paternity, adoption and shared parental leave and pay (workers only get the pay, not the leave), as well as protection against unfair dismissal. Having been wrongly denied annual leave, the GPs were compensated for it – up to six years for those who had contracts, for those who lacked them, two years, as the statutory limitations are different. In total about £300,000 was won back. It’s highly likely that there are other OOH GPs, and doctors in different circumstances, who are missing out on pay and benefits because they are being wrongly regarded as self-employed, and for those without contracts it can be harder still to get clarity. But expert advice is always at hand for members. BMA members seeking employment advice can call 0300 123 1233, email support@bma.org.uk or talk to an adviser online via the BMA website thedoctor | May 2021 29
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it happened to me Doctors’ experiences in their working lives
COMMON CAUSE: Radhamanohar Macherla in 1974 (left), his son Vamshi (centre) and with his wife Hema
Like father, like son ‘Please ring me when you can. Hope you are OK.’ Worried, my wife Hema texted our son Vamshi as we hadn’t heard from him for some time. It gave me a sense of déjà vu. It was 1974. A young doctor’s mother, and his wife, away visiting her parents, received telegrams. ‘I’m leaving for Bihar tomorrow; volunteered for smallpox programme.’ That 25-year-old doctor was I. Smallpox was wreaking havoc in India’s Bihar state. The World Health Organization had called for volunteer doctors to work in its daunting eradication programme. The urgency meant I had to leave the next day, a 1,500km journey. I was at the time carrying out postgraduate study in Hyderabad, 100km away from my parents and in-laws. The risks, including death from this highly contagious disease, were familiar to the public. My parents feared for my life. Newly married, my wife was worried and shocked that I was leaving the next day, giving her no time to discuss it. Telephones at that time were limited to only a very few privileged people in cities, and villages had none. Monsoon joined forces with smallpox and the floods devastated Bihar. Our team poised to continue with ‘case finding and containment’, entailing vaccination of residents of 40 houses around an index case within 48 hours. We had no protective gear. These tough hurdles caused me the least discomfort as I felt privileged to be a part of that great challenge. My family had a hard
time, however, grappling with the worries about my health and safety. News about smallpox and the flood-related deaths wasn’t helping their concerns. Forty-six years later I am now at the receiving end. But for my wife it is yet another emotional challenge, yet tougher this time. Our son is one among many doctors in a London hospital treating patients with COVID infection, the most devastating pandemic the current generation of health professionals has ever encountered. Hidden behind this fight are the stresses of the families of these healthcare staff. Initial personal protective equipment shortages and ever-increasing NHS staff deaths have made these families’ stress worse. It must be hard for the families with these vicissitudes – balancing their pride of being a supporter in this fight with worries about the risks their loved ones are taking. I am proud to have been a part, albeit a small part, of the WHO’s smallpox eradication programmes. It is our son’s turn now among many others to fight in this pandemic. ‘Mum I’m OK,’ Vamshi texted at 10pm. But was it a big relief for Hema? Next bit of text read: ‘Mum I must have had the COVID by now with these aches and pains. But don’t worry…’ Radhamanohar Macherla, now retired, was for more than 20 years a consultant physician with Barts Health NHS Trust
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Your BMA
@helenamckeown
@drlatifapatel
BMA representatives took your concerns about climate change, COVID and artificial intelligence to the world stage
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here has likely never been a time when it has been more important for doctors across the world to come together to share the problems we face and to look to each other for strength and solutions in the face of challenge and crisis. Last month we did exactly that at the World Medical Association’s annual meeting – held virtually rather than at the intended destination in Seoul, South Korea – and some of the most significant topics of the day were debated and discussed, from global cooperation in response to the COVID-19 pandemic to telemedicine, patient safety and medical regulation. BMA council chair Chaand Nagpaul and I represented our members at the meeting. It is not a new experience for us. At the 2019 meeting we took BMA policy to the global stage, leading on an emergency statement on the climate emergency which was supported unanimously at the general assembly. We called for the WMA and its constituent members to commit to advocate to protect the health of citizens across the globe in relation to climate change. This year, I had the pleasure of putting forward an amendment, seconded by the American Medical Association, which changed a paper proposing policy on artificial intelligence. Our addition meant the paper included a call for algorithms created to inform medical diagnoses and management to include a representative sample of data from women to ensure the gender inequality gap is not further amplified. It is an area I, and thousands of our members, are passionate about. Many of us will be familiar with some of the failings when it comes to fair representation in healthcare. For example, when you’re at medical school you often learn about disease symptoms that more predominantly feature among men such as the signs and symptoms of cardiac arrest. This sort of bias can pervade many areas of our working lives, just as it does in so many walks of life. As artificial intelligence has an increasing relationship with healthcare – and the rest of society – it is vital we ensure these algorithms are programmed with intersectional facts and not based on what my American colleagues aptly called ‘bad science’. BMA representative body chair Helena McKeown
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elena’s experiences at the World Medical Association highlights the importance of your role, as a member, in creating and influencing BMA policy. Being heard. Reflecting on my journey, I started medical school in 2005 and became a BMA member in freshers’ week (because it was free), but until 2010 I was a fairly silent member. I hadn’t been to any conferences, hadn’t engaged with the medical students committee and I didn’t really know much about BMA policies. That changed when I chose to study an intercalated degree, piquing my interest in academic medicine. I felt my medical school could have equipped me better for this option and that it disadvantaged students who couldn’t fund courses for themselves. I wanted to have my say and call for support for others who may be interested in academic medicine. I took a motion to the medical students conference that year, it went all the way through to the annual representative meeting and was adopted as BMA policy. Having understood my influence, I continued to submit motions to the medical students conference and then the junior doctors conference following graduation. It was empowering to see the things I experienced in my daily working life – things that I wanted to change and that I believed could be better – become policy which directed the work of the association. This process is so important – it’s a powerful opportunity each BMA member has to make a difference to our profession and our NHS. I hadn’t heard of the WMA until I became actively involved in the BMA, perhaps because we are the only UK association with a seat at its table. There are so many things that affect many of us, whether it is the state of your doctors’ mess or global issues such as climate change and the global response to the COVID-19 pandemic. Motions submitted by you as a member this year could go on to become policy taken on by medical associations across the world united, and your experiences can be heard and understood at a local, regional, national and international level. If you are reading this, I hope you can see from our experiences that your voice can make a big difference. If there is an issue you are facing or would like to influence, please take it to your local meeting or your BMA conference. BMA representative body deputy chair Latifa Patel thedoctor | May 2021 31
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