Friday, 27 November 2015

Top Junior Doctor Dr Halcrow did not die in vain; strike for a Fair Contract

Many of my colleagues and I have been deeply struck by the recent suicide of a NHS GP trainee Dr James Halcrow who was named the 'Top GP Trainee in the Country'. , only a year following the suicide of a NHS GP partner who had received a gold medal for the highest MRCGP exam result in his Deanery as a mature GP registrar.

Young Dr James Halcrow was a tired, overworked junior doctor and under duress from a GMC investigation with one interviewer asking him if he would drink socially? Since when should the GMC demand total abstinence of doctors? Why abstain from social drinking off duty and in one case asked a doctor for 4 years of total abstinence. He could not lie. He was too honest and could not meet this unreasonable GMC demand. Not even our criminal courts make this a condition.

He is remembered by all his doctor colleagues... 'Nov 2015 a post on the resilient GP facebook group from a GP.

"I knew James. I worked with him for 6 months during my GP rotation in medicine. The article is not exaggerating in any way. He was a fantastic doctor, and I was fortunate to consider him a friend. When I heard he went into GP training, I was pleased because he would have made a truly top GP.

I remember one time, we did a ward round and we were running late. He spent 40 mins with an elderly lady patient because something was bothering her and the nurses and the rest of us never got to the bottom of why. James managed to actually coax out that she had urge incontinence and had some accidents. He asked me for advice and I suggested some oxybutynin. The next day I arrived at work and James had already conducted his own follow up, pleased that the symptoms were better.

This was a particularly poignant reminder of what a dedicated, conscientious and responsible doctor he was.

I heard from a mutual friend who attended the coroner's inquest. Whilst no fingers were pointed directly, in my own heart I know full well the GMC had a lot to answer for. I am not only disgusted, but extremely sad that the system that sets out to regulate us can do so much harm.

sorry for the long post. I felt it was important to give an idea of just what kind of doctor we have lost."

A junior doctor colleague, "I worked with James. We rang him on the evening he was meant to be in at work after finishing his weekend nights and he didn't answer and we didn't think anything of it... Until we found out the sordid truth the next day: he had hung himself. The trust tried to be supportive but I have no doubt in my mind the rota and the job contributed to the stress he was facing. Coupled with ongoing GMC investigation and the pressure of a thankless and relatively unsupported job it must've really fed into his depression.

I only wish I had taken him seriously when he said he hated his job and cried himself to sleep at night instead of just saying "it will get better". It doesn't, it hasn't, and it will take more trainees raising concerns about that rota and job to make anything better."

Junior doctors need to strike for leverage to negotiate a fair and safe NHS contract for both doctors and patients. RIP Dr James Halcrow, you did not die in vain.

Anonymous GP Partner 03 Dec 2015 11:48am
"RIP James.
My thoughts and prayers with his family.
I was investigated by the GMC and It made me suicidal, the process dragged for 2 years only to be found not guilty. If It was not for my 1 year old son and my pregnant wife at that time, I would have killed myself.
I left the UK and not planning to come back again. Never felt happier and I am enjoying medicine again.
GMC shame on you
To all my colleagues in the UK :
Practice defensively
Retire early
Leave the UK
Change career
The status quo is not an option."

82% of GMC investigations of doctors result in no sanctions according to Professor Louis Appleby who was appointed by the GMC to review its procedures after the death of 28 doctors while under investigation last year and Pulse GP newspaper found that only one anonymous GMC complaint led to a doctor sanction in the past 2 years. The GMC needs to stop their "witch hunt" of doctors?

I cannot bear to see our finest doctors end their lives in utter despair. Here are my survival tips for junior doctors, and I hope this saves you and teaches you how to survive the NHS until a fair and safe contract is achieved for all.

1. Find a mentor, a supportive trainer, programme director, associate dean, or even dean, you may ask for advice.

In each programme, there are many personalities and you may find you gel with one more than the other. This is important if you run into conflicts at work with hospital managers trying to force you to work longer than the EWTD (European Working Time Directive). You can then confide in your mentor and they can have a quiet word and intervene discreetly to ensure both your safety and that of your patients. Remember you are a trainee doctor in an educational training programme. There is a duty to both educate and train you and for you to provide a safe service to patients. Tired doctors make mistakes.

Real-life scenarios:

A junior doctor confided in me that he tried to stick up for colleagues and raised concerns about managers scheduling a series of hospital shifts that breached the EWTD and he ended up allegedly being bullied by his trust. This creates an atmosphere of intense fear, and management may then exploit junior hospital doctors without any redress. Training programmes may deal with 'troublemakers' by never allowing them to complete training and may offer excuses such as we cannot find a GP training surgery for you ( leaving you unemployed for months) or we suggest transferring you to another area (which may be 100s of miles from where your family lives).

My advice would be to ask that a senior BMA industrial officer steps in, and if necessary meets with the hospital trustees to ensure EWTD is not breached and that junior doctors who raise concerns of patient safety from unfair working practices are not bullied, blacklisted or labelled as whistleblowers. Or you may need to pay for a private employment lawyer to fight your case.

A female mature junior doctor felt bullied at work and took time off sick. The trust allegedly accused her of breaching her contract when she took considerable time off for stress and she was allegedly referred to the GMC on lack of probity for contract breach.

My advice is to keep track of how many days you take off sick while training as if you take too many days off, you may not be able to obtain your CCT at the end of training or you may be asked to work extra weeks before you will be given your certificate of completion of training. It is no wonder some junior doctors may go in to work when ill because they may fear retribution for taking too much time out.

2. Consider part-time or flexible training.

If you are a working mother or father with children, you may wish to consider flexible training. In my time Professor Liz Paice was Dean of London Deanery and she ensured flexible junior doctors were protected and treated as supernumerary doctors, ie an extra pair of hands. Her background was Canadian medicine! This was vital to ensure flexible junior doctors were not abused or overworked when they were effectively part-timers. This meant that on call in hospital for me was often a mere 3-hour shift from 5 pm to 8 pm, and not a 12-hour shift that junior doctors are now scheduled to work. Bear in mind that parents are never 'off duty' when you come home and take over from the childminder, or pick up children from after school care. Ask your training programme if there is any possibility that you can train part-time.

Remember tired doctors are more likely to make mistakes and now NHS doctors may be charged with criminal involuntary manslaughter if they make a mistake at work and a patient dies as a result. If convicted, this may come with a jail sentence.

Real life case:

Lawyer Thomas said: "Is it symptomatic of your behaviour that day that you rushed to a decision without checking?" The junior doctor mother of 2 replied: "It's not that. It's a reflection of how long I had been working without a break." She had made a mistake into her 13th hour of work, was tired and now faces a jail sentence as the patient died.

3. Do not automatically accept a police caution.

If you drink socially, please be aware that a caution for drunk and disorderly in public or a drink driving conviction are GMC referrals. If a policeman suggests offering you a caution for say disturbing the peace, please consider refusing and instead fighting your case in court, as you may win and no GMC referral is then needed.

Real life scenario:

A doctor was allegedly asked to abstain from alcohol for 4 years by the GMC to have restrictions lifted. And inability to abstain from social drinking may have been the reason the GMC did not remove the restrictions on the junior doctor who hung himself. Until the GMC reforms its strict almost Draconian rules for NHS doctors, please take time out, seek help and counselling and return to work when well. Programmes like PHP based in London offers confidential counselling for doctors with depression, drink and/or drug problems and gives you a pseudonym for 100% confidentiality. I would not advise you voluntarily self refer yourself to the GMC unless it is mandatory, ie you have been convicted of a drink driving offence.

4. Do I become a grey person, blind, deaf and mute and walk on the other side to survive my NHS training?

A grey person is someone who keeps his or her head down, does not complain or raise concerns, and just gets on and does the job, ignoring all employment breaches, system failures and patient safety concerns. This is where it becomes difficult if you are a doctor with high moral fibre and cannot abide wrongdoing, especially if you witness harm to patients. You may be faced with Sophie's choice, your career or your ethics and morality to ensure patients come to no harm.

Junior doctor  and father of 2 young children, Dr Chris Day, chose to blow the whistle to protect patients when he raised concerns the hospital intensive care unit was routinely undermanned at night. As a result of his dispute with senior managers, he lost his training job, just short of becoming a consultant. Now he fights back to protect 54,000 junior doctors who need whistle-blowing protection to protect the lives of patients and NHS careers of junior doctors.

Not surprisingly, many top doctors are the ones who cannot keep quiet but speak out and are often labelled as whistleblowers or controversial, ie Professor Edwin Jesudason (Oxford graduate and paediatric heart surgeon), Dr Raj Mattu (consultant cardiologist), Dr Kim Holt (Great Ormond Street consultant paediatrician), Dr David Drew (consultant paediatrician), etc. Some of these noble consultants were sacked by their employing hospital trust and some put on garden leave instead of management tackling the root cause of potential risk and harm to patients.

What do you do if you are a mere junior doctor and your career and livelihood depend on you acquiring your CCT (certificate of completion of training). This is where your choice of training programme is vital. Talk to colleagues and ask for recommendations of where in the country they would or would not like to train. Do your due diligence. Some trusts are better funded and resourced than others which may be struggling to keep afloat. Trusts strapped for funding may be more likely to take short cuts, overwork junior doctors and may have more patient mortality and morbidity than neighbouring trusts with healthier books.

Please note training doctors do NOT have statutory whistle blowing protection so you may lose your training number and job if you raise concerns regarding patient safety in hospitals. 

5. "Voluntary" hours or shifts or "illegal" work which breaches the European Working Time Directive and puts tired doctors at high risk of making mistakes.

When you start as an F1 you may find yourself coerced into signing an EWTD opt-out form in order for NHS hospital managers to book you extra "voluntary" hours or even shifts without incurring a hospital financial penalty. Stop! Do not feel forced to sign but contact the BMA. You may end up as the only junior doctor who has protected his or her legal right and at the same time safeguarded yourself from committing a fatal patient mistake when exhausted and overworked.

Some hospital managers may routinely overbook clinics or fail to arrange cover for on calls. This means juniors may be forced to work extra hours beyond their finish time as "voluntary", under the duress of emotional blackmail or threat of GMC referral if they refuse. Managers call this "voluntary" so it does not need to be considered when looking at rota compliance or banding. Yet when a fatal mistake occurs in this 13th or 16th hour, the junior doctor may face double jeopardy, a GMC referral and suspension and a criminal charge of involuntary manslaughter. Know your rights! Learn how to say NO from the first day of your job and that starts by refusing to be coerced into signing an EWTD opt out form. EWTD is there to protect both doctors and patients alike.

If you feel you cannot say NO, then at least insist on internal locum rates or ask for time back. Do NOT work extra hours for NO pay. Bear in mind, under cross examination in a coroner's court investigating the death of a patient due to a tired doctor's mistake, you are expected to have delivered the same professional standards of clinical care whether it is your 1st or 13th hour of work even with no food or break and no HR personnel will stand by your side.

6. Alternative to spending years of training in what may be an oppressive bureaucratic atmosphere run by managers.

You may wish to continue training in Australia, New Zealand, Canada or America. Or you may wish to seek training in the private sector through old fashioned apprenticeships, ie learn on the job. GPs may be called a private GP after completing 2 years of foundation year training post medical school.

"I am currently working in NZ after completing my F2 in the UK last year and with working conditions as they are out here I can't comprehend what it would be like to work under the current proposals back home.

To put it in perspective I have attached the contract which all doctors in NZ are governed by after successful strike action a few years ago.

It's a wordy bastard but the key points relate to: basic pay being far higher than what it would be in the UK, leave which is the employer's responsibility to cover (at additional rates for those cross covering of $150 per day), free meals throughout the day, penalties of overworking up to $1000, agreed fair minimum locum rates, all exams/courses/membership fees paid in full, call back fees for non-resident on calls (minimum $400 per call back and $100 per phone call) and my favourite, section 15.4: 'During the meal break or rest breaks prescribed above, free tea, coffee, milk and sugar shall be supplied by the employing District Health Board'.

Surely the government cannot expect well-educated people to stay, given the opportunities that are easily available elsewhere?!

Keep fighting for the NHS and from all of your colleagues in NZ, we are 100% behind you."

Gone are the days NHS hospitals provided on site accommodation for doctors working through the night and weekends, provided hospital car parking permits for junior doctors, provided 24/7 access to hospital food, or a doctors' mess stocked with newspapers, tea, milk and toast. Now junior doctors may be scolded for putting 2 chairs together as makeshift beds if they dare close their eyes from fatigue at night while managers have on site beds. And now some managers may have created "voluntary" or illegal shifts for junior doctors to work beyond the EWTD to avoid financial penalty safeguards.

Update December 2015

The BMA conceded and suspended the junior doctors strikes.

Almost half of junior doctors left the NHS after foundation training. No leverage means junior doctors may continue to vote with their feet.

I hope this article helps to prevent a junior doctor suicide or junior doctor conviction for involuntary manslaughter for making a mistake when overworked and exhausted.

Update January 2016: Junior Doctor Strike is back on!

The BMA and up to 38,000 NHS junior doctors to strike on January 12, 2016 after talks mediated by ACAS with Jeremy Hunt failed to reach resolution on these 4 points. Good luck!

In the arms of the angel...

May your soul find eternal peace and rest, dearest Dr James Halcrow.

On January 12, 2016, tens of thousands of junior doctors formed picket lines across the country to strike for a fair and safe contract to protect the lives of all junior doctors and patients alike. Sadly one hospital called the police on their striking junior doctors and another Sandwell General Hospital attempted to block the strike with declaring a level 4 incident which was not upheld by the BMA.

A national junior doctors strike is a win:win as either it will achieve an actual victory with a fair and safe contract or a moral victory for trying.

Update February 2016: Junior doctors have no employment  rights if unfairly dismissed.

On February 10 as junior doctors go on strike a second time  across England,  a brave junior doctor Dr Chris Day is taking on Health Education  England in court.  He found a flaw in the junior doctor contract that gives junior doctors no employment rights,  if the training number  is removed,  due to unfair dismissal.  Simply put because NHS trusts issue one year contracts and not 2-5, ie for the length of training,  no unfair  dismissal claim can be made against a junior doctor's trust hospital. 

If the Deanery  removes your training number,  they too are untouchable as they do not exist  as a legal entity and argue they are not your employers,  that the trust hospitals are. They act as agencies, represented  by Health Education  England. In other  words  no one assumes responsibility.  

Please help Dr Chris Day with funding to fight  for the employment rights of 54000 doctors.

Update February 2016: Parliament has not closed the loop hole  that exempts  junior doctors from whistle blowing protection. An urgent Parliamentary amendment is needed! 

This means allegations of detriment suffered as a result of whistle blowing may not be heard in an Employment Tribunal because Parliament has unintentionally exempted junior doctors from whistle blowing protection and must be made aware so they can issue an amendment to extend the scope of whistle blowing protection to include training doctors.  An amendment has only been added for student nurses to date.

Why junior doctors won't stop striking. 

Junior doctor exam stress:

For junior doctors struggling with the MRCGP AKT exam, please read my e-book.