Sir,

The article on the aftermath of the Sellu case, which also made reference to the Bawa-Garba case, is a reminder that discrimination exists in the NHS. On paper, the cases of David Sellu and Hadiza Bawa-Garba both demonstrated worrying trends of system failures involving a chain of clinical staff. Ultimately it was two black doctors who were held responsible, both receiving grave sentencing.

It is a fact that complaints are greater against Black and Minority Ethnic (BME) doctors who are more likely than their white counterparts to end up before the GMC and face more punitive and guilty verdicts at their hands.

Reports on racism and discrimination in the NHS are not new. They are numerous and a serious cause for concern. In 2001, a report published by the health charity the King’s Fund stated that discrimination against ethnic minorities begins at medical school and ‘lasts till the day they retire from practice’. A BMA survey in 2003 revealed more than 80% of minority ethnic doctors believed that their ethnicity had a deleterious effect on their career advancement.

More recently in 2016, the first report from the NHS Workforce Race Equality Standard (WRES) showed that significant numbers of NHS staff from black or ethnic minority backgrounds still experience more discrimination and bullying in the workplace than their white colleagues and are more likely to report that they are experiencing discrimination at work from a manager, team leader or other colleague compared with white staff, regardless of trust type or geographical location.

Despite the diversity in the NHS workforce, BME members are grossly underrepresented in senior leadership and management roles as demonstrated in a 2014 national health executive report The ‘Snowy White Peaks’ of the NHS.

The NHS would come to a standstill without the contribution of its BME staff, including doctors, who constitute 40% of its 1.7 million workforce.

In both the Sellu and Bawa-Garba cases there were a catalogue of unfortunate errors/failings and system shortcomings that coalesced into the tragic deaths of two patients, and this is indeed regrettable. What is notable is that at the centre of both cases was a black doctor. Were there assumptions, prejudices, stereotypes and unconscious biases that played a role? From the hospital staff, the administrators, the families, the lawyers, the GMC, the jurists and everyone else who was involved?

These may be awkward questions for some, but the take-home message for BME doctors from these cases is clear; your education, your profession, your impeccable record and good standing will not protect you from discrimination. This bleak picture is not evoked to discourage the reader. It is a looking glass, a window of opportunity for us to truly see how we can make things better. It is what we are trained to do; to examine, diagnose and treat. I am hopeful for change.

Sala Abdalla

Registrar in General Surgery

Sir,

Reading the article relating to the Sellu case and that the costs of NHS negligence claims has quadrupled in the past ten years makes me wonder if clinicians have let this very important area slip from their control and the need to re-examine how we manage competence and good practice.

In my day, a face-to-face meeting between patient and clinician, arranged by the hospital secretary would often immediately straightened out what may be misunderstandings. Today would a small team of surgeons, senior nurses, patients and managers meeting monthly or as required supervise professional competence and regularly review treatment outcomes and complications. This process would be helped by clinicians being full time in NHS practice. It is now a very large organisation and about to get bigger making management almost impossible, surely time to think small which in my opinion is always best. One advantage of such a team would be for the patient an immediate answer to their questions not years after, which is now so often the case. Also would it not be the best way to secure quality outcomes and this would please both patients and clinicians. Further it would not involve either lawyers or politicians!

Reg Kingston OBE

Retired Surgeon

Sir,

We read with great interest the article regarding the appeal of pursuing a surgical career (What can surgeons do to increase the appeal of a surgical career? November 2017 Bulletin). We would like to highlight some different perspectives – namely, the views of myself as a junior trainee at the bottom of the surgical hierarchy and simultaneously those of my consultant, who has already achieved a successful surgical career.

For most people surgery is considered a rewarding and respected job, with consultant surgeons often pictured as being successful and wealthy. However, when compared with other specialties in medicine the road to a successful career in surgery is long and tough. During the past couple of years the interest in and applications for an ST3 job in surgical specialties has been declining and is likely to continue this trend in the coming years. There are plenty of reasons why a junior doctor is discouraged from a career in surgery.

First of all, it takes more than ten years after medical school to complete or reach a point of seniority in a surgical career.

Moreover, high workload, commitment, self-sacrifice – which are characteristics associated with and perhaps seen as necessary for surgeons – may prove off-putting to many doctors, who tend to prefer a more balanced lifestyle.

In addition to the length of training, high competition ratios are another disheartening factor. Competition ratios in the more popular deaneries are in excess of 5:1, which often results in candidates undergoing the application process several times to get an ST3 post.

Furthermore, junior doctors during their surgical rotation can feel less respected owing to the heavy workload, lack of time to communicate in a friendly atmosphere, consultants and trainees trying to catch up daily tasks both in ward rounds and theatres… It all leaves little or no time for good supportive interaction. Thus, poor experiences, along with bad interaction with seniors, could be detrimental and make potential surgical candidates feel inadequate and unfit for the job.

Some junior doctors and even surgeons at a consultant level have faced discrimination owing to their sex and race. It could be argued that this is one of the reasons why the field of surgery still remains heavily male-dominated, whereas the ratio of male to female students is evenly split at medical school.

But to what extent are these characteristics necessary? Do surgeons need to be dismissive, arrogant or have the typical type-A personality to succeed? Well, we believe that the context of our lives is changing as new models and new possibilities shape our work and our personalities.

An example of this would be for surgeons to become more supportive and more considerate of junior doctors by showing them that their work is appreciated, while at the same time teaching them to develop their skills.

Moreover, junior doctors should be released from the responsibilities of ward administration and ward jobs such as discharging patients, cannulating or taking bloods. There are already special practitioners and health assistants to perform these jobs. Especially when the emergency theatres are full of cases, junior doctors should be present to observe, assist, learn, practise and perform under supervision.

It should not be forgotten that consultant surgeons themselves work under enormous pressure with minimal or lack of junior support, meeting daily targets with minimal time in a strained NHS system due to lack of manpower and resources, subjected to constant monitoring by managers and the system. Hence, it is time for junior trainees also to understand the constant strain under which the NHS is operating.

To conclude, surgeons and consultants serve as mentors and role models and have an extremely important influence on students and young doctors’ desires to become surgeons themselves. Surgeons with an active family life should be present and junior doctors should embrace their example as proof that the coexistence of personal life and work is possible. Thus, if empowering and practical changes are implemented, we thoroughly believe it will be possible to inspire junior doctors to follow their dreams while maintaining a work–life balance that enables both their professional and personal goals.

Foteini Neamonitou

BST Clinical Fellow in Breast Surgery

Raghavan Vidya

Consultant Oncoplastic Breast Surgeon

Sir,

Congratulations on an excellent Bulletin in July. There were many important articles. In theirs, Oscar Lyons and Richard Canter ask crucial questions about leadership. One of my voluntary roles post retirement is to help whenever possible the Faculty of Medical Leadership which has a very significant surgical input (readers will know that it’s CEO and MD is former neurosurgeon Peter Lees and the Chair is our former President Dame Claire Marx). I would highly recommend their online resources especially the leadership standards documents.

On the subject of when should leadership training start I’d suggest that ‘the sooner the better’ is the best answer. Indeed a number of schools are teaching this to students well below ten years of age. In another role I am privileged to help Newcastle University with a number of pre university students aged from 13–18 in various groups. I certainly use that opportunity to give a summary of the foundations of leadership as follows,

  1. Know yourself – personality typing like MBTI helps the individual understand how they and others react in critical situations.

  2. Work in teams – there is much evidence that when proxies for teamwork are high, mortality can be reduced.

  3. Know your organisation in order to compare and contrast their core values and beliefs with yours. Is this the sort of place you really want to work?

My only disappointment with the article was that there was little reference to the massive database already extant. It is true that there are many questions yet to be answered but whether positive leadership has a positive effect on patient care is not one of them.

Professor Robert Wilson

Founding Senior Fellow Faculty of Medical Leadership and Management

Sir,

Having worked for some years in both the NHS and private hospitals, I have no hesitation in saying that surgical standards are often higher in the latter.

Reasons include the seniority and consistency of staff, a narrower range of interventions and the need to compete with other providers in order to deliver personalised, high-quality care.

The lack of protection from ‘Crown Indemnity’ means minds are more sharply focussed on the spectre of litigation.

An insight into the scrutiny with which outcomes are monitored, both overtly and covertly, is gained by attendance of regular medical advisory committee meetings held at private hospitals.

No doubt these institutions could share minutes to interested parties if requested.

Jai Chitnavis

Consultant Orthopaedic Surgeon

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