Opinion

Charging migrants more for NHS care isn’t just bad for migrants. It’s bad for all of us.

Opinion, Pay

The government has made a new pay offer for public sector workers. Prime Minister Rishi Sunak says he accepts the recommendations of the public sector pay review bodies in full. Great! Except that a Conservative backbencher already admitted what every public sector worker has known for years: the pay review bodies are rigged. But the thing I want to talk about in this article is where Sunak says the money will come from. Sunak says the government will fund pay increases by charging migrants more for healthcare.

Pitting migrants against workers already resident in this country is not a new tactic. Nor is using the NHS as a national icon around which to wrap your divisive rhetoric. We all remember the Brexit bus, but Dominic Cummings didn’t invent racism. In 1952, Nye Bevan railed against the potential concern that foreign people might avail of free healthcare in the UK. He wrote:

The whole agitation has a nasty taste. Instead of rejoicing at the opportunity to practice a civilised principle, Conservatives have tried to exploit the most disreputable emotions in this among many other attempts to discredit socialised medicine.

While we certainly ought to valorise Bevan’s arguments, we must also recognise the imbrication of colonialism in the origins of the welfare state. How did the UK come to have enough wealth to be able to fund a welfare state? Who has worked in the NHS over the course of it’s 75 year history? Who works in the NHS now? Which governments pay for the training of NHS staff? Who pays taxes to those governments? Who provides healthcare for those taxpayers in India, Jamaica, Nigeria?

Fine. But what do we do now? Claps won’t pay the bills. Nor will recalling the historical origins of the current political conjuncture. Understanding that the NHS was built on the backs of migrants is necessary, but not sufficient. The BMA – and others – have already pointed out that it is not ethical to pay for (still way below inflation) pay increases for UK workers by punishing migrants (including migrant workers who work in the UK public sector). Good on the BMA. But I want to add one more point. It is not just migrants who lose out when a Conservative government attempts to divide and rule working people. We all lose out.

The cost-benefit calculations of the migrant cost recovery programme[1] have always been suspect. (See here, here and here for critiques of earlier iterations of the programme). Looking at it now, it still makes little sense. If you charge migrants even more to come to the UK then you reduce the amount of migrants who want to come and the amount of migrants who want to stay (since working people may want or need to bring family members over to help with care, particularly in a country where childcare often costs more than a middle-class salary). One of the key motivations underlying the strikes is to improve pay in order to address the recruitment and retention crises in the healthcare workforce. A very high proportion of recruitment of clinicians is from abroad. For nurses, those trained overseas accounted for nine tenths of growth in nursing numbers in the past year. So encouraging current migrant workers to leave and disincentivising future migrants from coming may not be the best idea. That is, if this government really gives a fuck about the NHS and the care it provides.[2]

So what have been the real effects of the migrant cost recovery programme? Apart from consolidating anti-migrant arguments in public discourse, the key material change brought forth by the migrant cost recovery programme has been the creation of an administrative bureaucracy within the NHS – within most NHS trusts – whose purpose is to recoup costs from people. They are called overseas visitors managers (OVMs). This is a bureaucracy that we all pay for.[3] These are administrators and managers whose express purpose is to track people down who they think are meant to pay for NHS care, and then to make them cough up.

The people who they think are meant to pay for NHS care are “overseas visitors”. The Windrush scandal has already demonstrated that, in practice, OVMs can come for any UK residents, including UK citizens. But even if the overseas visitors managers (OVMs) managed to do what they were theoretically meant to do, do you really think that the institutional mechanisms used to extract funds from “foreigners” will stop at charging them? Once this bureaucracy exists, a future portends in which we are all in its crosshairs. It’s only a matter of time before the bureaucracy widens its remit. You are next. That is why the only way to view the migrant cost recovery programme is through the frame of solidarity with our fellow workers, wherever they are from: “an injury to one is an injury to all”.

When Rishi Sunak comes for migrants, it’s not just migrants who lose out. It’s everyone. Let’s fight to keep the NHS universal, free and comprehensive. Let’s fight together for better pay and better healthcare for all of us.

[1] There are two main components to the programme. The first is the health surcharge added on to the cost of a UK visa. The second is the requirement for NHS trusts to identify people who are not eligible for free NHS care and to charge them.

[2] There is also a separate argument regarding whether increasing pay by increasing government funding would actually incur the kinds of costs Sunak implies. The government would recoup a significant amount of the pay in the form of tax anyway: not just income tax but all the other taxes that working people pay as well, such as VAT. Healthcare workers would also be able to use that money to buy things that they are currently unable to afford, thus stimulating a lagging economy. Would that be inflationary? Well, the NHS isn’t going to increase its customer costs to cover the pay increase, is it? It’s free at the point of use. Oh wait, that is exactly what Sunak is proposing, for the one group who does pay for NHS care. His hypocrisy is galling.

[3] To charge people for something, you have to create a system. Until the creation of the migrant cost recovery programme under New Labour (for a decent account, read this), and its advance under David Cameron’s Conservative governments, the NHS did not have a system for charging people. Why would it? The NHS is meant to be free at the point of use. A cost recovery mechanism takes time and money to devise. And then more time and more money to continue to administer. People have to be trained. Administrators have to be employed. They need offices and equipment. And then you realise it would have been cheaper never to have created the system in the first place.

Pay restoration in Scotland: A Munro to climb

Conferences, Opinion, Pay

At the BMA’s Junior Doctors Conference this month (7th May 2022) members from all 4 UK nations voted overwhelmingly to demand full real-terms pay restoration to 2008 levels by supporting the motion COMP 1 (pictured). In real terms junior doctors working in England are paid around 25% less than their equivalent colleagues were 14 years ago. In nations such as Scotland where devolved governments set public sector pay policy, despite pay awards often being higher percentages than those given in England, pay erosion is actually even worse.

The reasons for pay parity with 2008 have been laid out before but, put simply, we all know in our gut that we are not worth only three quarters of what our colleagues were during the financial crash of the 2000s. If anything the job has got more technical and responsibilities have increased, even if what we take home at the end of the month hasn’t.

Demands for full pay restoration have not materialised overnight and come off the back of work that the Broad Left- and more recently and visibly the Doctors Vote campaign- have been doing. In May 2021 we achieved BMA policy of demanding a 15% pay rise to take us halfway there. But, in Scotland, we never even made it this far.

As pay is set by the government in Edinburgh, so is BMA policy for pay and negotiations in Scotland. The Scottish Junior Doctors Committee of 2020/21 voted not to adopt the 15% goal and instead decided to stick to the status quo that has already led to more than a decade of stagnant or swindled income. 

Traditionally, BMA Scotland presents evidence to the Doctors’ and Dentists’ Remuneration Body (DDRB) in a united, pan-Scotland way with a single pay demand. For the 2022 pay round this was “inflation plus 2%”. There are some positives to this: linking pay to inflation was a significant policy position made at this conference for UKJDC and, if permanently linked to RPI, would stop our pay being eroded by political choices that lead to high rates of inflation. 

However a pay rise of 2% in real terms is shamefully inadequate given the years of erosion already imposed. Our pay has dropped around 30% in 14 years and, with BMA Scotland’s current goal, it would take us 14 years again before our pay approached the 2008 baseline. This is longer than an entire training pathway for many juniors!

So, what do we do about it? There is something we can all do immediately, but more of the work needs to be done over the medium to long-term so we can build a movement capable of winning an ambitious- but ultimately achievable- demand. 

Bluntly, we are at least a year behind our colleagues south of the border in terms of securing our worth.  We have not invested the time or resources into educating our members about pay erosion that both UKJDC and grassroots online groups have done. We need regular and useful comms output to help bring Scottish doctors with us; this includes social media, physical media in workplaces, a pay loss calculator hosted on BMA sites.

A first step towards this is an online pay Q&A on June 8th (sign up here Online Event Registration Form). A high turnout will be noticed by elected reps and will be further proof that we want more radical action on pay and are willing to turn out and spend our time to make our voices heard. The new Email your MSPs template has space to customise the message, which we can use to wake up our Holyrood representatives to the fact they have been degrading our pay- and the health service as a result- for years. The analysis lined up for these two tools looks thorough and useful so engagement with them, viewing them as a launchpad for more, is worthwhile.

But beyond this we need to keep telling SJDC that pay is our priority. Email your reps, find them in your workplace and make it clear that our members support the conference position of seeking full pay restoration; it will help current reps deflect criticism that a focus on pay is unhelpful and not representative of our members, some of the critiques levelled at pro-restoration reps in Scotland.

Over the next year, we must re-examine our relationship with the DDRB. English junior doctors have not engaged with it for years as it is broken and in desperate need of reform. This year English consultants took this position too, striking another blow to the DDRB’s legitimacy in its current form. Scottish doctors still present evidence to the DDRB and turn up to talks with them. This undermines our English colleagues and wins absolutely nothing for us; the Scottish government has ignored even the paltry increases they’ve recommended in the past and probably will again. By walking away and eventually negotiating directly with the Scottish government until it is reformed, we reclaim power from the bureaucrats and send a message that our union is alive and kicking.

We do not act in a vacuum and SJDC need to be taking note of the mandate given by conference for planning radical action in England. We need to immediately commence a campaign to prepare, educate and organise rank and file junior doctors in Scotland so that we are adequately prepared to support our colleagues in the event of English industrial action. Besides being the right thing to do, winning in England will pile the pressure on the Scottish government to keep up, else they face an exodus of junior doctors southwards. Solidarity with any ballot and subsequent industrial action will give us a blueprint and help to inform any action Scottish doctors may need to take in the future, when nothing should be off the table.

But finally and imminently, you have the power to change all this. Across Scotland, regional BMA committees for juniors- LNCJDSs- are chronically underfilled as engagement is rock bottom. But who’s really surprised given the stresses of the pandemic and the seeming inertia in some crucial areas?

Stand for these committees and then stand for a seat on SJDC, or stand for one of the two seats in the upcoming national SJDC elections. Information about election timetables should be made available soon- they will open at the end of July, so follow your Broad Left reps and BMA Scotland accounts on Twitter.

Now is the time to take an active role in our union, or even to re-join it. If you’re excited by the progress being made in England, help us harness that momentum north of the border and make meaningful steps towards proper pay restoration. We are not worth less than our peers in England, so make sure we are not complicit in demanding any less than them- any less than we deserve.

Time to Withdraw from the Joint Statement?

Opinion, Terms and Conditions

Authors: Emma Runswick and Pete Campbell

On the 30th March, BMA Junior Doctors Committee and NHS Employers published a joint statement which stated that:

“the BMA agree that when not possible to implement, the working hours restrictions and rest requirements in the TCS will be suspended and that the Working Time Regulations 1998 (WTR) will be the fallback position for the duration of the pandemic.”

“Trusts should discuss proposed new patterns of work with affected trainees prior to implementation”

(emphasis ours)

Some supporters of the Broad Left, ordinary members of the BMA and the Junior Doctors Committee representatives strongly objected to this and the joint statement was rewritten reflecting some of our concerns. The up-to-date statement is available here.

We were, and continue to be, in favour of sensible flexibility during the pandemic, with the aims of providing appropriate medical cover particularly during staff sickness. However, we argued that giving employers permission to ignore our contractual rights for an undefined reason without agreement from the affected junior doctors, with no clear endpoint for that position, was dangerous.

We argued for changes, including highlighting the importance of safe working, ensuring consultation of affected trainees, and that trusts would have to prove that breaching our terms and conditions was truly a last resort.

End of “Emergency Covid-19 Measures”

On the 29th April NHS England wrote to all trusts requesting the restart of all urgent non-COVID 19 service and the gradual reintroduction of elective work. This has led to a slow withdrawal of the redeployment of junior doctors, and led us to reconsider the joint statement. The end of redeployment or restarting elective work is evidence that workload is normalising and normal TCS should be met. However, in lots of trusts, this is not happening.

“Step down” rotas are being implemented in some trusts which are designed to ‘catch up’ with delayed NHS services, some of these rotas continue to breach contractual protections with the backing of the joint NHS Employers and BMA statement. These rotas can be nothing like pre-covid rotas, with increased intensity, additional weekend working and additional hours.

Pay and Leave Arrangements

Many representatives working locally are yet to see fulfilment of the promise made by NHS Employers:

“NHS Employers is grateful for the commitment made by junior doctors and the BMA at this time and will take this into account when preparing for future negotiations once the COVID19 pandemic is resolved.”

Local trusts and Programmes are returning rapidly to old tricks, attempting to “charge” a 1.5 days of annual or bereavement leave for the new 12 hour standard day, denying leave requests and creating limits on what leave can be carried over into future rotations. Legislation aimed at allowing key workers to carry over untaken leave during the pandemic specifically excludes junior doctors.  

There is notably no national agreement on payment for untaken leave, and the new version of the contract has been withdrawn from the NHS Employers website – perhaps due to the new section on the value of a day of annual leave.

16.9       On termination of your employment, you will be entitled to pay in lieu of any outstanding entitlement accrued in the leave year in which your employment terminates or be required to repay to the Trust salary received in respect of annual leave taken in excess of entitlement. The amount of the payment or repayment shall be based on accrued salary for the leave year paid at a rate of 1/260th of your salary for each day accrued.

Terms and Conditions of Service for NHS Doctors and Dentists in Training (England) 2016 Version 9 (withdrawn)

There also doesn’t appear to be a pay deal for >1 in 2 weekend frequency, though some local BMA reps have won excellent deals (eg at Liverpool University Teaching Hospitals).

In nursing, the government has withdrawn the deal offering payment to “aspirant nurses” (final year nursing students) leaving many in the lurch, despite thunderously clapping for carers.

We cannot trust the government, or NHS Employers, to treat us fairly or recognise our work with mealy mouthed promises. If there is a second wave, we must not be put in this position again – we need better protections and agreements on pay and training arrangements in advance.

We are shattered

Many of us have had an extremely rough few months. Some of us have lost friends, family, and colleagues to the virus. Some of us have been sick. Some have not been able to see our families – abroad, or living away for protection, or shielded. Most of us have cancelled leave, given up training plans, worked harder rotas and stepped into unfamiliar medicine to play our part in pandemic response.

Now more than ever we need contractual protections for rest and working hours, alongside other positive trade union endeavours like the Fatigue and Facilities Charter. Many of the positive aspects of the response to the pandemic are already being stripped away. If we don’t act now to allow recuperation, there won’t be anything left to give in a second wave.

The BMA must now withdraw from the joint statement and work with local representatives to ensure safe rest and hours limits are implemented across the UK.

Abortion in Northern Ireland

News, Opinion, Uncategorized

Marie-Claire Bradley, a Bristol-based medical student from Northern Ireland, discusses the ongoing issue of abortion in response to debate heard at the BMA’s Annual Representative Meeting 2019, subsequent court cases and imminent legislative change.

In June this year, I listened to discussion on the above motion at BMA ARM 2019 in Belfast for the pictured motion which clarifies and sets out a framework for the implementation of BMA’s 2016 policy that abortion should be treated in line with other forms of healthcare and decriminalized across UK and Northern Ireland and policy from 1984, 1985 and 2003 which specifically supports the reform of law in Northern Ireland. The air hung thick, humidity emanating from hot palms and from under stiff collared necks.

Since then, a number of momentous legal shifts towards the fulfilment of this motion have been achieved. In July, a majority of MPs backed the bill brought by MP for Walthamstow, Stella Creasy to repeal Sections 58 and 59 of the Offences Against the Person Act 1861 – which make abortion a criminal offence in Northern Ireland. As a result, the law governing abortion in Northern Ireland, the Offences Against the Person Act 186, is due to change three days from the time of writing (on 21st October), if the devolved assembly does not re-convene before then. Interim rules currently govern the care of those seeking abortions in the meantime – these rules allow doctors to finally at least allude to the possibility of treatment in England without fear of legal reprisal. (1)

On 3rd October 2019, Sarah Ewart, (who was denied abortion despite scans definitively showing that the foetus was in viable) brought her case before the High Court in Belfast. The court considered the archaic wording of the 1861 Act – a near-blanket ban on abortion, except in cases where continuing the pregnancy would cause ‘physical and mental wreak’, as highlighted by Dr Kerr- speaker for the motion and member of Medical Students for Choice- at ARM. The court ruled that such a ban breaches the UK’s human rights commitments.

Abortion will remain a criminal offence in England, Wales and Northern Ireland, although, Northern Ireland is the only place where women and pregnant people face lifetime imprisonment for terminating a pregnancy, even in cases of rape, incest and foetal abnormality, and doctors and medical professionals also face life imprisonment for assisting. The potential for such a win for human rights in Northern Ireland is, joyously, a result of local political stalemate and governmental disregard for the region.

This departure from current archaic rules to better represent the will and the needs of Northern Irish people is particularly welcome in a time of such paralysing political uncertainty – The writer notes that the Act came into force 20 years before it was legally possible for women to own property. (2) At ARM in Belfast, Dr Kerr explained the influence that the criminalisation of abortion has had upon medical education – while the procedure affects 1 in 3 women and pregnant people, education on the subject across the UK is poor and medical students in Northern Ireland receive “little to no” training in this regard. Dr Kerr commented that the unavailability of the procedure leads to “forced pregnancy” which is “an act of violence and assault” and indeed, as Dr John Chisholm, Ethics Committee Chair, later mentioned, the UN Convention on the Elimination of Discrimination Against Women Committee condemned the law on abortion in Northern Ireland as a “grave violation of rights under the Convention”. Dr Chisholm, also echoed the words of the proposer of the motion, Dr Anthony Lempert and Dr Noel Sharkey, speaking for the motion, in stipulating, “human rights are not a devolved issue”.

There was a common preoccupation amongst speakers against the motion who feared that any such legislative overreach may impact upon the peace in Northern Ireland:-

Speaking against, Dr Dominic Whitehouse opened with the phrase, “peace is precious and fragile” and subsequently brought to the attention of ARM; the lack of an active assembly at Stormont for two years, the murder of “female journalist reporting on riots in Creggan area of Derry” and “letter bombs being delivered by dissident republicans to London airports and Waterloo station” as evidence that peace in Northern Ireland is once again dwindling and implying that the enactment of the legislative changes laid out in the motion would amount to a return to “colonial rule” and thereby threaten the peace.

The unnamed “female journalist” to whom Dr Whitehouse refers is Lyra McKee, her tragic and untimely death highlighted the pertinence of her investigative work unpicking the stories of young people left behind by the Peace Process. Lyra McKee actively campaigned for LGBTQ+ rights, was pro-choice and in favour of the decriminalisation of abortion.

Dr Rachael Pickering, also speaking against the motion, emphasised that being “from Shropshire” meant that the legislative change suggested was “imperialist”. Dr Pickering told ARM that Northern Ireland is “politically conservative”. In fact, the writer notes that the fifth Northern Ireland Peace Monitoring Report, funded by the Joseph Rowntree Trust, lists the necessity of “reform of abortion law and equal marriage” alongside the potential impact of Brexit as issues that need to be solved in order to further secure peace in Northern Ireland, citing evidence from the Northern Ireland Life and Times survey and opinion polls which show that “the majority of the population in NI support liberalizing the law on these issues”. The odd notion that the backdrop of political instability in Northern Ireland which was originally caused by Direct Rule should be an excuse for further denial of human rights in Northern Ireland is somewhat absurd.

Dr Pickering, an English Representative, was correct in saying that English Representatives probably shouldn’t dictate the consensus of Northern Irish people. The fifth Northern Ireland Peace Monitoring Report notes that the views of socially conservative political parties in Northern Ireland “are at odds with” the view of Northern Irish people. (3) Indeed, as Dr Lempert notes, 59% of people in Northern Ireland have voted in favour of decriminalisation. The consensus of Northern Irish people is for the motion.

The voice of this much needed Northern Irish perspective, came when Dr Noel Sharkey spoke in favour for the motion stressing the need for legislative change to ensure that Northern Irish people have the same human rights as people in the rest of the UK, emphatically stating that, “As a gay man I cannot marry my partner.” He explained that the lack of devolved government was not a reason to stall reform of legislation as the underlying health issues are “becoming more toxic and dangerous” as a result. Closing the debate, he powerfully stated that, the “Criminal framework is not preventative, it simply exports the problem […] it is time to trust women. Human rights is not a devolved issue. Instead of giving women in Northern Ireland air-fares, it is time to give them healthcare.”

Threatening uncertainty surrounding the border in Ireland casts a heavy shadow over economic well-being and the maintenance of the hard-won peace in the region and the right to choose hangs in the balance until Monday when Secretary of State, Julian Smith, will be forced to legalise abortion and same-sex marriage before 13 January 2020. Smith’s video tweet on 14th October urged the devolved executive to sit and discuss the law on abortion before the 21st October deadline immediately followed sit down talks between the DUP and Cabinet. Accusations ensued from MP Stella Creasy that the right to abortion is being used as a “bargaining chip” by the Government in the scramble to bend the DUP over to accept their Brexit deal. Indeed, the next day a subsequent statement from the DUP called for Stormont to sit once again to “oppose the extreme liberalisation” of the law.

Nationalise Care Homes – ARM

Conferences, Opinion, Terms and Conditions

Author: Giancarlo Bell

This is the fifth of several pieces arising from the ARM 2019, explaining our positions on the debates which occurred there.

Motion 90 ARM 2019.

Britain should nationalise its extensive network of private care homes so that the vulnerable residents of these establishments can benefit from the improved standards of care afforded by the staff and systems of the NHS. Nationalisation could also provide better regulation, improved working conditions, and higher pay for the millions of workers in the social care sector, as well as offering better integration between social care and NHS medical care processes. This was the crux of Motion 90, submitted by North East Regional Council at ARM 2019. While the Broad Left was firmly supportive of this motion, the room at ARM was divided, with many representatives questioning whether bringing social care into the NHS was the right strategy to improve falling standards. Despite the strength of the opposition presented at ARM, the Broad Left are delighted that the motion passed in all parts.

Before the recession, care homes were regarded as bulletproof investments for private equity firms. The British population was ageing, and so thousands more elderly people could be churned out into the private care system every year with a premium hanging over their heads – profit for the care home bosses. This perceived stability provoked increasingly risky financial investments and a series of reckless economic expansions, subsidised with the money of taxpayers and the savings of our elderly population. No company better embodied this story than Southern Cross, formerly the UK’s largest social care provider with a peak of 31,000 residents in 750 homes [i]. They followed the tried-and-tested pattern outlined above, with a constant cycle of buying and selling new properties and pushing into new markets. After the credit crunch, Southern Cross was hit by rising rents, decreased expenditure by councils, and falling property prices. They responded by squeezing employee pay and decreasing the quality of care provided to postpone their inevitable decline [ii].

Our elderly friends, loved ones, and colleagues should not be at the mercy of neoliberal market forces. We are a wealthy country, and we should guarantee a basic standard of living for everyone. While doctors in general, and BMA members especially, believe in a publicly funded NHS which is free at the point of delivery, these values are more contentious when it comes to social care. There has been something of a shift in the Overton window in this instance. While almost 200,000 of the half a million care home beds in the UK were operated by the NHS or local authorities in 1990, this number has dwindled to about 30,000 [i]. The public accepts the dogma that the state provides health care; while the private sector provides social care.

By bringing care homes into the public sector we can equalise the huge variation in standards of care seen across the care home industry. The private operators’ main motive is profit; the care of their residents is a secondary priority. As such, we have seen dwindling standards of care, and a growing incidence of neglect and abuse at care homes across the country [iii]. At ARM, opponents of Motion 90 argued that the care homes which scored most positively under the scrutiny of CQC review were small, privately run establishments. This may work out nicely for the people who can afford to live in such homes, but the working class are left to fend for themselves in those cheaper, often poorly run care homes with low-paid, overworked staff, because staying in a top-quality care home when nursing care is required can cost as much as £55,000/year [iv]. We would not accept such inequality in healthcare.

Employees in the care sector are at breaking point. They are working longer hours, for less pay, and with fewer benefits than their colleagues working in NHS hospitals. They also receive less training and are frequently employed on unstable zero-hour contracts with little in the way of career progression [v]. By bringing care into the NHS, we can employ care home workers on humane terms, with the pay and conditions they deserve, which will subsequently improve the standard of care they are capable of delivering.

Medical wards in NHS hospitals across the country are burdened with the complex issue of ‘acopia’ and ‘social admissions’. There has been fierce debate about the validity of these terms and about how to solve the issues underlying these admissions, but nationalising care homes could be an important step towards a solution. If care homes were provided on a universal, free basis like healthcare, and their staff were part of a wider, integrated NHS system, then elderly patients who are unable to cope at home could be admitted to somewhere to truly meet their needs, rather than taking up a costly hospital bed. This could save our NHS a significant sum of money.

Now that this motion has made it through ARM, the BMA should be unerring in its support for nationalising care homes. We must show that we believe in a humane standard of care regardless of class background, that we stand for health and social care which is comprehensive, universal, and free at the point of delivery. We must show solidarity with the workers in the care home sector. Our elderly population, and the workers looking after them, deserve better than to be treated as pawns in the games played by private equity firms.

[i] https://www.socialist.net/britains-care-homes-in-crisis-nationalise-them-now.htm

[ii] https://www.theguardian.com/business/2011/jul/16/southern-cross-incurable-sick-business-model

[iii] https://www.independent.co.uk/news/health/abuse-care-home-cqc-autism-learning-disability-whorlton-hall-police-a8969026.html

[iv] https://www.moneyadviceservice.org.uk/en/articles/care-home-or-home-care

[v] https://www.independent.co.uk/news/uk/home-news/care-home-workers-half-leave-jobs-within-year-staffing-levels-problem-report-communities-and-local-a7658281.html

Knife Crime is a Public Health Issue – ARM

Conferences, Opinion

Author: Adaeze Chikwe

This is the fourth of several pieces arising from the ARM 2019, explaining our positions on the debates which occurred there.

Motion 87 ARM 2019. 87 a, b and care for reference and were not debated.

The Broad Left supported this motion which passed unanimously.

Knife crime is an ever-growing epidemic in the UK, with rates reaching record level during 2018. According to the Office for National Statistics, the number of killings due to knife crime in 2018 were 732, one of the highest rates ever recorded in the UK(1). Unfortunately, the response to this epidemic by both the government and the Home Office so far fails to combat the issue by only focusing on reactionary policing and criminalisation, rather than preventative measures.

The solution we see unsuccessfully rehashed year upon year by the government is the use of ‘stop and search’, where pedestrians are stopped by the police at random on the streets, often on the basis of preconceptions and stereotypes about the race and gender of supposed perpetrators of knife crime. According to the Home Office, black people are 40 times more likely than white people to be stopped and searched(2). Official responses and rhetoric reinforce the ignorant and damaging stereotypes already placed on the heads of black people, such as that black people are criminals and more likely to partake in violent behaviour.

Although stop and searches may be successful in the short-term, this solution does nothing to stop offenders carrying knives on the street again at a later date, and instead increases the frustration and lack of belief in the police force from particular groups of people wrongly targeted for stop and searches repeatedly.

Knife crime is a public health issue.

We recognise that to truly make a dent in this rising wall of knife crime, a more grassroots approach needs to be undertaken where organisations and charities go directly into communities to find out why some people (often young adults) feel that carrying knives on the street is their only option, and intervene in the early stages before attacks can be carried out. Furthermore, these organisations have a variety of functions such as providing positive guidance to young people who might not have had this guidance earlier on in life, providing first aid sessions that teach young people how to stem blood loss from a knife wound and helping young offenders find employment and further education when coming out of prison to prevent them from re-offending.

The motion called on the BMA, as a trade union for doctors, to recognise the role that healthcare has to play in combatting knife crime. Instead of taking a no-questions-asked approach whilst treating victims of knife crime and ushering them immediately out of the hospital doors once treated in order to free-up beds in our already over-stretched NHS, healthcare workers need the training to be able to sign-post victims towards services that can break the cycle of violence that often leads to re-attendance.

Additionally, we need further implementation of youth workers in trauma centres all around the country, such as those from the organisation ‘Redthread’ that work side by side with clinicians in hospitals to engage victims of knife crime directly from their hospital beds. Organisations like this take advantage of this time when victims are at their most vulnerable and reflective in order to have a greater effect and prevent re-attendance(3).

There is evidence that a grassroots approach to combatting knife crime is effective, as shown in Scotland. The Scottish ‘Violence Reduction Unit’ (VRU) implemented a variety of programmes that aimed to educate rather than castigate both the victims of knife crime and those at risk of partaking in knife crime. They launched a mentorship project in schools designed to educate young people about how to challenge offensive behaviour without using violence(4). The VRU have outreach teams in hospital emergency rooms to sign-post victims to services that can help them move on and rebuild their lives regardless of their circumstances. As a result of the efforts of these organisations, there has been a 39% decrease in homicides over the last decade.

If Scotland can reduce their knife crime levels, we can absolutely do the same in England and Wales.

Collectively bringing attention to this issue by promoting outreach and grassroots services will enable those at risk of partaking in knife crime to see that these programmes are available. We need to continue to pressure the government into prioritising the public health approach rather than rely solely on stop and searches. We can do this through the BMA and independently, by writing to MPs and starting petitions to have a greater proportion of money used to combat knife crime funnelled towards grassroots organisations and outreach services. Furthermore, we can raise awareness that these services are available in our communities and invite grassroots organisations to schools and youth clubs.

The knife crime epidemic, although experienced by few, needs to be acknowledged as a public health problem by all, whether you are from a community directly impacted by the effects of knife crime or not at all.

References:

  1. https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/bulletins/crimeinenglandandwales/yearendingdecember2018
  2. https://www.theguardian.com/law/2019/may/04/stop-and-search-new-row-racial-bias
  3. https://www.redthread.org.uk/what-we-do/#a&e
  4. https://www.bbc.co.uk/news/uk-scotland-45572691

What Union Should Medical Associate Professionals Be In?

Conferences, Opinion, Organising

Authors: Brocha Goode and Emma Runswick

This is the third of many pieces arising from the BMA’s Annual Representative Meeting 2019, explaining our position on the debates which occurred there.

Motion 108 ARM 2019

At the 2019 BMA ARM, supporters of the Broad Left brought forward a motion that the BMA should unionise Physician Associates (PAs), as well as other Medical Associate Professionals (MAPs), and create a branch of practice for MAPs within the BMA. It fell, save for the last part where the RB agreed to work with ‘groups’ representing PAs and MAPs in the future for the benefit of all. The main arguments against consisted of keeping the BMA a doctors’ union, and not wanting to ‘water down’ the role of the BMA in protecting the rights of doctors. Why did supporters of the Broad Left bring this motion forward?

Physician Associates and other Medical Associate Professionals

The role of the Physician Associate was created recently by the UK government as a potential solution to the workforce crisis created by the Modernising Medical Careers programme, which reduced the numbers of middle-grade doctors. University training programmes for PAs run across the UK, and they will soon join medical rotas in large numbers. We are told that in 10 years there will be 10,000 PAs working in the NHS. The role is ill-defined, but includes assessing patients, requesting investigations and creating management plans.

There is no specific trade union for PAs.

Other MAPs exist in smaller numbers in Surgery, Anaesthetics and Critical Care. Some groups have no direct entry, drawing only on highly qualified and experienced nurses. The Advanced Critical Care Practitioners are one such group. Some of these groups already have representation, many do not.

The Problem – We all need a union

It is important to separate the question of unionisation from your feelings about MAPs. It is no longer important whether you support or oppose PAs or MAPs as a concept. Individual interactions with PAs or other MAPs are irrelevant to the issue at hand. PAs exist.

They are workers. They are our colleagues. They are valued members of the Multi-Disciplinary Team. The concept of a PA comes from the USA, where it is a well-defined role separate to that of a doctor. In the UK, however, this is not the case – their roles often overlap with tasks traditionally performed by doctors. Their training, though shorter, is so similar that students share clinical skills sign-offs with medical students. NHS England has decided that their role is so similar to F1s that from August, PAs will be placed on some F1 tracks and rotas.

The current implementation of PAs by NHS managers and Universities has the potential for competition and conflict. We are already seeing concerns about training opportunities and worry about the poor differentiation of our roles by both professions. The position of the PA is also open to abuse. A person in a fluid role can be asked to take on more responsibility than they are trained or paid for. PAs have not yet been given prescribing rights or professional registration, yet they are asked to make management plans for patients. Doctors, who hold professional registration, must then ‘supervise’ and take the legal responsibility for these plans, without additional time. This situation is bad for PAs, for doctors, and for patients.

Misplaced resentment is growing between the professions, but these problems were not created by PAs. These problems were created by the poor definition of their role and poor implementation – these are problems created by the government and managers and the fault lies with them. Without representation by a strong established union, PAs may find themselves mistreated and exploited to the detriment of themselves, doctors and patients.

The Royal College of Nursing (RCN) as a Model

Similar issues were raised by nurses when Healthcare Assistants, and more recently Nursing Associates, were introduced. The Royal College of Nursing, the trade union and professional association for nurses, decided that the smartest way to deal with these issues was not to argue worker vs worker, but to fight together as union vs government. The RCN recruited these new staff groups into their union and won proper definition of those new roles. This ensured that Nursing Associates could not be asked to take on responsibility that they weren’t trained for and protected the role of the Registered Nurse.

The RCN recruit and organise Nursing Associates and Healthcare Assistants without accepting that the roles are equivalent to that of a Registered Nurse. The RCN maintains its role as a trade union and as a professional association whilst accepting members that do not have professional registration.

We should look at the RCN as a model. They know that division causes weakness, and unity gives strength. This strength allowed them to protect all groups of nursing staff. Their common needs as a nursing family trumped their differing qualifications.

Conflict and Commonality – Why the BMA?

In the BMA, we have several existing Branches of Practice with frequently conflicting views. We represent GP Partners and GP Salaried Doctors; Students and Academics; Consultants and Juniors. PAs, like these groups, are in the medical family, just like Nursing Associates are in the nursing family. Royal Colleges have accepted this. The GMC and the government both agree. We have more in common than that which divides us. Where conflicts between Branches of Practice occur, the BMA has systems to resolve that. These could be extended to include our colleagues from other professions.

 We shouldn’t leave PAs and other MAPs to seek piecemeal representation by the general unions operating in the NHS. If there was an existing union with enough MAP members for them to be effectively represented as a group, we would be advocating they join it. MAPs are currently spread across several unions, but mostly go without.

We also shouldn’t wait for years for them to form their own union with a fraction of the strength we have now, after the damage has been done. Asking MAPs to create a new union is a near impossible task and would suck up all their work for the foreseeable future. By the time they were set up and had gained negotiating rights all the big debates would be over, to the detriment of staff and patients. Furthermore, in separate unions, there would be no effective way of managing any conflicting interests between us.

That conflict has the potential to include use of one professional group against the other during industrial disputes. As it stands, PAs are a risk to doctors’ terms and conditions and doctors are a risk to PAs’. Doctors’ pay and PAs’ ability to refuse out-of-hours work could come under attack from management making unfavourable comparisons. Working together, that risk could be eliminated.

Solution

We should seek national recruitment, organisation and bargaining for Physicians Associates and other MAPs through the BMA, so we can work together for agreed and common goals including:

  • High quality training;
  • Professional registration for all members of the clinical workforce;
  • Adequate role differentiation, so one cannot be asked to do the job of the other during rota shortages or union disputes.

For many in the medical profession, this tastes bad. It tastes like an acceptance of medical understaffing, of reduction in training standards. Some argue that unionising MAPs puts the definition of a doctor, or of the BMA, at risk. The BMA was set up to define and defend the role of the registered medical practitioner. Now, the BMA needs to do so again.

How do we work to define our roles as separate on the MDT without working together? How do doctors and MAPs protect their roles and working conditions without the power of a strong well defined and well-funded union? Unionising is the right solution to the issues we face, and the only real solution right now.

The RCN has given us the model. We should be recruiting and unionising PAs. For similar reasons, we should recruit other MAPs, such as Surgical Care Practitioners or Anaesthetic Associates, that don’t have a trade union home. We cannot afford to let this snowball away.

BMJ Independence – ARM

Conferences, News, Opinion, Reports, reflections and accountability

Author: Chris Smith

This is the first of many pieces arising from the ARM 2019, explaining our positions on the debates which occurred there.

Motion 55 ARM 2019. 55a and 55b are for reference and were not debated.

We are delighted that this motion fell. Several Broad Left members had submitted speaker slips against the motion.

The proposer argued that the BMJ was damaging the BMA by publishing information about Spousal Expenses, sexism and so on. He argued that our members saw the BMJ as the ‘official mouthpiece’ of the BMA and that we therefore needed a Memorandum of Understanding to limit their editorial independence.

We believe it is the behaviours of members and representatives that has damaged the BMA, not the reporting of these issues. These issues show how completely necessary it is for the BMJ to be empowered to investigate and report on our shortcomings and failures, both for transparency of the union and so we can reflect and change when appropriate. The free press is important: it provides the disinfectant of sunlight.

The BMJ is internationally respected, with the 4th highest impact factor in the world. It is also a great boon for our members – the surplus provided to the BMA is in the millions. If the journal is sullied around the world by a memorandum which forces it to be a vehicle for BMA propaganda it will diminish trust in the journal and trust of the association.

The BMJ is, and should remain, a critical friend. This motion argued against a free and impartial press- a right enshrined internationally by documents such as the United Nations Convention on Human Rights. We believe the integrity of the BMJ should remain intact and will continue to argue that our trade union should not be meddling with a prestigious and editorially independent publication.

BMA Ambassador Scheme

Opinion, Organising

Emma Runswick

BMA ambassadors receive:
− £30 GiftPay vouchers for every new member
− 25% off your annual membership (if you recruit 6 new members)
− a new ambassador welcome pack
If you would like to become a BMA ambassador click below, send the email and we’ll do the rest.

BMA email 10th April

I’ve been a rep for 6 years and now sit on BMA Council, one of two medical student members. I have a trade union background before that, and have been busily recruiting and organising for the BMA since I joined medical school.

When I first heard about the ambassador scheme, I found it distasteful. I don’t require an incentive to recruit to our union. I have an ideological commitment to trade unionism – we have to fight together to win together. I encourage others to join because I think it is in their interest to do so. The scheme was set up by the commercially named Marketing Department 🤮 without consultation with representatives.

However, there are positives to the ambassador scheme. I joined because it gave me easy access to all the materials like leaflets, pens and the BMA tablecloth that I had previously been unable to get access to. I had been nicking these from the BMA staff at some events, but always rapidly ran out.

It also gave us a bigger say in what went ON the leaflets – we got the marketing team to come to Medical Students’ Committee as part of the ‘membership challenge’ 🤢 and we made changes – to promote the work of the union for both individual members who need help and members as a collective.

I used the Amazon voucher they gave me (it used to be amazon, no longer because of tax dodging and bad employment practices) to buy my BMA medical school branch a tripod and other equipment for recording and webcasting our events.

I use the ambassador scheme enough that they know I am recruiting, but I don’t use the ‘official link’ that gives me a voucher unless we know collectively what we are going to spend it on. I may use it again for leafleting for medical students about the new junior doctor contract, as at the moment it’s unclear what funding there will be for specifically penultimate and final years who have a vote.

I have encouraged other medical student representatives to join the scheme for these reasons, and most of Medical Students’ Committee are on the scheme. I hope that in time, the ambassador scheme will die out and become a basic and essential part of the rep’s role.

Ideally, there would be an easier way for medical student reps and activists to get access to materials, and I think it’s likely that my use of the scheme is the exception rather than the rule, but I reckon I’ve recruited ~60 members alone, and many more at designated events, where BMA send staff to support recruitment. I have gained £0 financially.

Organising 101: Recruitment

Opinion, Organising

This is based on the training Emma Runswick delivered for BMA Medical Student Representatives. It has some use for all of us, but the chosen examples may not fit your environment.

_______________________________________________________________

My name is Emma and I’m a Trade Union Activist. As elected representatives, you are too.

Our job is to build the strength of the union, so we can achieve more for our members. As students, we also have another job – to prepare our members for the challenges of work, and encourage them to stand up for themselves and become representatives as doctors.

We get our power from numbers, from the density of our membership. Like herd immunity, we are all better protected the more of us that are members. A representative of 98% of a medical school’s students has more clout than a representative of 65% of students. We also draw strength from the activity and engagement of our members. Where members tell reps about problems, and are prepared to act together to solve them, we have levers available that don’t exist with a passive membership. When there is competition for representative roles, reps have to show they are effective and accountable. So when we think about organising, what we aim for is full union membership, with significant activism and engagement of the ‘lay’ (not rep) members.

To achieve that, we have to stop thinking about recruitment and retention as something done by adverts and freebies. Recruitment is not a one-step job, nor one conversation. A rep may have to have several conversations over months to recruit somebody. More conversations would be required to recruit a member into activity. Other conversations are required to retain members when things inevitably go wrong, or when members have joined for free in freshers’ week and have no idea what the union does. Organising is an ongoing and constant process, which we all have to engage in all the time.

To assist you, it may be useful to develop a script. Mine goes something like:

*Pick something relevant to them – for pre-clinical students, a good example is UKMLA; for clinical students, travel bursaries, UK Foundation Programme Office, disability adjustment in exams; for junior doctors, contracts and training; etc.

Recruitment is not just a job for freshers’ week and inductions, though you should go to these. Like recruits like – you will recruit members far better and far more usefully than most BMA staff, because you know what it is like and what they need. Recruitment is also for teaching, grand rounds, medical formals, lunchtime, coffee breaks, and general conversations. Ask final year students if they have their contract or rota, if they have checked it using the BMA tools, if they are a BMA member. Ask your colleagues what they think of UKMLA, how much travel has cost them this block, whatever. Slip it into conversation. TELL PEOPLE YOU ARE THE BMA REP. Wear your lanyard and badges.

Organising is essential if we want our union to be strong. We can all play a part in that.

You can get materials for recruitment – leaflets, free stuff – from https://www.bma.org.uk/about-us/how-we-work/local-representation/local-negotiating-committees/promotional-materials

You can also access rewards for recruitment by joining the Ambassador Scheme: https://www.bma.org.uk/membership/bma-ambassadors

Those wanting to be active can have a look at this https://www.bma.org.uk/about-us/get-involved/represent-and-volunteer

 

Addendum Issues:

Junior Doctors’ Contract: sympathise! They are right, we didn’t do as well as we would have wanted in that dispute. However, we took an organisation that hadn’t struck in 40 years on strike, and we won significant concessions. If you compare the initial contract ‘offer’ to the one imposed, you can see how effective striking and negotiating was. We weren’t prepared for an industrial dispute that big, and if we want to do better, we have to be more organised, and we have to be stronger. We need you to be a member, and then people like us can change the union so we never give up a mandate like that again.

Chris Day/whistle-blowing: nobody really knows what happened there, even Council members like those on the Broad Left. However, everybody now agrees that we do have whistleblowing protection if needed from detriment by our training provider. Now, we need to be acting to make sure nobody has to whistle-blow. We work in understaffed and unsafe environments, and if we want to improve those, we have to break the locum cap, campaign for visa restrictions to be removed, win better policies for cover and training, fight for better pay, and ensure better workforce planning. Those are all things your union does with and for you, and we are stronger if we have more members. On Chris Day specifically, hopefully there will be a frank conversation when his personal Employment Tribunal case is concluded about what happened and the role of the BMA.