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“Yes.” This was the dismaying response of consultant breast surgeon, Mr Hemant Ingle, when asked at a talk, hosted by the Centre for Health and the Public Interest (CHPI), whether he thought another scandal on the scale of that caused by Ian Paterson could unfold today. Disgraced breast surgeon Paterson is currently serving a 20-year sentence after unnecessarily operating on over 1,200 patients at NHS and private hospitals in the West Midlands area between 1997 and 2011. Three months into my first year of General Practice Specialty Training, I sat in that auditorium utterly stunned at Mr Ingle’s candour. Was it pessimism or devastating realism? Having watched the appalling events unfold in a screening of the ITV documentary ‘Bodies of Evidence: The Butcher Surgeon’, we were honoured to be joined by a panel of experts, including Debbie Douglas, one of the indescribably courageous patients who helped to expose Paterson. Over the next hour, the panel unpacked the factors deemed to have enabled Paterson’s actions, his potential motives and the consequences of the subsequent inquiry for society at large. It made for disturbing listening. Having trained entirely within the public sector, as all new medical graduates must do in the UK, I was completely ignorant to the circumstances within private hospitals which had catalysed Paterson’s reign of terror. I had no idea that private hospitals bore no responsibility for the patients treated within their walls, that doctors working in such hospitals often had no requirement to adhere to otherwise national guidance on healthcare provision, that private hospitals may have no facility to provide adequate emergency treatment to those suffering medical complications after procedures performed on their own premises. Before that evening, I had never before heard a patient state so heartbreakingly that they struggled to trust medical professionals. That disquieting symposium was not my first exposure to the sinister side of medicine. Seeking supplementary education in a field strikingly neglected in my own core undergraduate and postgraduate medical education, I had, just a few weeks before the CHPI event, joined a webinar hosted by the British Society of Sexual Medicine (BSSM). One of the presenters was a patient who had experienced first-hand the pernicious effects of vaginal mesh insertion. Whilst her story had a positive outcome, other vaginal mesh patients have not been so fortunate. Thousands of women continue to suffer from chronic pain, fatigue and urinary dysfunction, amongst countless other symptoms. Through subsequent investigations, it has emerged that vaginal mesh manufacturers had significant financial links to clinicians, researchers and Royal Colleges, and that side effects and complications were widely under-reported. Campaigns such as Sling The Mesh, founded by Kath Sansom, ensure that this landscape is changing, but it should not have come to this. I’m not sure how to feel any more. I’ve spent a lot of time with doctors over the last eleven years. At sixth form, I would send countless unsolicited emails to consultants at local hospitals, pleading for the chance to observe their surgeries, to shadow their ward rounds. Throughout university, I scribbled down every word of juniors, registrars, consultants, hoovering each crumb of knowledge that might make me the best doctor that I could be. Since I graduated in 2020, and started working as a Foundation Year Doctor in London, these professionals have become my peers, my colleagues, my 'bosses'. Whilst of course, some have been more personable, more welcoming, than others, I have thankfully never had the misfortune of encountering a character like Paterson. In Ipsos' 'Global Trustworthiness Index', most recently released in October 2021, doctors were ranked highest in 28 countries, with over 70% of UK respondents believing us to be the most reliable of all professionals. This was the mindset in which I trained; I felt comfortable and worthy of such an accolade. I want to be the person that patients can rely on at their most vulnerable, that relatives feel they can approach with any worry, large or small. To hear now that, for entirely good reason, the implicit confidence that the public had in their medical professionals is no longer a guarantee, made me feel rather unsteady. How do I feel about being part of a profession in which such deceit can go unchallenged? Do I want to be associated with 'experts' who fail to acknowledge the legitimate anxieties of their patients? I'm not going to leave medicine. Fortunately, the Patersons of the world are hugely outnumbered by respectable, conscientious, genuine, caring doctors – those that do earn the premier spot in an Ipsos poll. However, I do think that I have been naïve. Whilst Paterson’s actions are deplorable, a single ‘rogue’ surgeon can be dealt with. This is not to downplay the absolute devastation and anguish that he has caused his patients and their loved ones, and not to diminish the fact that his ousting took far too many attempts from those bold enough to question him, and not nearly enough support from those who should have held him accountable. It is the systemic failures which allowed Paterson to operate unmonitored, which enabled vaginal mesh surgeries to continue unchecked, which permitted side effects to go unrecorded, that I find so unsettlingly insidious. Whether these repeated failures in the healthcare system are underpinned only by financial motives, by greed, as seems the most obvious explanation, we may never know, and perhaps finding reason should not be our priority. As a doctor, my duty is to advocate. Fortuitously for themselves and those whom they are now able to advise and support, both Debbie Douglas and the patient featured in the BSSM webinar are intelligent, well-spoken, confident women. Others affected by the scandals mentioned here, and countless more that are not, may not be so well-equipped. Those who are perhaps older, less educated, who do not speak English as a first language, with other medical conditions rendering them less able to campaign, rely on others to do so on their behalf. This is only one piece of the jigsaw – in order for patients to request help, they must know who is able to help them, and must feel secure and empowered to ask for assistance. Similarly, doctors must feel emboldened in discussing issues with appropriate colleagues. This is not necessarily easy. A conversation after the CHPI panel discussion highlighted how GPs in particular, often mistakenly viewed as lesser doctors, may feel pressured to maintain respect for themselves within the medical profession and, thus, be reluctant to escalate patient concerns for fear of ridicule from secondary or tertiary care. It goes without saying that such anxiety should never alter the care we provide to patients. However, this perceived imbalance of medical aptitude, resulting in such a discrepancy in the level of esteem to which medical professionals are held, is just one example of a saddening toxic facet of the medical world. This is also reflected in the response to whistleblowers, both in the moment and through the lasting effect on a professional’s career, as exemplified by Mr Hemant Ingle speaking of the hospital that previously employed both himself and Paterson: “They don’t like me, of course they don’t”. Only by changing this mindset, and curating a more supportive, protective, transparent culture, where healthcare professionals of all levels and types can freely voice concerns, can we ever hope to avoid such disasters in the future. So, in real terms, what should I do as a training GP? Put simply, I must abide by the GMC’s ‘Duties of a Doctor’. Firstly, I must remain aware and knowledgeable of current biomedical and medicolegal affairs to ensure that I do not inadvertently, even if innocently, reassure or dismiss patient concerns through ignorance. Attending regular knowledge update courses and accessing appropriate journal articles are more formal avenues of learning, but I should supplement these by keeping abreast of health news in popular media, such that I may pre-empt problems with which patients may present. This is all with the understanding that I must never act beyond the limits of my competence and must never allow fear of criticism to prevent me from seeking advice, whether this is from more senior colleagues, supervisors or specialist doctors. For my patients, and indeed for colleagues who may come to me with their own queries, I should reciprocate by remaining approachable and sympathetic. My interactions with colleagues and patients alike should take place in a partnership model – while of course there are many times when hierarchy can be appropriate, I aspire to be the doctor who equips her patients to become experts in their own health and to advocate for themselves. I will strive to communicate with patients in formats appropriate to each individual. Once a patient has chosen to trust me, I must be mindful of the fact that trust can just as easily be lost as gained. I shall keep patient safety at the fore by following GMC guidance on raising and acting upon concerns, reporting any adverse effects of medication or treatment that are divulged to me, obeying my duty of candour if I believe a patient to have been placed at risk, not allowing any conflicts of interest to influence patient care, and acting with overarching honesty and integrity. Yes, another Paterson-level scandal could, and will almost certainly, unfold again. However, if I aspire to achieve each aim outlined above, I will indeed become the kind of doctor that sixteen-year-old me held in such high regard. Until we fix the system, all I can do is my best.

The conference theme, ‘The Surgical Multidisciplinary Team: delivering safe, skilled, and effective care’ will focus on career progression for various practitioner groups whilst exploring the benefits of working collectively in a modern surgical team. Delegates will hear personal experiences of the challenges faced from the perspective of a Surgical First Assistant (SFA) and a consultant and a surgical trainee’s experience of working with non-medical practitioners. In addition, delegates will hear presentations on the need for a professional indemnity cover and much more. Register

This ASCEND (acquiring skills, career exploration, networking and development) webinar aims to help students and newly qualified practitioners to develop the practical and personal skills needed to succeed during the early years of their perioperative career. It will focus on two main skills - leadership and the management of anaesthetic emergencies. Leadership is often mistaken for something that only comes with vast experience in a particular discipline. We will be re-examining ‘what is leadership?’ and introducing some leadership opportunities available early in your perioperative career. Management of anaesthetic emergencies is a crucial part of perioperative care. This is not only relevant for anaesthetic practitioners, it incorporates the whole theatre team. Being able to identify an anaesthetic emergency is a valuable skill in your early career. Learning outcomes: An introduction into leadership opportunities available early in your perioperative career. Understand different styles of leadership and how you can deploy them in your everyday practice. Identifying anaesthetic emergencies and learning through virtual simulation. Register

Giving birth in England is considered very safe. But it doesn’t mean we can’t do more, and it doesn’t mean we should only look at mortality. There are other questions we need to be asking: What kind of start are we giving mothers? Do they feel safe giving birth? Do they feel safe in pregnancy? Do they feel safe in those first few weeks and months looking after that tiny new person? Motherhood is hard. Looking after mothers so that they can take good care of their babies makes good sense, so maybe looking after those who are caring for mothers makes good sense too? The Royal College of Midwives (the UK’s only midwifery union) predicts that there is a shortfall of over 2000 midwives in England [1] and yet a recent survey of its members revealed that 57% are considering leaving the profession in the next year.[2] As a student midwife, it is disheartening entering a profession where morale is so low, and I wonder what effect this has on safety? All jobs have their downsides and midwifery is no exception. But if changing these downsides meant safer better births, is that not worth the cost? No more missed breaks. No more reduced breaks. No more finishing late without being reimbursed. No more midwives with UTIs because there simply hasn’t been time to stay hydrated and use the bathroom. No more signs up about staff room valuables being stolen because everyone would have a locker. No more ‘pay rises’ that are effectively pay cuts. No more buying extra uniforms because not enough have been provided to comply with infection control policies. No more fishing a teabag out with the end of a knife. Maybe that last one sounds silly? But I do think the small things count. The small things that can help staff feel cared for whilst they put their emotional and physical energy into keeping mums and babies safe. Caring for a new baby is an amazing time for many parents, but it’s no walk in the park. Often friends and family members want to make it easier for the parents, but they don’t know how to. There’s a bit of a cliché that if we look after the mum, we’ll look after the baby. I wonder if it is the same in midwifery? If we look after the midwives, we look after the mums. If we imagine a hypothetical scenario where somebody’s life is in danger and the doctor says we can save you, we just need to do ‘x’. Most people will do whatever ‘x’ is to save their life – it is a very basic survival instinct. However, real life scenarios are rarely this straightforward; in real life, the risks are not always so clear cut, sometimes we have good evidence of the mathematical risk of doing (or not doing) something, and at other times we don’t know. The other problem with real life scenarios is dealing with real people, each with their individual needs, values and lifestyles. So in real life, the issue of safety is also more complicated than survival. Safety in maternity services is not just about keeping mum and baby alive. It is absolutely a worthy goal to improve perinatal mortality rates, I am not sure anyone would argue with that, but this should be our base level for safe care. And what comes on top of it is not just a bonus, it is actually very important and can have a huge impact on future health and wellbeing. So what are a few of the key safety issues? We can’t think about safety in maternity without considering some of the alarming disparities highlighted in the Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE) report.[3] It showed that black and Asian women have a higher risk of dying during pregnancy and that those who live in the most deprived areas are also more at risk of death in pregnancy and the period after. We can’t consider safety in maternity and ignore the recent Ockenden report,[4] which highlighted major failings at one particular trust, but with wider implications. Like previous investigations into maternity service failings, one key issue is workplace culture. The kind of culture where staff live in fear of speaking up when things are going wrong, the kind of culture where staff don’t want to go into work anymore. We have maternity services with a one size fits all approach, where a lot of midwives are leaving and staffing is already short, where disparities in outcomes because of race exist, all set in a culture where fear and blame are rife. How did we get to this? I can’t imagine any midwife sets out to become a part of the problem. But how can you give individualised care when you are just keeping your head above water? How can you stay in a job that leaves you exhausted because you are covering the shortfall? Tackling disparities requires time to train staff to become culturally competent and plan care that is personalised and non-judgmental. As midwives and student midwives, safe care includes appreciating the nuances of each client we work with. Appreciating the nuances of each team member so that effective teamwork changes the culture and it is a joy to go to work every day. So many of these changes start with individuals. Individual midwives. Individual student midwives. Individual obstetricians. What if we looked after these staff members? What if we gave them the same great care and respect we expect them to provide? This is not a negative woe-is-me kind of blog. This is a dreaming blog - this could happen! There could be more care and compassion for the maternity workforce. And what kind of difference could it make? With recent railway strikes, there are whispers of union action in other public services. This issue feels more complicated in caring professions like midwifery. Balancing the legal right to strike with the legal responsibility to care for childbearing women. I have never met a midwife whose primary reason for choosing the career was to make money. It is a job of passion, love and dedication. But this does not mean it should be poorly paid with poor conditions. Quite the opposite in fact. Midwifery is sometimes seen as a profession primarily relating to women, and this is true. But actually, midwifery affects everyone: partners, children, whole families, future generations. Midwives are involved in virtually every pregnancy, and almost every birth is attended by a midwife. Everybody is born. What kind of working conditions would you have wanted for the midwife caring for you at your own birth? And what kind of working conditions will midwives have as they serve future generations? Because you can bet your life it will impact the quality of care they can offer. References 1 Falling NHS midwife numbers show worrying trend says the RCM. Royal College of Midwives, 18 May 2022 2 RCM warns of midwife exodus as maternity staffing crisis grows. Royal College of Midwives, 4 October 2021 3 Saving Lives, Improving Mothers’ Care: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-19. Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK), November 2021 4 Ockenden Report: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust. 30 March 2022