I would spread the cloths under your feet: But I, being poor, have only my dreams; I have spread my dreams under your feet; Tread softly because you tread on my dreams. WB Yeats
The dreams of disabled doctors to succeed in the NHS workplace matter. Disability is a ‘protected characteristic’ under equality law. Data collection for the NHS workforce (e.g. NHS Workforce Disability Equality Standard) is part of a valid strategy to describe the extent of discrimination against disabled doctors in the NHS. But disabled doctors should not just be protected by the law, they should be supported to achieve their dreams of gainful employment.
Värlander (2012) articulates that disability is, in fact, a productive resource within any organisation in fostering creativity, innovation and problem-solving skills, diversity promotion, humility, and holistic attitudes towards employees [1]. Organisations need these attributes to thrive under adversity, to be fluid, people- and purpose-driven, and ready to adapt flexibly to change. The NHS is no different.
However, workforce recruitment, retention, and morale are threats to the sustainability, quality, and scope of health and social care services in the UK. The recently issued NHS People Plan provides no clarity about additional government spending on NHS recruitment, training, and education, despite acknowledgement of the need to do far more to support workplace wellbeing, diversity, equality, and inclusion [2]. Curiously, one never hears about workforce planning for disabled doctors. As a disabled doctor, I find it hurtful that despite the current existential workforce crisis, disabled doctors not in clinical work in the NHS, including formal training schemes, do not appear to be actively welcomed to return to practise.
Some doctors, on suddenly becoming disabled, might feel unable to ‘declare’ their disability in attempting to re-enter the workforce, whether in formal training or not. This could be for a number of reasons, not least a reluctance to accept an identity of being disabled. Some doctors who know they have a disability might want to keep it ‘hidden’ to maximise their chances of getting the job in the first place. There are advantages to disclosing your disability: for example, the implementation of reasonable adjustments is a legal provision for disabled applicants under the Equality Act [2010], and the openness itself can encourage trust and team building. However, we know from a detailed study of disabled people discussing employment experiences in various sectors, opinions about disclosure of disability are found to be strongly influenced by the nature of disabilities, including visibility, stigma associated with the disability, as well as perceptions about the “disability-inclusiveness” of the employing culture [3]. Furthermore, people with more “visible” disabilities, including use of mobility aids, thought it was important to discuss their disability early in the employment process, usually during the job interview, and they often took the opportunity to emphasise how they handle their disabilities so they do not affect doing the job well. But the NHS is known not to be an especially “disability-inclusive” organisation. In a recent online survey of disabled doctors and medical students, conducted by the BMA from November 2019 to January 2020, with 705 responses from around the UK, over ¾ of respondents (77%) reported being worried about being treated unfavourably if they disclosed a disability or long-term health condition.
A conversation about sudden-onset disability in NHS doctors needs to happen. A study from the Joseph Rowntree Foundation reviewed that, on average, two percent of people of working age become disabled each year, of these, 15 percent had an ‘accident’ in the previous year; 44 percent had experienced the sudden onset of a health problem; and 41 percent had intermittent, chronic or unspecified conditions which got worse. “Catastrophic disability” develops from more sudden medical events (e.g., stroke, hip fracture, etc.), and it has been increasingly realised that socio-economic factors impact significantly on disability trajectories [4]. In young to middle-aged persons, the most important causes of disability are congenital or perinatal conditions, trauma, acute or rapidly progressive diseases. For almost all of these conditions, the typical time course of the disabling process is rapid and is assumed to be pursuant to the underlying cause [5].
Doctors can suddenly become disabled. The practise of clinical medicine itself involves uncertainty [6], and, likewise, the timing of the onset of disability in an adult’s life can be uncertain, or totally unpredictable. Disabled doctors should be supported through this uncertainty to fulfill their career potential. For example, doctors often recommend that employers implement a phased return to work to help facilitate an employee’s return after long-term sickness absence, as a ‘reasonable adjustment‘ for a disability under the Equality Act [2010]. A phased return to work can be beneficial so employees can return to the workplace and continue to make an important contribution to an organisation or business despite their health issues. The “phased return” should involve detailed discussions about realistic, attainable goals, and might consider a whole plethora of amended duties, targeted educational supervision, personal mentoring, and expert occupational health support [7]. But what about a phased start to a new job if a disabled doctor has been off work for years? Junior doctors are particularly vulnerable because of the short-term nature of their contracts and the long duration of their training schemes.
The factors impeding returning to work for patients with disabilities have been well rehearsed elsewhere. Organisational context is reported to influence return to work; training has been necessary to ensure managers felt comfortable discussing with employees the adjustments they required, and, even within organisations, there may be variation in the willingness of different managers to make reasonable adjustments [8]. There is, at the time of writing this, no national infrastructure in England to support the safe return to work for doctors who have suddenly become disabled in adulthood. I hope a solution based on the public values of the NHS will prevail and support disabled doctors return to work. Statutory organisations should help doctors who have been unexpectedly and suddenly disabled. It can’t be left to market forces.
Planning in clinical medicine is important for the future, and no less so for doctors who find themselves disabled but who want to re-enter the workforce. As doctors, we advise patients that person-centred planning should build a patient’s strengths and skills, including health, support networks and use of technology. It is counterintuitive to think there would be no such planning for a doctor who has suddenly become disabled.
Finally, it is worth noting that the barriers faced by disabled doctors in training not only mean they are not permitted to flourish in NHS training, they are not just confined to standard breaches of the equality law, but, rather, reflect other ‘stinking thinking’ about training and education. Sir Ken Robinson, who died recently, argued that education uses uniform curricula, focused on conformity, compliance and linearity, with identical textbooks to prepare kids for the same tests at the end of the year, treating education like industrial manufacturing, when, in reality, it should be like organic farming, promoting the development and well-being of the whole student and recognising the vital interdependence of the student with the community.
We can empower disabled doctors to work or return to work in the NHS, if we want to – with the right statutory support and national leadership. The cultural apathy causing this not to be addressed thus far has been existential.
References
[1] Värlander, S. (2012). Management practice and disability: An embodied perspective. Scandinavian Journal of Disability Research,14(2), 148-164 (accessed 23 August 2020).
[2] David Oliver: Do the NHS workforce plans really add up? BMJ 2020; 370 :m3203
[3] Jans LH, Kaye HS, Jones EC. Getting hired: successfully employed people with disabilities offer advice on disclosure, interviewing, and job search. J Occup Rehabil. 2012;22(2):155-165.
[4] Latham K. Progressive and accelerated disability onset by race/ethnicity and education among late midlife and older adults. J Aging Health. 2012;24(8):1320-1345.
[5] Ferrucci L, Guralnik JM, Simonsick E, Salive ME, Corti C, Langlois J. Progressive versus catastrophic disability: a longitudinal view of the disablement process. J Gerontol A Biol Sci Med Sci. 1996;51(3):M123-M130.
[6] Simpkin AL, Schwartzstein RM. Tolerating Uncertainty – The Next Medical Revolution?. N Engl J Med. 2016;375(18):1713-1715.
[7] Laurie Anstis, A step by step route to full role recovery, Employers’ Law, July/August 2013, pp. 18/9.
[8] Grant, M., Rees, S., Underwood, M. et al. Obstacles to returning to work with chronic pain: in-depth interviews with people who are off work due to chronic pain and employers. BMC Musculoskelet Disord 20, 486 (2019).
Dr Shibley Rahman
Dr Shibley Rahman is currently a special advisor in disability for the NHS Practitioner Health., and a member of the Disabled Doctors Network He still actively researches in dementia and delirium predominantly, having successfully completed his Ph.D. from Cambridge. After his junior medical hospital posts, he became physically disabled, but he completed in London successfully his MBA (with a special interest in performance management) and his Master of Law (with a special interest in equality and discrimination).
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.