_OHFP.indb 27 _OHFP.indb 27 30/05/2014 16:17 30/05/2014 16:17 28 CHAPTER 1 Being a doctor Capacity Someone who has capacity can comprehend and retain information material relevant t o the decision, especially as to the consequences of not having the intervention in questio n, and must be able to use and weigh this information in the decision-making process. For a patient to have capacity they must: \200 Be able to understand the information rele vant to making the decision and consequences of refusal Retain the information long enough to allow for decision-making \200 Weigh up the informa tion to arrive at a decision \200 Be able to communicate the decision they have made. Rem ember that: \200 Patients may have the capacity to make certain decisions and not others \200 Capacity in the same patient may fl uctuate over time. Capacity is most often impair ed by chronic neurological pathology such as dementia, learning diffi culties, and psychiat ric illness, but is also impaired by acute states such as delirium, acute severe pain, alco hol and drug intoxication (both recreational and iatrogenic \200\223 eg morphine). Childre n and capacity Children under 16yr of age were once regarded as lacking capacity to give co nsent, but now if the child meets the criteria then they are regarded as having \200\230Gi llick \200\231 competence (Fraser guidelines1), and may give consent. It is always advisabl e, however, to involve the parent or guardian in discussions about the patient \200\231s ca re if the patient allows (see also b p403). No capacity When the patient does not have capacity and is over 18, family and friends are not able to make a decision on the patient \200\231s behalf; their views should, however, b e listened to. Where the patient lacks capacity and there is no next of kin to consult an I ndependent Mental Capacity Advocate (IMCA)2 may need to be appointed who advises cli- nicia ns in making decisions on behalf of the patient in their best inter- ests. In an emergency situation, the patient is treated under the \200\230doctrine of necessity \200\231, that i s, doing what is in the patient \200\231s best interests until they attain capacity to make the decisions themselves. Gillick competence/Fraser guidelines Although 16 is the usual age at which people are autom atically allowed to give their own consent, younger people can consent to most treat- ments or operations if they are capable. This follows a famous case in 1986 when Victoria Gillic k went to the courts to get authority to be informed if her daughters sought contraceptive treatments. The law dis- agreed and decided that if a child was competent, he/she could con sent to treatment without parental knowledge \200\223 this is often referred to as being \200\230Gillick \200\231 competent when a child meets the criteria in that case. 1 Gillick or Fraser? A plea for consistency over competence in children. BMJ 2006; 332:807. 2 Mental Capacity Act (2005); (cid:27)www.legislation.gov.uk/ukpga/2005/9/section/35 OHFP.indb 28 OHFP.indb 28 30/05/2014 16:17 30/05/2014 16:17 29 CONSENT Consent Understanding consent and obtaining it satisfactorily can be diffi cult. If you are ever unsure seek senior help. Obtaining consent The individual who obtains consent from th e patient should be aware of the risks and benefi ts and be able to com- municate the proce dure in a language that the patient will understand. If you do not regularly perform the pr ocedure yourself or are not trained to take consent for the procedure then you must not obt ain consent for it. Obtaining consent satisfactorily is a skill that can be learned from se nior colleagues, so initially shadow your seniors when they are taking consent from a patie nt to learn how to do it properly, then have a senior colleague supervise you the fi rst fe w times to ensure you include all the relevant information. Informed consent In order to give informed consent, patients must fi rst be deemed to have capacity to consent under the specifi c circum- stances (b p28). Consent should refl ect th e fact that the patient is aware of what is going to happen and why. They should be aware o f the consequences of not undergoing the procedure, the potential benefi ts, and any altern atives, and be free from any coercion. The common risks and side eff ects should be discuss ed, as should the potentially rare but serious consequences of the procedure. As a rule, an y risks which might aff ect the decision of a normal person should be discussed \200\223 p lus any risks that might be of specifi c importance for the individual patient, such as whe re the profession of the patient makes a normal trivial risk of special importance (eg a ti ny risk of post-operative vertigo might be of particular importance for a window cleaner). The patient should be pro- vided with information well in advance of the procedure to allow them to think it over and prepare any questions they may wish to ask. Types of consent There are three main types of consent: \200 Implied The patient off ers you their arm as you approach them with a needle and syringe to take blood Expressed \200\223 verbal You explain that you are going to perform a lumbar puncture, by describing the procedure and potential complications and the patient agrees to have it done Expressed \200\223 written The patient is given an extensive explanation of the procedure and complications and informed of the alternatives. A record of the consultation is made wh ich both patient and doctor sign. This document should be completed prior to the planned tr eatment or procedure, and consent verifi ed at the time of the procedure. Diffi cult situations There are many situations where problems arise with consent issues. I f in doubt seek senior advice or consult one of the medical defense unions (b p600) which h ave 24h telephone support. If a patient has capacity to give or withhold consent, and choos es not to receive treatment even in the face of death, then treating that patient against t heir will is potentially a criminal off ence. This includes patients with psychiatric illne ss. Note that this situation is distinct from that of a patient with a psychiatric illness who may lack capacity to make decisions regarding psychiatric treatment, and may be detaine d and given psychiatric (but not medical treatment) under the Mental Health Act (b p364). _OHFP.indb 29 _OHFP.indb 29 30/05/2014 16:17 30/05/2014 16:17 30 CHAPTER 1 Being a doctor Medical errors Every doctor makes mistakes varying from the trivial and correctable to the severe and avoidable. What to do at once/within an hour \200 Stabilize the patient, call for senior help early \200 Do not compound the error by trying to cover it up or ignoring it \200 Correct whe re possible, apologizing to the patient as appropriate \200 Don \200\231t underestimate t he seriousness of the situation; have a low threshold for asking for help to ensure things do not get any worse \200 If serious and you have time, start documenting events, includi ng times \200 If, sometime after an error, you realize you wish to add further details to the notes then do so but make it clear when these additions have been written by timing an d dating them. This is perfectly acceptable \200 Amending notes, without making it clear that your entry was made retrospectively and with a clear date and time, is serious misconduct. Serious untoward incidents \200\223 rare \200 An apology is not an admission of guilt, s o apologize and explain to the patient early. Apologize that the event has taken place, it is not necessary to \200\230give confession \200\231 at this stage \200 Inform your seni or/consultant immediately \200 If you believe your error has caused the patient signifi c ant harm then you should speak to your defense organization (b p600) as soon as practical. Disciplinary procedures If you have made a really serious error the hospital may choose to exclude you from working. That is, to send you home at once and ask you not to return until they have carried out preliminary enquiries. It is not a judgemental act but is designed t o allow a calm and quick investiga- tion. You must be informed why you have been excluded. You may be asked not to talk to others involved. If this happens to you, ring your defense organization at once. You should be given a named person to contact in the hospital. You ca nnot be excluded for more than 2wk without a review. Go and stay with friends or family, do n \200\231t be on your own. Let the hospital and others know how to get hold of you. Less serious errors should be treated as a training issue and dealed with by your consultan t initially or the trust clinical tutor/postgraduate dean. A period of close supervision or retraining may be appropriate. Sources of help \200 Clinical events Your consultant, your educational and clinical supervisors, the postgraduate dean, your defense organization Non-clinical events Your consultant, the postgraduate dean, the BMA. Don \200\231t forget f riends, and family and remember that these events resolve extremely slowly, taking years in the big cases, so don \200\231t expect large numbers of answers in the fi rst week. OHFP.indb 30 OHFP.indb 30 30/05/2014 16:17 30/05/2014 16:17 31 COMPLAINTS Complaints Every doctor has complaints made about them. These can be about your clinical ab ility, conduct, or communication skills. They may be justifi ed or spurious but they are in evitable, therefore do not feel your world has fallen apart when you are told a complaint h as been made about you. How the system handles complaints There are two types of complaints \200\223 formal and in formal. If a patient complains to you informally it is in everyone \200\231s best interest, and will save many hours of clinical time, if you are able to resolve the situation to the patient \200\231s satisfaction there and then. If you are unable to do so, but feel the pr oblem may be solvable by more senior input, then call for help. Don \200\231t agree to do s omething which you are unable to carry out. How to respond to a complaint \200 All formal complaints are collated centrally in the ho spital. In the rare event you are sent a complaint personally, do not respond but pass it to the complaints dep artment. In most trusts the department that handles complaints is known as PALS (Patient Ad vice and Liaison Service). They also provide more general advice and support for patients If a patient makes a complaint to you about care they have received from a colleague (docto r, nurse or other) then listen to them but try to avoid appearing to agree or support their position, no matter how much you may share their opinions. Depending on the seriousness of their allegations, either off er to feedback the comments or advise them to discuss matter s further with PALS If a complaint has been made about the care of a patient you saw, you may be asked for a statement. This is an internal document and should be written as a l etter, but bear in mind if the case goes to court this document could be requested by the p atient \200\231s lawyers Simply state the facts as you see them, do not try to apportion blame. You may be able to e xpand on your notes, particularly the details of conversations which may not have been docu mented Do not take it personally \200 If you feel it is clear how any error could be avoided in future then state this as well. Patients are often satisfi ed by knowing that any mistake t hey suff ered will not be repeated for others All the statements made by the staff involved are then collated and a letter is written on behalf of the chief executive (and usually signed by them) to the pati ent. This usually ends the matter There are further steps, both with the trust and then regionally, if this is not enough. Serious errors \200 Preventable death of a patient \200 Signifi cant harm to a patient, in a predictable way \200 Disciplinary off ences including: substance abuse \200 being drunk on duty \200 sexual/racial harassment. _OHFP.indb 31 _OHFP.indb 31 30/05/2014 16:17 30/05/2014 16:17 32 CHAPTER 1 Being a doctor Incident reporting Clinical incidents are defi ned as: \200 Anything which harms patients \200\231 care or disrupts critical treatment \200 An event which could potentially lead to harm if allowed to progress ( \200\230near misses \200\231). They range from minor incid ents, eg incorrect results, to life-threatening, eg wrong blood group in a blood transfusio n. Non-clinical incidents include: \200 Incidents which involve staff , relatives, or visito rs \200 Incidents which involve non-clinical equipment or property. The aim of incident r eporting is to highlight adverse incidents or \200\230near misses \200\231, assess them, a nd review clinical practice as a result. Ultimately it is designed to reduce clinical risks and improve overall quality of patient care. When a clinical incident/near miss occurs \200 Make sure the patient is safe \200 Compl ete a trust critical incident reporting form (usually online) \200 Forward the form to th e clinical risk coordinator (usually automatic if form is electronic) Ensure your seniors are aware of what has happened \200 Consider completing some formal r efl ective practice in your ePortfolio. Examples of all too common clinical incidents1 \200 Blood samples from two diff erent patients being confused \200 Failure to report or follow-up abnormal results \200 Equipment failure \200 Drugs prescribed to patients wh o have a documented allergy \200 Delay in treatment/management. Completing incident forms \200 Fill in an incident form as soon as you can after the event so that you don \200\231t forget any relevant information Check you are fi lling in the correct form. All NHS trusts now use online incident reporting systems though there may be paper backups \200 Include the time, date, staff involved, as well as the issues being reported Check if the named consultant needs to fi ll in/sign the form \200 If you are reporting a n incident involving your colleagues, inform them and explain the situation. Learn from their mistakes without judging them. The critical incident form is copied to clinical risk directors for evaluation at panel mee tings, where changes to clinical practice are discussed. Hints and tips \200 If a critical incident form is fi led involving yourself, don \200 \231t assume you \200\231re a bad doctor; use it as a learning experience Find out the reason and circumstances and clarify the situation with the person fi ling the report Go over the incident and review your actions, asking if there is anything you would change; if it helps, discuss it with a colleague. 1 See (cid:27)https://www.gov.uk/government/news/never-events-list-update-for-2012-13 for a list of events that should never happen (but sadly, still sometimes do). OHFP.indb 32 OHFP.indb 32 30/05/2014 16:17 30/05/2014 16:17 33 COLLEAGUES AND PROBLEMS Colleagues and problems Many of us may have worked with a colleague who worried us pro- fes sionally \200\223 \200\230I wouldn \200\231t want to be treated by Dr X \200\231. When do es this become enough to do something? And what do you do? Clinical incompetence \200 The GMC is quite clear that we all have a clinical duty to rep ort colleagues who we believe to be incompetent. This does not equate to pointing out every fau lt of every other doctor but it does mean that you cannot ignore serious concerns if you be lieve patients are at risk of harm Serious concerns about a trainee should be passed to the relevant consultant. Ask to see them in private. It may be easiest to open the conversation with a q uestion, to ask them to put your mind at rest: \200\230I don \200\231t know if you are awa re that Dr X does not use chaperones? I \200\231ve always been told we should use them for intimate examinations. I \200\231m here because two women told me that they had felt uncomf ortable with Dr X. \200\231 If the problem is with a consultant then you should either talk to another consultant or, i f it is very serious, the medical director If you are unsure whether a problem exists, or how serious it is, then talk to a friendly c onsultant informally (eg your supervisor or a clinical lecturer you got on with at medical school). Recreational drugs/alcohol \200 There is a clear diff erence between a doctor occasionall y drinking too much whilst off -duty and one who helps themselves to controlled drugs or who has devel oped an alcohol problem Likewise, regardless of substance, there is a diff erence between what someone does that only aff ects themselves and actions which aff ect quality of patien t care. Any colleague who appears on duty whilst badly hungover is a potential risk to pati ent care and should be removed from clinical duties (and should be encouraged to recover in the mess or go home). Repetitive behavior of this kind should be discussed with the collea gue, and/or their educational supervisor \200 Drinking during working hours, arriving dru nk, or use of controlled drugs are totally unacceptable and you have a duty to alert your c onsultants to any such problem. They will consider the GMC guidance and following a meeting with the individual involved will decide if GMC referral is appropriate or if a local warn ing and period of \200\230probation \200\231 is needed These problems are better tackled e arly whilst solvable than left until they cause patient harm and ruin a career. Psychological problems \200 Every year doctors develop serious psychological illnesses ju st like the rest of the population and doctors are just as bad at self-diagnosis \200 The more common problems include frank depression and hypomania, the rare include psychosis an d schizophrenia (b p365); the symptoms often come on gradually such that even close colleag ues may not notice the transition from mildly eccentric to frankly pathological Depression is commonly masked well whilst at work \200 Talk to an individual directly, or their consultant, if you are concerned about their health. _OHFP.indb 33 _OHFP.indb 33 30/05/2014 16:17 30/05/2014 16:17 34 CHAPTER 1 Being a doctor Hating your job Experiencing problems at work is common and usually transient. If you fi nd things do not improve try to identify the problem. However diffi - cult things are at work , you should always remain polite, punctual, and helpful. If you don \200\231t you may be t he one perceived to be the problem. Stress at the workplace The responsibility that comes with being a doctor, the demands of y our job, fear of litigation, and high expectations from peers and patients can leave you ph ysically and mentally exhausted. If you feel things are getting on top of you reassess your workload. Speak to colleagues to fi nd out if there are easier ways of doing things. Take annual leave and upon your return approach your work schedule diff erently to help regain c ontrol of things. Ensure you have time to relax away from work and keep up your outside int erests. If things don \200\231t improve, talk to a friend, contact the BMA (b p600) for adv ice, or discuss the situation with a trusted senior or mentor. Handing in your resignation If you can fi nd no other option and you are clear medicine isn t for you, you can always leave your job. Find out how much notice you are required to giv e and who to direct your letter of resignation to. During your last weeks, stay an active m ember of the team rather than taking a short-timer \200\231s attitude. Complete any outstan ding work and tidy up loose ends before leaving. Bullying at work Bullying can be from your seniors, peers, other healthcare professionals, patients or their relatives. If you feel you are being bullied, discuss it with someone, ei ther at work or independently (eg the BMA). Speak to your predecessors to fi nd out if they had similar diffi culties and how they handled the problem. Keep a diary of relevant event s, together with wit- nesses, and approach your consultant. If it is your consultant who is the problem, approach another consultant you trust or contact BMA coun- selling (b p600). Sexual harassment This may start very innocently and gradually escalate into intimidating b ehavior which may aff ect your work, social life, and confi dence. In the fi rst instance m ake it clear that their advances are not welcome and confi de in someone you trust. Find ou t if other colleagues are also being harassed and report the harassment to your educational supervisor. Again, the BMA can be a useful source of advice. Discrimination All employers must abide by an equal opportunities policy that includes stan dards on treating all employees. Before deciding to take things further confi de in a trust ed senior colleague. Keep a record of any events that stand out as being discriminatory, do cumenting dates, times, and wit- nesses. Contact the BMA for advice. You may have to submit a formal letter outlining your concerns, so make sure you are prepared to pursue a formal complaint before committing yourself on paper. OHFP.indb 34 OHFP.indb 34 30/05/2014 16:17 30/05/2014 16:17 35 CAUSES OF STRESS Relaxation Have a break There are few problems that must be solved immedi- ately. Leave the ward, ask someone to hold your bleep, and take 5min to unwind. Try taking deep breaths and concentrating on the feeling of the air rushing in and out of your lungs. Count the breath s and try to clear your mind. Try squeezing the muscles in your feet then feeling them rela x; do this with all the muscle groups from your legs to your neck. Think about something yo u are looking forward to. Do not let medicine take over your life. It doesn \200\231t take much to make life seem massively better; try the following: \200 Talk to friends \200 G o for a walk \200 Watch sport \200 Watch a fi lm \200 Play a game \200 Go shopping \200 Have a good cry \200 Exercise \200 Go to the pub \200 Watch a comedy \200 Ha ve a massage \200 Take a long bath \200 Cook \200 Go out for a meal Plan a holiday \200 Talk to parents \200 Have a lie in \200 Listen to music \200 Ha ve an early night \200 Join a class/club \200 Read (another) book. Try to avoid the following: \200 Smoking \200 Excessive alcohol Drugs/sleeping tablets \200 Excessive caff eine. Causes of stress Attitude There is no point worrying about things you have no control over; it is natural to feel concerned about future events but almost everything will turn out we ll in the end, even if it is not as you have planned it. The job See b p18 on being effi ci ent. The job gets much easier with time; these skills become second nature and you perform individual tasks quicker. Yourself Be honest with yourself: Are you tired? Everything is ha rder, slower, and more stressful when you have not had enough sleep. Think about what makes you stressed and whether this is a problem with your attitude, the way you do the job, oth er people or the nature of the job. Try to accept, change or avoid these stressors. Other p eople If someone is annoying you then consider telling them so. Plan how you will tell them , do it in private and do not blame them; just explain how it makes you feel. Most people w ill be apologetic and try to change. If you feel it is all getting too much and/or nobody cares try speaking to: BMA counseling (you don \200\231t need to be a member) Samaritans 08459 200 169 08457 90 90 90 _OHFP.indb 35 _OHFP.indb 35 30/05/2014 16:17 30/05/2014 16:17 36 CHAPTER 1 Being a doctor Pay and contracts The number of hours you are allowed to work in a shift and the total for a given week are determined by two sets of rules: \200 \200\230New Deal \200\231 on juni or doctors \200\231 hours and pay, which was an agreement between the BMA and all the UK De partments of Health to improve the working conditions of junior doctors. European Working Time Directive (EWTD) \200\223 this sets limits on working hours and mini mum rest periods that are more stringent than those in the New Deal. Junior doctors across Europe were initially excluded from the EWTD, but there has been a staggered process of hou rs reduction and all posts must now be EWTD compliant. EWTD \200 Maximum of 48h of work a week \200 Maximum shift length of 13h \200 11h of continuous rest every 24h or compensatory rest must be given \200 24h continuous rest eac h week or 48h in a fortnight \200 All time when you are required to be on site counts as work, whether you are actively working or resting. New deal \200 Set limits on working hours now superseded by the EWTD \200 30 min of uni nterrupted break after approximately 4 hours of work \200 Detailed requirements about the requirements for diff erent working patterns. These aff ect the maximum length of any on-c all period; most foundation doctors will work a full shift rota. Monitoring and rebanding \200 Monitoring actual hours worked by junior doctors is done to check they mirror the theoretical hours of the rota. All training posts have to be monitor ed for at least 2wk by all participants every 6mth. This is a contractual requirement for e mployer and employee Accurate hours monitoring is a matter of probity and is important to ensure that you, your colleagues and future post holders are not put in a position where pa tient safety may be compromised. You should monitor your hours honestly \200\223 this incl udes resisting pressure to under-report hours. Sadly, this pressure may come from your own consultants and can be diffi cult to deal with. Discuss with your colleagues, your educatio nal supervisor and your local BMA representative if this happens If your post turns out to be monitored as a diff erent band to the one you \200\231re paid then your pay can go up but is protected against going down. Your rota cannot be changed in such a way as to aff ect your salary without the agreement of the majo rity of the doctors on the rota \200 The guidance for \200\230rebanding \200\231 and pay protection is complex. It is available from the NHS Employers website, where the latest basic salary rates can also be f ound: (cid:27)www.nhsemployers.org If you are a BMA member, they have several further resources on-line regarding pay, contracts and hours: (cid:27)bma.org.uk OHFP.indb 36 OHFP.indb 36 30/05/2014 16:17 30/05/2014 16:17 37 PAY AND CONTRACTS Pay and banding contracts Junior doctors in the NHS receive a set basic rate of pay, acco rding to the grade and the number of years they have worked. Those whose posts involve more than 40h/wk and/or out-of-hours working, receive an addi- tional sum, known as a banding supplement , based on a multiple of their basic salary (Table 1.3). This supplement should refl ect the overall work- load and the extent of out-of-hours working required in the post . \200 Band 1 average total hours of actual work under 48h/wk \200 Band 2 average total hours of actual work <56h but >48h/wk \200 Band 3 average total hours of actual work ove r 56h/wk. Bands 2 and 3 are not compliant with the EWTD and should no longer be in use. Ban ds 1 and 2 are subdivided according to the number of hours worked at antisocial times (week ends, evenings and nights), with A representing more out-of-hours working than B and C . Table 1.3 Banding multiplier These rates are subject to annual review as part of the doctors \200\231 annual pay award. Posts with <40h/wk worked exclusively between 8am \200\2237pm Mon \200\223Fri are unbanded and receive no supplement. Band 1A +50% +40% Band 1B Band 2A +80% Band 2B +50% Band 3 +100% Band 1C +20% For more information on pay and pay slips, see Fig. 1.1 (b p39). _OHFP.indb 37 _OHFP.indb 37 30/05/2014 16:17 30/05/2014 16:17 38 CHAPTER 1 Being a doctor Making more money There are several ways to make money in addition to your basic income. Yo u must keep records of all additional income and declare these in your self-assessment to t he Inland Revenue at the end of each tax year.1 Research There are usually several research projects being under- taken in most hospitals which require volunteers to have experiments performed on them. These range from a 5min interview to a week-long study and in most circ umstances the volunteers are rewarded fi nancially (eg 5 to over 500). These may carry a risk of harm. Locums Most hospitals employ locum doctors to cover staff sickness or at busy times. Locum doctors often already work for the hospital, but work additional shifts for extra money; al ternatively they may be from outside the hospital. It is important to remember that the hou rs you work as a locum should be added to your basic or regular hours and should not exceed the limits of the New Deal2 or European Working Time Directive; some contracts may stipula te that you cannot work locum shifts in other hospitals or departments. There are many locu m agencies that you can register with; they are often advertised in BMJ Careers. Rates of p ay vary, but an F1 can expect pre-tax rates of 20 \200\22330 per hour, and F2s 25 \200 \22335. If your own hospital is employing you as a locum, you may be able to negotiate a be tter rate. Cremation certi \201 cates The cremation form has two parts (b p94). The fi rst is completed by a ward doctor (usually the F1) and the second by a senior doctor, often fr om another department. Under arrangements prior to 2014, junior doctors were paid around 70 for completing the form; this fee is under review as part of the 2014 reforms (see b p98 ). The bereavement offi ce handles the forms and issues any checks. Make sure you see the b ody, checking identity and that there is no implantable device that needs removing (b p94); they do really explode. However, this system and the associated fee is under review as par t of the 2014 reforms to death certifi cation. Published articles A small number of journals and medical newspa- pers pay authors for arti cles which appear in print. The amount varies from between 25 to 250 depending on the l ength and importance. The jour- nals \200\231 websites often outline payment and the types of articles they are after. Gifts The GMC are quite clear in their message that you should not encourage patients or th eir families to give, lend, or bequeath gifts to yourself, others, or to organizations.3 If you are given a gift then it is acceptable to take it as long as it has negligible fi nanc ial value. If you are given money then it is sensible to pass this onto the ward sister who can put it in the ward fund account. 1 (cid:27)www.hmrc.gov.uk/sa/index.htm 2 Junior Doctors \200\231 Handbook 2012. British Med ical Association. 3 (cid:27)www.gmc-uk.org/guidance/good_medical_practice.asp OHFP.indb 38 OHFP.indb 38 30/05/2014 16:17 30/05/2014 16:17 39 MAKING MORE MONEY Fig. 1.1 A sample pay slip. Always check your payslips carefully, before storing them safely: make backups of electroni c payslips and never throw paper copies away. They can be a useful record of tax, pension, and loan payments long after you have enjoyed spending the money. If you think a mistake ha s been made, contact the salaries and wages division of the HR office for your trust, quoti ng your assignment number (employee number). In the event of signi \201cant underpayment, you can request an interim payment be made pending the resolution. Department Gen Med Employee name Dr Tertius Lydgate Job Title Foundation House Officer 1 Sal/wage 22636.00 Tax office ref 199/C2 Location Middlemarch Hospital Payscale description Foundation House Officer 1 Standard hour s 48 Tax code 1000L 3 Description Tax Inc. date 5 Aug 2015 PT sal/wage 22636.00 NI number JD354523D 1 2 Amount 4 1886.33 Amount 494.22 6 Description Basic pay 7 Banding supplement 754.53 NI 219.05 5 NHS Pension Mess fee 169.77 6.00 8 Student loan 119.23 9 This period summary Pensionable pay 1886.33 Pay date 26 March 2015 Pay method BACS Taxable pay 2471.09 15 Total payments 2640.86 Total deductions 1008.27 Gross pay Taxable pay 10 12 13 Tax paid NI letter D 11 Pension conts 14 Employee number 16 17 18 NET PAY 1632.59 1 This is the total annual basic salary for your pay point. Latest updates are released as Pay Circulars on the NHS Employers website (cid:27) www.nhsemployers.org 2 This is the date when you are next due to go a point up the pay scale, usually 12 months of full time employment after your previous date (or date of first starting working as a do ctor). When changing trusts mistakes can be made so always check this date is correct. 3 Your tax code shows the amount of income you are entitled to earn in the current tax year that you do not pay any tax on. This figure should be multiplied by 10 to give your total allowance. This will be the basic personal allowance for the tax year, as set by the govern ment, adjusted to take account of any under- or over-payments you may have made in previous years. Each tax year runs from April to April. After your first tax year in paid employmen t, you will receive a P60 summarizing your tax paid during that year with the code that sho uld apply to you in the next tax year. A copy should also be sent to your trust, but if you move trusts around this time, the new trust may not receive the correct information unless you show them your copy of the P60. If your new trust does not know the correct code for y ou, they will use an emergency code, set as the basic personal allowance, which may or ma y not be correct. The letter after the code should be an L unless very specific circumsta nces apply to you. See also (cid:27) www.hmrc.gov.uk 4 This will be approximately 1/12 of your annual salary. 5 6 Under the Pay as you earn sc heme (PAYE), your trust will automatically deduct your tax from your income each month. Bot h your basic pay and your banding supplement are taxable. In your first few months of emplo yment, you may not pay any tax until your income has risen above the personal allowance for that year. Enjoy this while it lasts! If you receive a banding supplement, it will appear here (see Table 1.6). 7 National Insurance contributions pay for certain state benefits, including your state pen sion. These are not optional, and will be deducted automatically, according to thresholds. The current rate is 9% of income over 149/week, though this is subject to annual review. 8 The NHS pension scheme remains a very good deal, although terms and conditions have been changed significantly in recent years and are subject to further negotiations. Your pension contributions are not taxed and will also be deducted automatically according to various earnings thresholds, unless you o pt out of the scheme. Pension contributions are calculated from your basic pay - your bandi ng supplement is not subject to any deductions. See also (cid:27) www.nhsbsa.nhs.uk/pension s 9 Any loan you have taken from the Student Loans Company will enter repayment in the April of the first year after you graduate in which your gross pre-tax income rises above a threshold (currently 16,365). A ny earnings should be deducted automatically at 9% of earnings above this threshold. You ca n choose to repay faster if you wish. Keep a record of all repayments you make and check th em against your annual statement - errors are common when changing trusts. Payments that ap pear to have gone missing can be credited to your account easily if you can provide a copy of your payslips. See (cid:27) www.studentloanrepayment.co.uk 10 The numbers in this section will keep a tally of your total payments from that employer during the current tax year. If you change trusts, the numbers will be reset, but your tax thresholds should not be. 11 Your NI letter reflects the contribution group you fall into. For almost all of those in the NHS pension scheme, this will be D . 12 Pensionable pay does not include any banding supplement. 13 Pay dates will vary between trusts but are generally around the last Thursda y in the month. It can be difficult to get paid on time at the start of employment with a new trust. 14 Trusts will transfer the money into your bank account by BACS transfer. These can take u p to 3 working days. 15 Your taxable pay includes your basic pay and your banding supplemen t, less any pension contributions. 16 Don t get too excited by this number \200 17 \200 a nd try not to get too sad about this one \200 18 \200 because this is what you re going t o have to spend until next month comes around. _OHFP.indb 39 _OHFP.indb 39 30/05/2014 16:17 30/05/2014 16:17 40 CHAPTER 1 Being a doctor Money and debt As the average medical graduate debt now exceeds 24,000, and rising fast, fi nancial management priorities have changed. This section is not compre- hensive but aims to give some important pointers and warnings. Debt clearance Most graduates have three diff erent types of debt: (1) Short-term high-inte rest debts (eg credit cards overdraft, if at full charge). Pay these back fi rst and as fast as possible. Try not to extend them just be cause you have an income (2) Medium-term commercial loans (eg a high street bank graduate studies loan). These should be paid back next, as spare funds allow (3) Student-loans at very low rates of interest \200\223 pay these back last. Pay close at tention to the annual percentage rate (APR) and charges attached to any loan arrangement. I nterest-free loans or credit cards can help in the short term but ensure you don \200\231t get saddled with a high APR later. Loans are a competitive market so shop around \200\223 especially for something like a car loan where the car dealer rarely off ers the best rate. Think \200\230total cost \200\231 not just \200\230monthly repayments \200\231. Some basic rules for \201 nancial planning \200 Short term Clear debts with the highest interest as soon as possible \200 Medium term Try to accumulate about one month \200\231 s salary as \200\230emergency \200\231 savings Long term The NHS pension scheme remains the best available at present and you will be auto matically enrolled in it unless you opt out. With this taken care of, you could think about trying to save for the deposit on a property (even if just 100/mth). With interest rates currently low, home ownership is an attractive option if you can raise a deposit. Bear in mind that there are large up-front costs to house buying (eg legal fees, stamp duty), you w ill be responsible for all maintenance and will not be able to take the property with you w hen you move to another part of the country. Financial advice Since you now have a salary increasing every year and virtually guaran- te ed for life, fi nance companies will swarm round you like wasps round jam. Beware of some v ery slick sharks \200\223 their aim is only to get you to buy their products. There is no altruism here: \200 Truly independent fi nancial advice is hard to obtain \200\223 ask h ow independent they really are Firms must now show what commission will be received for any product you choose, both to the individual who sold it to you as well as to their company Do not buy from the fi rst or most persuasive salesperson, but take your time to consider what you really want and need. Financial and other products Critical illness cover and income protection See b p11. Check if it still pays if you are capable of doing a less demanding job. Check if it pays for all conditions you may get at work. OHFP.indb 40 OHFP.indb 40 30/05/2014 16:17 30/05/2014 16:17 41 MONEY AND DEBT