The Doctor – issue 22, June, 2020

The magazine for BMA members

thedoctor

Issue 22 | June 2020

What next?

The impact of the ‘new normal’

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Tough calls

Preserving humanity when patients and families are apart

Ask a Kiwi

How did New Zealand cope so well?

Assessing the risk Fighting for better protection for BAME doctors

08/06/2020 10:12

thedoctor

The Doctor BMA House Tavistock Square London WC1H 9JP Tel: (020) 7387 4499

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Call a BMA adviser 0300 123 1233 @TheDrMagazine @theBMA The Doctor is published by the British Medical Association. The views expressed in it are not necessarily those of the BMA. It is available on subscription at £160 (UK) or £225 (non-UK) a year from the subscriptions department. All rights reserved. Except as permitted under current legislation, no part of this work may be photocopied, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical or otherwise without the written permission of the editor. Printed by YM Chantry. A copy may be obtained from the publishers on written request.

Editor Neil Hallows (020) 7383 6321 Chief sub-editor Chris Patterson Senior staff writers Peter Blackburn (020) 7874 7398 Keith Cooper (020) 7383 6390 Staff writer Tim Tonkin (020) 7383 6753 Scotland correspondent Jennifer Trueland 07775 803 795 Senior production editor Lisa Bott-Hansson Design BMA creative services Cover Photographer Ed Moss

The Doctor is a supplement of The BMJ. Vol: 369 issue no: 8249 ISSN 2631-6412

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In this issue 4-5 Emotional burden

Extended working hours, concerns for safety, and massive uncertainty are all affecting doctors

Welcome Chaand Nagpaul, BMA council chair This issue of The Doctor magazine offers an insight into a profession adapting to unprecedented challenges – and a powerful reminder of the effect of this crisis on doctors, patients and our NHS. The coronavirus crisis has changed everything: the roles we are working in, the responsibilities we have taken on and the ways in which we interact with patients. And on a personal level, the stories and analysis contained within this magazine highlight for me the remarkable efforts made by doctors across all sectors of the NHS. As one of our pieces says: ‘If the pandemic has shown anything, it’s that doctors flex and they adapt and that even at the toughest of times, they are willing to share their skills and learn new ways of working.’ To do all of this while dealing with so much bereavement, and under constant threat of burnout, is the greatest accolade imaginable.

We consider the wider effect of this unprecedented public health crisis with input from doctors concerned about the future for their specialties and their patients. It is striking just how far and wide the effects may be felt – from vulnerable children who need safeguarding not currently being seen in hospitals to delayed presentation at GP surgeries or hospitals for serious conditions.

We also look at the ‘new normal’ for doctors whose working lives have changed beyond recognition and look to New Zealand for lessons on the crisis. We feature a piece demanding adequate personal protective equipment for a significant proportion of doctors who, even now, still report struggling to access basic protection.

In this issue of the magazine we also consider the difficulties relating to communicating bad news to patients and families, particularly when unable to do so in person and consider the effect of the crisis on the mental health of the workforce, through a vast BMA survey of doctors.

This edition also features a vital piece looking at the alarming effect of this virus on people from black, Asian and minority ethnic backgrounds – with doctors working on the front line speaking to us about their fears. This issue could not be of any greater importance and we will continue to demand a national system for assessing the level of risk facing individual doctors to be consistently applied across the NHS.

6-11

A new normal How doctors’ working lives have changed, and what the BMA is doing to keep them safe

12-13

Prepared for the worst How did New Zealand cope so well with COVID-19, and what can we learn from it?

14-15

PPE: a problem yet to be fixed Doctors continue to report problems accessing basic protection

16-19

The long road back When and how the NHS should start adjusting back to normal

20-21 Locking down and speaking up

A Freedom to Speak Up guardian offers advice on exposing injustice

22-24 Tough calls Maintaining humanity, when patients and their relatives are kept apart

25-29 Fighting the odds and On the ground

The fight for better protection for doctors at particular risk from COVID-19

30-31 Dousing the flames The BMA writing competition winning entry

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The emotional burden Extended working hours, concerns for safety, and massive uncertainty is causing some doctors to suffer intense mental distress. Tim Tonkin recounts their experiences and sets out the help and support the BMA is offering

‘I

don’t think I realised how stressful it was directly until I wasn’t sleeping, and bursting into tears in the car and when saying goodbye to my kids on the way to work.’

‘I feel I have aged over the past three months, with variable levels of anxiety and stress, it’s been a rollercoaster of emotions, whilst trying to run a practice and protect my staff.’

‘I have never experienced this much stress in my whole career of 15 years.’

These heartfelt and brutally honest confessions as to the physical and mental demands being borne by doctors leading the fight against COVID-19,

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reveal the extent to which the pandemic has tested the mental resilience and wellbeing of NHS staff throughout the UK. A recent BMA COVID-19 tracker survey found that 41 per cent of doctors were suffering with depression, anxiety, stress, burnout, emotional distress or another mental health condition relating to or made worse by their work, with 29 per cent saying this had got worse during the pandemic.

Emotional toll There have been more than 40,000 deaths in the UK of people who had tested positive for COVID-19.

While the emotional effect

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of any death is most acute for the loved ones of those who have lost their lives, the drawn-out and everincreasing human tragedy wrought by the virus has unquestionably taken a huge emotional toll on doctors and other frontline healthcare professionals.

‘I think as doctors we want to be able to fi x people and make them better,’ a West Midlands junior doctor told the survey.

‘Working on a COVID ward where all the patients are frail and elderly, and the majority of them dying and there being nothing we can do, has seriously impacted on my team’s and my own mental health.’

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Family risk As of 29 May, a total of 29 doctors who had been actively serving in the NHS were confirmed to have died having tested positive for the virus.

Of this total 27 were from BAME (black, Asian or minority ethnic) backgrounds and all but one was male.

One East Midlands-based junior doctor told the survey that while she accepted the risks to her own health, the prospect of her family being infected as a result of her work was an incredible emotional burden.

‘I feel like I am more concerned for my family members and even though they support me fully, it feels like I am opening them to risk unwillingly.

‘It does feel like I’ve signed up for the Army and that I may get injured on the way and I don’t mind that. I signed up to be a doctor well before COVID when HIV, hepatitis and TB were feared.

‘But my family didn’t choose this career path, I feel like I’ve forced the risk on them and I can’t get away from the guilt.

Any time a family member coughs or looks unwell I worry that I am responsible.’

Long-term challenges As well as dealing with the immediate pressures of the pandemic, such as meeting an increased patient demand while faced with inadequate resources, and concerns about risks to personal and family members’ health, many doctors are already worrying about what challenges they might face further down the line.

‘This has been a time of huge challenge and uncertainty,’ explained one GP from north-west England.

‘GPs have had to drastically change the way we work and consult and have been worried about risks to ourselves, staff, patients and our own family and friends.

‘There will be mental health issues for some considerable time after this pandemic passes, and dealing with the recovery phase is likely to be more demanding than the main part of the curve.’

Steadfast support In light of the mental and emotional pressures being faced by the medical profession, the BMA has sought to do all it can to provide timely and accessible practical support.

This includes the launch of a 24-hour COVID-19 emergency line, allowing doctors to receive specialist advice or guidance from BMA advisers on matters relating to the pandemic such as concerns about PPE and workplace risk assessments.

The BMA is also calling for more support for doctors suffering with poor mental health and wellbeing and has set out 10 recommendations which should be considered as part of a comprehensive strategy.

In a message sent on 29 May to all members, BMA council chair Chaand Nagpaul reiterated that no matter how long the effects of the pandemic were felt, the association would remain steadfast in supporting doctors across all parts of the NHS.

He said: ‘The BMA exists as a professional association and trade union to look after you so that you can look after your patients.

‘We will continue to stand with you throughout the course of this pandemic, and to fight your corner in the days, weeks, months and years ahead.’

The BMA’s emergency line can be reached on 0300 123 1233, with additional support via webchat or by contacting support@bma.org.uk Confidential 24/7 counselling and peer support services are open to all doctors and medical students (regardless of BMA membership), plus their partners and dependents, on 0330 123 1245

NAGPAUL: ‘The BMA will stand with you throughout the pandemic’

In addition to the support listed above, the BMA has: – Called for and secured a risk assessment framework for vulnerable and BAME doctors – Pressured the government to ensure proper PPE supply – Pushed for death-in-service benefits and made gains for the families of doctors who die having contracted the virus – Secured a government inquiry into the disproportionate impact of COVID-19 on BAME healthcare workers and communities – Offering free membership to recently qualified medical students and retired doctors returning to work to support the efforts to tackle the pandemic – Secured the right to remain for the families of overseas doctors who die having contracted COVID-19 – Produced detailed ethical guidance to support doctors in decision-making – Delivered hundreds of care boxes with toiletries and other wellbeing materials across the UK.

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A NEW NORMAL? D

octors’ personal and professional lives have altered significantly since the COVID-19 pandemic recalibrated the UK and its health service.

They have risked themselves on the front line, often cut off from their families and friends.

Work patterns have altered for better or worse.

For some, working from home has highlighted the pressures of life in the NHS before the pandemic. ‘The lack of a daily commute, the comfortable and quiet working environment, and the challenges of adapting to new ways of working have all made me thrive,’ one consultant at Birmingham Women’s and Children’s NHS Foundation Trust says. ‘Sadly I think this speaks to the poor state I was in pre-lockdown.’

So, as lockdown eases, which of these new practices will become part of the ‘new normal’ in the NHS? What has the profession gained and lost? How can and should the profession adapt?

In the following pages, doctors describe the new challenges of training, the fragility of locum work, and how eased pressures in some areas allowed medicine to be practised as it should be.

Walsall child and adolescent mental health specialty trainee 6 Ann Paraiso raises concerns about completing the competencies she needs to become a consultant. An ST3 in the south of England talks about the terror of watching a colleague die from COVID-19.

Keith Cooper talks to doctors about their experiences and sets out the action the BMA is taking to keep doctors safe and learn from the pandemic

An emergency medicine consultant celebrates having the time to practise medicine while attendances dropped. A locum GP and mother writes about work drying up and the challenges of juggling her career with childcare.

Many of the issues raised are already being addressed by the BMA. It’s calling for better support for doctors who need childcare.

‘It’s only right that the Government supports them so that they can care for patients,’ its representative body chair Helena McKeown says.

Its Dr Diary app, which helps members to keep track of work patterns, has been updated. An ‘alert’ system flags when inputted workloads are out of kilter with job plans.

BMA sessional GPs committee chair Ben Molyneux says access to work for locum work is now improving from its previous fragile position. ‘However, there are a number of locums who are struggling financially with limited options,’ he adds.

The junior doctors committee is working hard to address trainees’ concerns.

The lives of doctors are sure to change further as lockdown eases and the country braces for further possible spikes and outbreaks in COVID-19 cases.

Doctors will do what they’ve always done to survive. They’ll adapt and learn and press to improve and support their profession and patient care.

The names marked * have been changed in the following piece

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An assault on the senses

I

t’s a profound psychological challenge for an entire workforce to realise their own mortality while coming to terms with the fact they, their family or their colleagues may not make it through this.

The atmosphere in the hospital when our first colleague died from COVID is something I won’t soon forget. The terrified look in people’s eyes and the tension, every interaction with colleagues bombards your senses, as they talk of concerns, fears of the unknown.

That mantra of ‘most people are fine, they don’t become critically unwell’ is hard to keep up when all you see and hear about are those at the

Keep a record of your workload during COVID-19 Track your activities, know your work patterns, steer your job plan.

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critically unwell end of the spectrum.

I’ve also seen a colleague, a nurse, well known throughout the hospital, surviving, after she was admitted weeks beforehand, very unwell. She was clapped out of the ward through the entire hospital to the front entrance.

Then there’s the effect on my personal life, on my wife. We are expecting our first child. It’s not the pregnancy we had planned for. She is unable to enjoy sharing this with her family. We are unable to plan where we will live as rotations are paused. We had planned to move nearer to family for support.

I’m unable to share in aspects of our pregnancy too, unable to be there with her at scans owing to social distancing. The hardest thing to deal with is the potential risk I come home with. We talked about living apart.

Despite my wife having the final say in not wanting to move apart I still feel guilty at not putting up more of a fight. One thing is for sure though, I wouldn’t have mentally survived this without her.

David Jones* is an ST3 in the south of England thedoctor | June 2020 07

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ED MOSS

PARAISO: ‘Virtual meetings are an absolute godsend.

Why would you travel hours for a one-hour meeting?’

Virtual benefits

I

t can take months to settle into a new post but it’s been trickier for my latest one. You work very closely with your multidisciplinary team in child and adolescent mental health. Yet there are members of mine, nurses, psychologists, and secretaries, who I still haven’t met since starting in February.

This is my last post as a registrar before applying for a consultant post next year but there are worries that competencies might not be reached and that CCT [certificate of completion of training] might be put off. I was lucky enough to get assessments done when patients were coming in. My supervisor has been reassuring in our regular meetings via Microsoft Teams. But there are still lots of unknowns.

Virtual meetings are an absolute godsend. Why would you travel hours for a one-hour meeting? It can take two hours to get to one in Birmingham if stuck in traffic. It’s ridiculous you have to do that in this day and age.

Giving young people the option for telephone or virtual consultations could be a good thing to come out of this. It’s important that we see them and are able to monitor physical health. Virtual meetings or telephone contact may, however, increase contact without increasing pressure on the service.

Day-to-day work with patients and families has changed significantly. Unless it’s an emergency or urgent, we don’t

bring them in. Contact is by telephone or virtually. I’m going to look into how this is for patients formally. Some say it’s the best thing ever because they don’t like face-to-face.

People with autism or high anxiety can find it easier to communicate over the phone.

Others find it very distressing. I’ve not yet met some of the young people I work with. Introductions in consultations are now very different. It’s about reducing anxiety levels first.

With young people going back to school, I feel we may see a real spike in all kinds of crises. They are worried about COVID-19 and social distancing in schools and more up to date than we give them credit for.

We know that things won’t be the same and for young people that will be massive. I can’t even say as an adult – and parents can’t reassure their children – about how things will be. That’s a very abstract and hard concept to grasp, especially if you’re autistic or young.

Ann Paraiso is a specialty trainee 6 in child and adolescent mental health in Walsall

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The new fragility of being a locum

‘Y

ou’re no longer needed,’ they told me the weekend after lockdown. Like many GP practices, their need for locums, like me, vanished overnight with COVID-19. Patients stopped coming to surgeries; partners and staff could not take holidays or time off for other work, such as minor surgery.

I always knew work as a locum was uch of my day used to be spent on the wards in the high unpredictable or could end suddenly when security hospital where I work. I now step on to them I became one last summer. But I’d never briefly, with surgical mask and visor, and only for tasks which considered the context of a pandemic. can’t be done remotely, such as medical emergencies or There are very few shifts available now. seclusion reviews.

You previously saw one or two people apply Ward rounds are by video conference. With security an for a session. After lockdown, it was more issue, laptops are placed at a safe distance from patients. like 25. Those that do come up are in hot They squint at the blurry images, trying to pick out which one COVID hubs. It worried me to do this faceis talking. It’s me. The background is computer-generated, to-face work with two school-age children obscuring my home. It’s strange, impersonal and very odd to and an emergency medicine consultant as be talking to high security patients from my living room. a husband.

Most of the patients’ usual activity has ceased as staff are You don’t get sick pay as a locum and required to work remotely where possible. There is no more death-in-service payments are unfairly woodwork, horticulture, or face-to-face therapy. For days on reduced if you die on a day when you’re not end, they set eyes only on nursing staff or their peers. on shift.

I am as ever impressed and inspired by colleagues of all This new fragility of locum work is disciplines for their ingenuity and resolve in providing as unsettling and financially concerning. much support and activity as possible within the limits of I’d feel stuck right now if I was the primary these odd times. earner. It was more difficult to find work with We’ve opened a Nightingale Ward within the hospital for the schools shut. enhanced physical healthcare when general hospital care is All those informal childcare arrangements inappropriate, no longer necessary, or unavailable; fortunately you rely on as parents have disappeared. not an issue so far. It was opened in a timeframe that China Family and friends can no longer share pickmight envy. ups while social distancing remains.

In line with national changes, we’re now moving gently I’ve put in to work for NHS111, where the towards more usual ways of working. They seem so long ago. patients have gone. I hope it will start to Limited face-to-face work with patients is recommencing. replace some of my lost income. These are While we remain behind masks at two metres removed, a unprecedented times and there has been semblance of normality is returning. It’s very welcome. rebalancing. Work as a locum certainly feels James Long* is a staff, associate specialist and specialty more fragile. doctor in a high security mental health hospital Sally Lang* is a locum GP in east London

Caring in the secure estate

M

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A transformed emergency department

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love emergency medicine and because of COVID-19 I’ve had the time and space to practise it properly – instead of being swamped as in recent years.

We’ve doubled the footprint of our emergency department. There were more doctors, when elective work was put on hold, and fewer attendances in line with national trends.

GPs and ambulances seem less likely to send or bring patients to hospital. There’s been a change in attitude from the public. People appear more accepting of care in the community; they’re becoming aware of the dangers of hospital. Daughters and sons are more willing to have their parent home as soon as possible. They are ready and willing to facilitate transport home. It’s made a huge difference to the number of patients attending the emergency deaprtment.

It has, however, been terrifying that we’ve had fewer attendances with significant conditions including heart attacks, strokes and appendicitis that shouldn’t have been affected by COVID-19 and the lockdown.

Also worryingly, we’ve seen fewer people suffering with domestic abuse than we expected. We know it’s likely to be more prolific during lockdown. We’ve found, however, that the quality of our domestic-abuse assessments has improved exponentially. We have had time to delve into issues and explore concerns in a holistic way, and to record this information in detail.

When juggling an overcrowded department – as was the case pre-COVID-19 – the team only had time to ask the basic, essential questions and notes were written in extreme haste.

Junior staff have had more time to take extended histories. Senior staff can spend more time with them and have more opportunity to review patients face to face. Junior staff learn by observing these interactions.

And so we can pass on better information to other services such as the police and independent domestic abuse advisers. They can then make more nuanced plans, and respond more promptly and appropriately.

We’ve had time to organise extra support or alternative plans for patients, so we can treat people effectively in the community, avoiding admissions.

Having time and space to practise true emergency medicine, like this, is good for patients and reduces other departments’ workloads, and bed occupancy. There’s been more beds for those who do need admission, so patients are not left waiting hours in the department before moving to wards. Patients have almost always been admitted within the four-hour standard.

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Staff have also received amazing psychological support during this time.

The stress of working in an overcrowded department – meaning staff can’t provide the standard of care they want to – has affected us for years. It is now more openly discussed and accepted.

We’ve got a ‘wobble room’ where you can go and just take a moment, breathe, sob, cry or think. We have access to meditation and mindfulness programmes and trained coucsellors are at the end of a phone. We’ve had access to proper food at whatever time – even in the middle of the night. We’ve got emergency rotas with extra flexibility built in, in case of physical illness but they also allow people to admit psychological illness and say, ‘I can’t face coming in today, I just can’t’.

This time and space to practise emergency medicine, as it should be, has been a unique opportunity.

There is a vast amount we can learn. What we’ve been doing in the first weeks of COVID-19 is not sustainable.

We can’t keep cancelling elective procedures, asking staff to work in alternative areas and using every inch of space for emergency presentations forever.

But what we were doing before wasn’t sustainable either. Our emergency departments were swamped, the very definition of a major incident, like COVID-19, but without the whole system response and additional resources.

Susan White* is an emergency medicine consultant in the south-west of England

Safeguarding doctors’ rights and health The BMA has kept close track of the many changes which came with COVID-19 and is leading efforts to safeguard doctors’ rights, finds Keith Cooper The association last month reached an agreement with NHS Employers that flexible working practices, introduced to tackle COVID, do not become permanent by default. It has started talks on how junior doctors can be properly financially rewarded for increasing weekend on-calls to help battle the virus. Many have worked more than the one in two weekends which their contract allows.

As patient numbers in primary care start to return to previous levels, GPs are calling for secondary care referral pathways to be re-established. While continuing to use the digital technology so prevalent in lockdown, they want the pendulum to ‘swing back a little’, says BMA GPs committee chair Richard Vautrey. ‘General practice is built on long-term relationships and face-to-face contact,’ he adds. The committee is concerned about how mass vaccination programmes, such as for the flu, will be delivered with social distancing arrangements. Some demands on GP time is also increasing. Hospital clinics are expecting primary care to carry out investigations which they would otherwise do. There are concerns also about increasing home visits for shielding patients.

BMA junior doctors committee chair Sarah Hallett says the JDC is working with health education bodies on ‘no-fault’ ARCP (annual review of competence progression) outcomes when training has been adversely affected. It is also pushing for fair and equitable responses to disrupted recruitment in specialty training, and for doctors to start taking annual leave, and for that leave not to be lost. If it cannot be taken as leave, it should be available as pay.

The BMA staff, associate specialist and specialty doctors committee is raising concerns about on-call rotas becoming more onerous as working patterns change. In common with the rest of the BMA, it is raising alerts about the lack of PPE. ‘Black, Asian, and minority ethnic SAS doctors are also extremely concerned about the effect of COVID-19 and their health,’ says SASC chair Amit Kochhar.

Medical academics are being supported with their contracts – and ensuring they are properly paid – after being moved out of university and research to more frontline positions in the NHS, and back again, says BMA medical academic staff committee co-chair Peter Dangerfield.

The BMA public health medicine committee aims to learn from the vast international effort about how to rebuild capacity and capability at home where it has suffered from years of austerity cuts.

It is keen to lead the debate about the future of public health when its response to the pandemic inevitably comes under heavy scrutiny.

BMA consultants committee chair Rob Harwood says consultants must be involved in redesigning health systems for the new normal.

He will be calling for investment in hospital IT to help more doctors work from home. Consultants will press for staff to be given time to rest. ‘Many people gave up leave, worked in awful work patterns, took on all sorts of new responsibilities,’ he says. ‘We need to recognise that, despite the mountain of elective work.’

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Prepared for the worst How did New Zealand deal so well with COVID-19, and what can we learn from their experience?

Keith Cooper reports ‘Our central government and ministry of health stepped up early on’

N

12

Threat to ethnic minorities

NATIONAL HERO: Dr Bloomfield emblazoned on a hand towel

So how have doctors there helped – and been helped – in their effort to bring their country into an enviable elimination phase?

To find out – and as part of the BMA’s effort to aid international cooperation – The Doctor spoke to doctors in charge at Middlemore Hospital, one of the busiest in Auckland and at CMH (Counties Manukau Health), one of 20 health boards in the country. The hospital serves 570,000 people, a third of the city’s population, including diverse and disadvantaged communities.

Ethnic minorities, such as Maaori, have relatively high rates of diabetes – a known risk factor for COVID-19 – and are generally less mobile, says CMH director of population ST FABIOLA

ew Zealand’s response to COVID-19 has been praised the world over. While other countries continue to report thousands of new cases each day, New Zealand said on 8 June that it had none which were active.

It had at that point 1,154 confirmed cases in total compared with 286,000 in the UK – a staggering contrast despite population differences.

The virus was eliminated in New Zealand, announced its prime minister Jacinda Ardern in late April, allowing lockdown restrictions to be gradually eased.

‘Elimination doesn’t mean eradication,’ explains its director-general of health Ashley Bloomfield, a doctor so popular that towels embroidered with his likeness are selling out. ‘It means we get down to a small number of cases so that we are able to stamp out any cases and any outbreak.’ thedoctor | June 2020

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health Gary Jackson.

‘In the main, cases have been in the younger population, people aged 29 years old, the biggest travellers. We were really worried the disease would spread in the community to those living in overcrowded, damp and mouldy homes,’ Dr Jackson adds.

Middlemore’s chief medical officer Peter Watson puts New Zealand’s acclaimed response down to its relative isolation, good national leadership, its time to prepare, and good luck.

‘Our central government and ministry of health stepped up early on,’ Dr Watson tells The Doctor.

‘They provided a plan that was clear and easily understood by everybody.

They closed the borders early, we went into lockdown early.

There was a coordinated JACKSON: Was concerned the strategy which was stuck to. disease would People knew what they had spread to those to do and what part they had in poor housing to play.’

Even good plans won’t wash anxiety away, of course.

‘The fear from medical and nursing staff was palpable,’ Dr Watson says. ‘We were witnessing what was happening overseas, but we had a two- to four-week head start. We could drop what we were doing and move fast.’

‘Scary’ modelling New Zealand recorded its first case in late February and by mid-March preparations accelerated. By now, its modelling predicted ‘scary numbers’, says Dr Jackson. ‘But it also showed it would be a while for those scary numbers to rise. That gave us time to clear some of our more urgent patients.’ Elective surgery was prioritised for 10 days before being closed down completely.

Staff who identified as vulnerable to the virus were sent home, removing 10 per cent of the workforce. They’re now coming back. Personal protective equipment was stockpiled, staff trained in its use and fitted for masks. Still, New Zealand suffered supply

WATSON: The Government provided a clear plan

‘People knew what they had to do’

problems like the rest of the world.

‘We sit at the bottom of the world with a small population so we don’t have much pull on the international supply chain, we were struggling.’

Dr Watson says. ‘Everyone wanted to wear everything all the time. It was difficult.

We ensured staff had up-to-date information rather than going online and seeing what was happening in Manhattan.’

Despite its success so far, the pandemic has exposed vulnerabilities in New Zealand’s health system, Dr Watson says. ‘We have a low rate of intensive care capability per head of population,’ he adds. ‘If we had had the northern Italy or New York scenario, we would have really, really struggled.’

The aftermath CMH is preparing and checking for mental health issues which it knows followed previous crises, the earthquakes, terror attacks and volcanic eruptions which come with its territory.

Then there’s the psycho-social effect from unemployment as its economy shrinks and remains constrained by COVID-19 public health measures. Foreign tourism, a big contributor, is impossible in a country with closed borders.

‘As in any society, it is the people at the bottom of the pile who are going to bear the burden,’ says Dr Watson. ‘It will be a long slog,’ he adds. ‘It’s not like an earthquake or volcanic eruption that is pretty sharp. We’re setting in for a new normal.’

BMA calls for international pandemic effort This is the first in a series of piece examining the role of doctors’ abroad in battling COVID-19.

BMA representative body chair Helena McKeown said New Zealand’s experience showed the importance of good, clear leadership as demonstrated by its prime minister.

‘So often when we examine what has gone wrong it comes down to poor communication,’ she adds.

The World Health Organization, and its Member States unanimously agreed to an independent review of the international response to COVID-19 at the 73rd World Health Assembly, held virtually last month.

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PPE: a problem yet to be fixed The BMA continues to take robust action on PPE after doctors reported continuing shortages and resulting severe stress and safety concerns. Keith Cooper reports

T

he struggle to obtain protective gear in hospitals and GP surgeries has faded from headline news in recent weeks.

However, it’s still a problem for many doctors on the front line, according to the latest and fifth BMA tracker survey. These trackers have kept tabs on supply issues since they first emerged.

The survey of 8,455 doctors, carried out at the end of last month, shows a continued trend in improvement in some areas.

But that’s only part of the story.

A significant proportion of doctors still report struggling to access basics: masks, gowns, and ‘The lack of protective glasses. The supply PPE causes problem now seems chronic and unnecessary months of struggle is now hitting anxiety’ staff mental health.

‘The ongoing lack of NHS PPE [personal protective equipment] causes unnecessary anxiety,’ one male GP, aged over 55, said. ‘We have not received full PPE at the surgery’.

Lack of access to PPE and ‘communication difficulties’ had led to short tempers and intolerance, another doctor describes. ‘Often you come on shift to find others at their wits’ end and instead of being the peacemaker, you end up feeling we’re all in the same boat, suck it up.’

Mask supply In the latest survey, around one in five respondents reported shortages – or no supply at all – of FFP3 (filtering facepiece 3) masks when working in more risky areas where AGPs (aerosol-generating procedures) are carried out – a similar proportion to the late April tracker.

The supply of masks to doctors in other areas, including general practice, has also not improved.

Access to disposable gowns and aprons has got better in AGP areas but worse for doctors in non-AGP areas, the results show.

These trends were reflected in doctors’ comments, several of which pointed to the early problems and improved access but also to residual anxieties brought on by shortages – and their apparent and sometimes devastating effect.

One doctor told of her husband’s admission to hospital with COVID-19 and pneumonia, after they were refused access to PPE. ‘With two young boys at home and both of us unwell, without family in the UK, I was very stressed,’ they added.

‘We had the support from our next-door neighbours and friends who offered help and we are very grateful.

‘Colleagues from the ward became unwell within days of the exposure and we had a sad fatality. One of the nurses died from COVID-19 infection,’ this doctor added.

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FIDLER: PPE often not protective for women WRIGLEY: Doctors are anxious about lack of protection in their workplace

‘Colleagues became unwell within days of the exposure’

‘This has been very difficult for me, my family and the team from the ward. Stress has affected my children as well, and my younger son developed anger from all of this.’

This latest survey also reflected previous findings that many doctors felt pressured to see patients without adequate protection. Almost one in three (28 per cent) of doctors said they had felt such pressure often or sometimes.

There has been a big national push on PPE, headed by the Conservative peer who ran the 2012 Olympics, Paul Deighton, a former investment banker. The Army was drafted in early on and a private delivery firm, Clipper Logistics, was contracted.

Poor fit The BMA has called for ministers to take whatever action is necessary to scale up production in the UK. It has urged health secretary Matt Hancock to explore overseas suppliers and tap into EU jointpurchasing arrangements.

The association has flagged the struggles of female doctors to find masks that fit, leaving some with sores and ulcers after long shifts. ‘PPE is too often neither personal nor protective for women,’ BMA consultants committee deputy chair Helen Fidler has said.

With dental surgeries due to open in June – and demand for non-COVID care rising – the need to sort out the PPE supply chain fiasco is all the more pressing.

Around four in 10 respondents to the survey reported a significant increase in demand for non-COVID patient care. More than half (52 per cent) were ‘not all confident’ or ‘not very confident’ that they would be able to manage patient demand as normal NHS services resumed .

Despite better access to PPE, the supply problem of protective gear looks likely to be around for some time.

BMA council deputy chair David Wrigley said that while PPE problems varied across the country the survey showed it remains a significant problem.

‘Despite all the Government promises on PPE supply it is unacceptable we see doctors anxious and worried about a lack of proper protection in their workplace.

We need to hear from doctors about this and ask them to contact us via first point of contact.’

As well as taking robust campaigning action to secure a better supply of PPE, the BMA has also produced extensive guidance for members. The BMA website has information on areas such as the PPE doctors should expect, guidance on usage, specific concerns about CPR, and for doctors who have beards for religious reasons. Go to: bma.org.uk/advice-andsupport/covid-19/ppe/covid-19-ppe-for-doctors And turn to page 29 for an example of how the BMA helped a doctor who experienced PPE shortages.

To contact the BMA, call 0300 123 1233, email support@bma.org.uk or talk to an adviser online via the BMA website, www.bma.org.uk

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SARAHTURTON

AUDHALI: ‘We are losing chances to intervene earlier’

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When and how should the NHS start adjusting back to normal after the pandemic? And what problems have been stored up in the meantime?

Peter Blackburn reports

The long road back T

‘We might be storing up trauma for the future’

he emergency department at Whipps Cross Hospital in London is normally bustling – the usual mix of people needing serious care, others looking for support or guidance and those with nowhere else to go.

In these warmer months, the 26-bed paediatrics ward should have at least 10 to 15 patients needing care at any one time.

However, much of Nadia Audhali’s workplace has felt eerily quiet for weeks.

When surveying the scene during the coronavirus crisis, paediatric registrar Dr Audhali has found a waiting room empty of children and a quiet ward with just two, three or four patients in beds.

There are similar stories of rapid change, and potential consequences, across the NHS as efforts to meet the threat of the virus have resulted in very different workplaces and working lives for doctors in all specialties and settings.

NHS England chief executive Sir Simon Stevens said in late March that the NHS had transformed rapidly.

The NHS has proven itself to be adaptable and agile and staff have shown their

bravery and brilliance in often desperate circumstances.

But the NHS becoming, in large part, the National COVID Service has affected patients and staff far and wide – and questions are now being asked about how it can return to normality.

Patients staying away For Dr Audhali the effects of change are obvious – and deeply concerning. Parents have been keeping their children away from hospital, for fear of contracting the virus.

‘We are losing chances to intervene earlier… we might be storing up trauma for the future,’ Dr Audhali says.

‘I would have thought there would be a knock-on effect.’

Maternity services have been affected too, Dr Audhali says. ‘These are very vulnerable times for women and I think all this has been quite mentally traumatic.’

These are not just concerns for the present but worries about the future difficulty being stored up.

As Dr Audhali says: ‘People may be deteriorating or getting new problems and their threshold to come to medical attention is so much

‘We are having to deal with a backlog of problems’

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higher. These are all lost chances to intervene.’

Backlog fears West Midlands clinical oncology consultant Jyotirup Goswami tells The Doctor his trust had continued with many operations and was trying to keep any potential backlog as minimal as possible, but that patients on multiple lines of chemotherapy had seen their treatment delayed or deferred over concerns for their vulnerability to COVID-19 in hospital.

Dr Goswami says some surgical procedures had been delayed with surgeons working in other environments, and screening numbers were ‘lower than usual’.

‘Going forward it will be a real job putting the waiting list back in some sort of shape, especially with surgery,’ he says. ‘A lot of trusts haven’t been able to perform major cancer surgery for some time and that is a concern.’

In general practice life has changed considerably. Doctors are largely working from home using video software and online consultations – with the move showing the benefits and limitations of this sort of work.

But it is patient care as well as the working environment that has been affected by the virus.

Patients’ understanding in not flooding the NHS, and also their unwillingness to access services during the pandemic, are likely to have a major effect.

Merseyside GP Rob Barnett outlines his concerns about patients with potential cancer.

Dr Barnett says: ‘We haven’t been able to refer for eight weeks and of course we understand the reasons for that but practices have

‘It will be a real job putting the waiting list back in some sort of shape’

been hanging on to patients when they should have been referring them. This has made things very difficult for colleagues. The fact that we’ve not been able to organise simple investigations like ultrasound scans has put pressure on the system.’

Dr Barnett says a lack of visual cues from patients while working remotely, as well as issues such as translation, could contribute to the problem, too. And NHS organisation has also proved a concern for Dr Barnett, with GPs told to work on bank holidays but services such as blood sample couriers not aligned – ‘it’s worse than one arm doesn’t know what the other arm is doing… both arms are completely disconnected from the body in this command-and-control environment’.

Dr Barnett adds: ‘Clearly we are having to deal with a backlog of problems and that’s going to take time to work through the system.’

York GP David Hartley found similar issues with blocks on X-rays, ultrasounds and other investigations – and the knock-on for patients who desperately need endoscopies or other investigations, and doctors who feel ‘increased stress and pressure’.

In Dr Hartley’s and Dr Barnett’s surgeries the demand from patients is growing – and the key will be whether this continuing demand is from patients who have been sitting on symptoms that need much more urgent investigation or treatment.

And with even minor interventions such as ear syringing proving hard to provide, the knock-on effects

for health could be widespread.

Dr Hartley says: ‘We have been seeing two sorts [of patients] – those who have sat on symptoms and regular folk with chronic conditions who have anxieties and things.

But at the moment we don’t really have anywhere to send them to investigate. With a cold medical hat on it will be interesting to see if we see a spike in late presentations later this year.’

Dr Hartley says most patients are able to take delays ‘on the chin’, but ultimately the concern is where those delays leave patients and the NHS.

Routine work waits So, what are the solutions to this potential crisis, particularly in general practice? For many GPs the answers are resources and prioritisation of the opening up of necessary avenues of treatment and investigation. And genuine permission from the powers that be to start routine work, rather than politicians and health leaders simply focusing all their efforts on testing would also be welcome.

‘There needs to be a significant push to allow routine work to start,’ Dr Hartley says. ‘That’s not just hospital investigation but in general practice too. We need to be told to start the routine monitoring of complex elderly patients on multiple medications and check what is happening with potassium and sodium levels and all that sort of thing. We need permission to start routine work again, to get lab results through again.’

Dr Barnett agrees: ‘The question is how safe is it for GPs to be sitting on things before patients get seen in the

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need better support from primary care, we will need technology that will enable doctors to do virtual rounds, we will need increased contact from district nurses and from some of the other professions allied to medicine such as physios and occupational therapists. This pandemic has taught us that health and social care are two interdependent systems and they cannot go back to their previous silos.’

Issues the NHS will be unpicking for months, and perhaps years to come, are wide-ranging and complex. The majority of doctors The Doctor has spoken to fear the effect on current and future mental health, and the possibility that society is storing up great trauma, and in areas such as public health delayed vaccinations and a whole variety of other issues are a cause for great concern.

MATT SAYWELL

hospital? There’s no doubt that the things we haven’t been able to have caused a great deal of anxiety for patients and doctors.’

For Dr Barnett ramping up of services and investigations supported by proper investment and influenced by the views of clinicians in primary and secondary care is crucial.

The effect of this virus is felt across society – and in few areas more so than the care sector. Nadra Ahmed, executive chair of the National Care Association, says it has been a difficult time for care homes where some of society’s most vulnerable people have faced a challenging period of solitude and loneliness.

Ms Ahmed says getting back to some of the most important aspects of prepandemic times – like human interaction, care and attention, nutritional and medical support – while ensuring a ensuring a safe environment is vital. Ms Ahmed says ‘a regime of regular testing for residents and staff as well as families who visit’ will be required in absence of a treatment or vaccine.

There are other vital priorities the National Care Association has identified for the sector: PPE regularly available in care settings with costs at pre-pandemic levels; a more joined-up relationship with clinicians and primary care; the care workforce to be acknowledged and recognised as professionals; funding levels for social care increased; and a secretary of state for social care post to be created.

Care England chief executive Professor Martin Green says: ‘When we get back to normal the care sector will

WRIGLEY: Doctors don’t necessarily want things to return to ‘normal’

Protection first Guidance from the BMA suggests health leaders should be ‘realistic and cautious’ about restarting shelved NHS work and rebalancing COVID and non-COVID capacity.

The guidance says there must be adequate PPE (personal protective equipment) for health and care workers, decisions about staffing levels and redeployment must be safe and made with employee representatives and measures must be taken to safeguard staff wellbeing.

It also suggests clarity must be given to healthcare workers about the future contractual position and plans to restore training and career development and calls for ‘effective and transparent’

‘How safe is it for GPs to be sitting on things before patients get seen in the hospital?’

public communication so that patients know what they can and cannot expect, increased remote working where clinically appropriate, local decisions to be guided by clinical expertise.

For BMA deputy council chair David Wrigley the key to restarting services is that health managers do not force doctors back to their old normal.

‘The important thing to say is that doctors don’t necessarily want things to return to “normal”,’ he says.

He adds: ‘There are no quick solutions here – it needs discussion, it needs resource and for everyone to work in the same way. Most of all it needs managers and people in the remote bodies overseeing the NHS to speak to those of us working on the ground.’

It is perhaps the case that the future effect of the coronavirus crisis will not be known for many months, if not years, but the instincts and experiences doctors are having now must be the driving force behind the decisions made in the coming weeks if tragic cases and worrying trends in so many areas of healthcare are to be averted.

If you need emergency support on COVID-related issues out of normal opening hours, you can call us 24/7 on 0300 123 1233 or visit bma.org.uk/covid19 thedoctor | June 2020 19

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Locking down and speaking up Doctors must be allowed to expose injustices at work without fear of recrimination during the COVID-19 crisis, write University of Birmingham Freedom to Speak Up guardian Julian Bion and head of inclusion Byron Batten

I

n her two recent addresses to the nation, the Queen has drawn parallels between the coronavirus crisis and our response to adversity in the Second World War. The analogy is apt. We have come together to defeat a common enemy. We have massively expanded intensive care capacity. Staff have volunteered to redeploy to acute and critical care areas despite the risks to their own health. Leave has been cancelled – who needs a holiday when we can’t travel?

Our armed forces have built new Nightingale hospitals in days. We have ‘made do and mended’.

Dunkirk spirit Vacuum cleaner and motor manufacturers have reconfigured their production lines to create ventilators; cottage industries, schools and haute couture firms have evoked the Dunkirk spirit in producing masks and visors for local services.

Whole communities have come together on Thursday evenings to applaud the commitment of NHS and care staff, and others who maintain vital services.

However, the uncertain and inadequate supply of PPE (personal protective equipment), and changing instructions on its use, have caused considerable moral distress among staff, and raise difficult issues about balancing a duty of care to one’s patients against the need for self-preservation.

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Regrettably, there have been reports of staff being reprimanded for raising concerns about PPE; the BMA has provided guidance on this matter.

Window for change What is clear is that this crisis offers a potential opportunity. For example, led by our Inclusion and Health and Wellbeing Team, our trust has implemented telephone staff support incorporating our Freedom To Speak Up service, backed up by clinical psychology and psychiatry: preliminary experience suggests this has been very helpful.

Staff who have concerns about redeployment or exposure to risk, or indeed any other matter which may adversely affect working relationships and patient care, should discuss them first with their line managers.

In the event that this conventional route is problematic, there is also another pathway for speaking up confidentially, and in a manner that can promote organisational reflective learning: the Freedom to Speak up guardian.

The Freedom To Speak Up network was established at the recommendation of Sir Robert Francis QC, in a report arising from the MidStaffordshire inquiry.

Every NHS trust in England now has a guardian, part of a national network led by the national guardian, Henrietta Hughes. Protection of the

right to speak up is associated with organisational excellence (see the national guardian’s annual report), but some staff still fear that doing so may either compromise their career prospects (a concern particularly prevalent among junior doctors), or expose them to micro-aggressive behaviours from co-workers or seniors.

Freedom to Speak Up guardians, supported by a number of local champions or confidential contacts, enable staff to speak up about patient care or about experiences in the workplace, without suffering detriment.

These matters can then be taken to the appropriate line manager with authority for investigation or action. The identity of the individual who has spoken up is protected unless they are willing to have this made known.

Between April 2017 and March 2019, 19,331 concerns were raised with trust guardians, most frequently relating to allegations of disrespect, bullying, discrimination, and compromised patient safety.

Since ‘lockdown’ was implemented on 23 March, in my experience and in informal discussions with colleagues, the typology of concerns seems to have changed, focusing on PPE and exposure of self or family to risk, and lack of access to SARS-CoV-2 testing. Whether this change represents displacement by more pressing concerns, or an

FRANCIS: Freedom to speak up recommendation

improvement in collaborative behaviours in response to a common threat, will become clearer when the pandemic subsides.

I would hypothesise that those trusts whose leaders are creative, collaborative and reflective will be better equipped to deal with the economic consequences of this pandemic than those who have suppressed or ignored expressions of concern. This is not just a matter for chief executives; it needs to be practised by all of us. Take time to be kind. Take time to listen. Lock down the virus but liberate the voice.

Julian Bion is the Freedom To Speak Up guardian for University Hospitals Birmingham and professor of intensive care medicine at the University of Birmingham and Byron Batten is head of inclusion-improvement, communications and engagement at University Hospitals Birmingham. The views expressed in this article are those of the authors thedoctor | June 2020 21

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Tough calls The already difficult task of breaking bad news has been made much harder by rules preventing families from being at patients’ bedsides. Jennifer Trueland speaks to doctors sharing their expertise, and maintaining humanity

I

t’s never easy to tell someone that their loved one is seriously ill and might not recover. When the conversation has to take place on the telephone, it’s even harder.

Yet this is something that has become very much part of life for many doctors and other clinicians – some of whom have virtually no experience in doing this, and all of whom are under extraordinary pressure.

But if the pandemic has shown anything, it’s that doctors flex and they adapt and even at the toughest of times, they are willing to share their skills and learn new ways of working.

That’s been the case whether it’s involved helping patients to stay in touch with families while visits to hospitals and care homes are heavily restricted or breaking bad news about a patient’s deterioration.

Antonia Field-Smith, a consultant in palliative medicine, is one doctor who used her experience to help colleagues take on new roles as the pandemic began to grip. Having watched what was happening in countries such as Italy, she knew that her domain – end-of-life care – would become a bigger part of the role of medical ‘Staff look after dying staff from other specialties. And she wanted to help. patients, but not ‘Obviously staff do look after dying usually as many in a patients, but not usually as many in a short short space of time’ space of time,’ she says. ‘We realised we would have to support the staff who were suddenly thrust into this world of dying.’

What she and her colleagues did was to take those years of palliative care experience and use them to develop a short guide to speaking to patients’ relatives. This gives a suggested framework for telephone conversations that make it clear to relatives that someone is seriously ill, giving them a chance to ask questions and ensuring they understand what they are being told.

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Conveying uncertainty Dr Field-Smith, who works at West Middlesex Hospital, part of Chelsea and Westminster Hospital NHS Foundation Trust, says it was all part of equipping the wider healthcare team to cope with increased levels of death among patients.

‘We made the guide because we wanted to rapidly upskill people in the hospital, because we could see that doctors and nurses and other members of the team were going to be needing to speak to families.

‘What we noticed is that staff are very good at talking to patients – they get a lot of training for that – but less so with relatives. I think that’s because a lot of our Western way of working is around patient-centred care – it’s about what the patient thinks, and getting permission from the patient to speak to relatives. But I think when people are dying, that shifts a bit.

‘Obviously the patient is always part of that bigger centre of care, but it affects the relative too. In palliative care we recognise that, but I think that’s harder for other doctors and staff to recognise and they don’t get as much training in that. Suddenly they’re having to do it over the phone and in this really stressful situation with all this uncertainty. I could see it in my own hospital and I saw on Twitter that a lot of doctors were saying they found those conversations difficult.’

She and her palliative care consultant colleague Louise Robinson prepared their tool – with the help of her film director brother Jim Field Smith – based on an Italian resource.

‘In our guide we had a few suggestions for what people could say, but it wasn’t prescriptive,’ she says. ‘It’s not about putting words into people’s mouths, it’s helping them find their own words, and as you get more experienced you find phrases that you can use.’

They were particularly keen to help doctors to convey the uncertainty of COVID-19 with patients’ families. ‘We have had a lot of patients where we have honestly thought they were going to die, and we’ve had to tell the family that we didn’t know which way it would go, and then they haven’t died. But we’ve had to share that uncertainty. In our experience, doctors and nurses find it difficult to talk about uncertainty – as do politicians. They don’t like to admit that they don’t know. So, a huge part of our guide was sharing this business of uncertainty.’

When they shared the guide on Twitter, the response was overwhelmingly positive, with many asking if they could use or adapt it. Dr Field-Smith understands why so many have felt a need for help, and uses the principles of the guide in her own practice.

‘I still think it’s hard, even though it’s my job and I’ve trained for many years, and I’ve had many difficult conversations and situations, and I still find it difficult. Having the guide, either mentally in my head, or next to the phone, and being able to refer back to that is helpful. There’s emotion there, obviously, and it’s just being able to think back about what I’ve said, have I reassured people, have I comforted them. We’ve all been thrust into this situation, with not a lot of time to prepare, and I find working in PPE [personal protective equipment] hard – we’re wearing the

FIELD-SMITH: ‘Doctors found those conversations difficult’

masks even when we’re talking on the phone on the ward, so it’s muffled as well.’

Visiting rights Along with having to break bad news, doctors have found themselves in the position of finding ways to keep patients in touch with their relatives, at a time when hospital visiting has been massively restricted.

Across the UK at the start of the pandemic, this virtual ban on visiting (except in particular circumstances, such as a birth partner) included patients who were dying. Even though that changed, allowing a family member to make a short visit to someone at the end of life, this sometimes hasn’t been possible. Potential visitors cannot come to hospital if they themselves have symptoms of COVID-19, for example, and they have to be prepared to wear PPE to minimise risks to their own health.

Hospitals too have found it hard, particularly in intensive care units, where the infrastructure and type of procedures often make it difficult to admit visitors safely, meaning that many patients were dying without the presence of loved ones.

In April, the Scottish Academy of Medical Royal Colleges, along with the Royal College of Physicians of Edinburgh, the Marie Curie charity and Scottish Care, produced

‘I’ve had many difficult conversations and situations, and I still find it difficult’

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‘We all die.

And as doctors, I don’t think it ever becomes normal for us’

guiding principles stating that patients judged to be dying of COVID-19 or anything else must receive equal access to visits from family or friends.

RCPE president and geriatrician Andrew Elder says that looking to the future, health services must ensure people have the right to be at the bedside of a dying loved one.

‘It’s not simply a matter of infection control – these are matters of our humanity, matters that define who we are, our understanding of what life is, and how our lives must end. We can find ways to allow families to be together at this time.’

FaceTime in PPE Sarah Simons, a clinical fellow in ambulatory care and emergency medicine at Whittington Health in north London, has been one of the many, many doctors trying to make this happen, by, for example, facilitating threeway FaceTime calls when relatives aren’t able to visit.

This hasn’t been easy, she concedes, partly because patients often can’t talk, but also because using PPE makes communication difficult in person, let alone by phone or video call.

‘My trust has said that when someone is imminently dying, then one relative can come in, but that’s if they’re not ventilated or on respiratory support – they’re on an oxygen mask, maximum.

‘But it’s really hard as a junior doctor to call someone up in the middle of the night and say you’re really sorry but your loved one has died. That’s one reason I think that our consultant colleagues have stepped up massively and we

have a team of local GPs who have come in to support us, and a lot of their job is family liaison. ‘That’s a dedicated job so while we are all running around wearing the PPE, they are keeping families informed and telling them what’s going on.’

Patients and families have, for the most part, accepted limitations on visiting, she says.

‘It’s been really hard but I think for the most part that people understand it.’

Dr Simons hopes that the pandemic will lead to a more honest public conversation about death and dying – but says it has been a difficult experience for all doctors.

‘Death is death. We all die. And as doctors, I don’t think it ever becomes normal for us, but we see good deaths, and we see less good deaths.’

COVID-19 has been different, she says. ‘It’s the scale, it’s the fact that there’s no treatment. The problem with COVID-19 is that it’s wildly unpredictable, so we don’t know who’s going to get sick and how, although we’re learning a lot. But it is the scale – it’s the fact that everyone in the ward has it, and we’ve had so many deaths of healthcare professionals, and not just deaths but people going off sick. We’re a pretty fit workforce, but this is something that’s taken down so many of us, which is different.

‘We need to protect ourselves as well. Anyone who is a healthcare professional wants to do that to help and to make people better. But we’re incredibly high risk ourselves, and although we’re doing everything we can to protect people, we need to protect ourselves as well.’

The absence of face-to-face discussions While doctors are skilled at developing therapeutic relationships with patients and families, the pandemic has made this more challenging, says Julian Sheather, specialist adviser on ethics and human rights with the BMA Communicating bad news, that a relative is unlikely to get out of ITU, is difficult at any time, but is harder when it’s not in person. ‘To have to do this in a mediated way presents greater challenges,’ he says. ‘It’s harder, there’s no question about it, without being able to look people in the eye, without being able to read their body language, or get a sense of where they are coming from emotionally.

‘There’s a sense that it’s harder to manage the impact of any statement that you’re making – it becomes more of a clinical transfer of information rather than a compassionate human exchange.’

This can lead to ‘moral distress’ in doctors, he says, because they feel they cannot act in the way they would wish to because technology can be a barrier.

‘The BMA is providing support for doctors to manage emotional distress, and this is a part of that. This is one factor of a highly stressful time, and it’s vital that doctors are given the support that they require,’ Mr Sheather adds.

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Fighting the odds

COVID-19 has had a disproportionate effect on different ethnic groups – one reason why the BMA has been pressing for effective risk assessments to be made available to doctors and other NHS staff.

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‘I

am an associate specialist in anaesthesia which involves managing airways and ventilation as a procedural anaesthetist. I am exposed to high viral load when conducting aerosol-generating procedures such as general anaesthetic.

‘I asked my line manager and health at work for a risk assessment due to my age and [because I] suffer from long-standing underlying conditions such as diabetes and hypertension.

‘I was not supported or considered as a higher risk of contracting COVID infection. I am more scared at work as the PPE [personal protective equipment] supplied is inadequate and often controlled and locked away.

‘I feel unsafe.’

This was the account of one BAME (black, Asian and minority ethnic) doctor in his 60s who contacted the BMA to express concerns about the conditions of the working environment amid the COVID-19 pandemic.

The medical profession’s attempts to better understand the novel coronavirus have often felt like the painstaking piecing together of some vast and awful jigsaw puzzle.

While there is still undoubtedly much to learn about the virus, it has been possible to ascertain some important observations regarding the pathology of the disease, namely those who appear to be at greater risk of infection, severe illness or death as a result of contracting it.

Provisional analysis of mortality rates by the ONS (Office for National Statistics) reveals that risk of death

from infection with COVID-19 is significantly higher among people from BAME backgrounds.

The ONS found that black people are 1.9 times more likely than white people to die from COVID-19 infection, even after accounting for age, underlying health and other socio-demographic factors.

Risk assessment lacking This disparity in risk has also been observed in people from South Asian backgrounds, with men from Bangladeshi or Pakistani backgrounds 1.8 times more likely to have a COVID-19-related death while women from these ethnic groups are 1.6 times more likely than their white counterparts.

Despite coming from a minority ethnic background and belonging to an age group and being part of a demographic, the associate specialist’s experience and inability to get the workplace to conduct a risk assessment reveals a damning lack of consideration for the needs of someone statistically at greater risk of the virus.

Sadly, the doctor’s experience would appear to be far from unique.

Findings from the BMA’s COVID-19 tracker survey highlight notable differences in doctors’ experiences of workplace risk assessments and access to PPE, according to ethnic background.

The survey finds for example that while 91 per cent of white doctors undergoing a COVID-19 risk assessment by their employers reported being satisfied with the

‘I was not supported or considered as a higher risk of contracting COVID infection’

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NAGPAUL: ‘Employers must take proactive steps to minimise exposure to the virus’

TOXIC ENVIRONMENT: BAME doctors feel more pressured to see patients in AGP areas without PPE, finds BMA research

process, this figure fell to just 80 per cent among BAME staff.

When asked whether they felt pressured into seeing patients without PPE in AGP (aerosol-generating procedure) areas, 3 per cent of white doctors said they often were and 17 per cent said they sometimes were.

In contrast 10 per cent of BAME doctors often felt pressured, and 31 per cent sometimes pressured.

BAME doctors were found in the survey to be more likely to experience shortages of FFP3 (filtering facepiece) masks in AGP areas, that they were more likely to fail first-time fit testing and be more fearful about speaking out.

Lacking practicality While acknowledging that all frontline doctors face risks in the fight against COVID-19, the BMA has also noted the increased susceptibility faced by those from particular groups including BAME backgrounds.

It was for this reason that the association wrote to NHS England chief executive Sir Simon Stevens back in April to call for the creation of a national profiling framework to identify, and thus help to protect, NHS staff likely to be at greater risk.

Throughout the pandemic, the BMA has called for a range of actions to better protect at-risk frontline medical staff, including an investigation into the disproportionate impact the virus has had on BAME healthcare workers, something that is now being reviewed by Public Health England.

The association also wrote to NHS England chief executive Simon Stevens in April urging for the creation of a national profiling framework to identify and protect staff likely to be at greater risk, with such a framework

being published on 12 May. On 29 May, NHS Employers updated its existing guidance including details on how to enhance assessments to take account of key factors that might increase vulnerability, such as race and ethnicity.

In a message sent out to all association members, BMA council chair Chaand Nagpaul describes the guidance as long overdue but nonetheless an ‘important step’ in helping to provide greater protection to staff.

Dr Nagpaul also emphasises that all doctors were entitled to workplace risk assessments amid the fight against the virus and urged staff to make full use of guidance and resources drawn up by the BMA in this regard.

‘A tragic consequence of this deadly virus has been the increasing number of our colleagues who have lost their lives from contracting the infection,’ he says.

‘What is more alarming is that so far 94 per cent of those doctors have come from a BAME background.

‘If you or a fellow healthcare worker is identified as high-risk, employers must take proactive steps to minimise your exposure to the virus, including through redeployment to less hazardous areas or supporting them to work remotely where possible.

‘The BMA’s new resources specify that all doctors should be able to have a COVID-19 risk assessment and helps you determine your level of risk.

‘The resources also sign posts practical actions that should be taken to avoid or mitigate the risks which older, BAME or pregnant doctors – as well as those with pre-existing conditions – might face if working in settings with coronavirus-positive patients.’

The long wait for national guidance during the thedoctor | June 2020 27

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AFTAB: Employers should not be waiting before taking necessary practical steps

COVID-19 and BAME doctors timeline 10 April 16 April 21-28 May 2 June

outbreak has seen many trusts deciding to develop and adapt their risk-assessment processes to reflect the increased dangers faced by BAME staff.

Local guidance

studies so that we know exactly what is causing these disproportionate deaths in BAME colleagues before practical steps are taken to protect them?’ he asks in a recent blog published by the BMA. ‘Do we ever wait for a complete understanding of a disease before we start helping the affected patients with at least symptomatic treatment?

‘We know for a fact that BAME colleagues in the NHS are disproportionately being affected by COVID-19 infection and losing their lives. Practical steps need to be taken now to mitigate the risk as we cannot simply sit idly by whilst we wait for a full understanding of the cause.’

‘Practical steps need to be taken now to mitigate the risk’

Somerset NHS Foundation Trust was one of those that took the initiative ahead of the framework and put out its own guidance on risk assessment in light of the growing evidence that BAME staff were being disproportionately affected by the virus.

On 24 April the trust’s chief executive Peter Lewis and director of people Isobel Clements wrote to all BAME staff to explain and reassure them as to what action the trust would be taking.

This action included placing all BAME staff in a vulnerable and at-risk category and prioritising them for COVID-19 testing, providing information on fit testing for FFP3 masks and updating guidance for line managers to assist them in discussing cultural issues or the existence of underlying health conditions when risk assessing BAME staff.

In its letter the trust made clear that while there was no ‘conclusive research or national guidance we feel that this is the right approach to take’.

For consultant ophthalmologist Sakkaf Ahmed Aftab an absence of definitive data or a complete understanding as to why BAME individuals appear to be more at risk of the virus is no reason to not take proactive steps to protect them.

‘Is it right for our employing organisations to wait for the result of the national inquiry or for the result of other

COVID-19

emergency support support@bma.org.uk

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BMA first major body to call for government inquiry into the deaths of BAME healthcare workers Government announces inquiry into disproportionate number of BAME deaths New risk assessment guidance is released in England, Scotland and Wales – which the BMA had first called for Public Health England releases its review on the impact of COVID-19 on BAME communities which the BMA describes as a ‘missed opportunity’

Identify the vulnerable Mr Aftab’s own workplace, North Lincolnshire and Goole NHS Foundation Trust, has developed a sophisticated ‘options decisions tool’ specifically to protect staff.

The tool, one designed for male staff and one for female staff, provides an algorithmic set of instructions to help managers identify vulnerable individuals based on a number of criteria including age, underlying health conditions and ethnicity.

Based on the outcome of the assessment tool an individual can be classed as being at moderate, high or very high risk, with the guide explaining where, and indeed if, the individual in question can be safely deployed.

The BMA has issued its own advice to doctors informing them of their rights and means by which they can raise concerns about risks to their health, as well as the responsibilities of employers.

It also advises doctors who they can expect to assess them and what action could be taken following an assessment.

The association is also providing pastoral and emotional support to doctors and medical students concerned about COVID-19 and their health. If you need emergency support out of normal opening hours, you can call us 24/7 on 0300 123 1233 or contact an adviser using webchat.

08/06/2020 10:21

on the ground Highlighting practical help given to BMA members in difficulty

PPE shortages meant a doctor had to choose between a patient at serious risk or needless exposure to COVID-19.

BMA intervention made her workplace safer A junior doctor, new in her career, was working in a ward where AGPs (aerosol-generating procedures) were common and where staff had gone off sick with suspected COVID-19 infections.

She had been given respirator masks, but they had not been fit-tested, and she was aware they were not providing all the protection they should.

The situation was exacerbated because the PPE (personal protective equipment) has been locked away in a cupboard to maintain the stock, with just a single key. On one occasion, the doctor was called away to a life-or-death situation and could not obtain a mask at all.

No doctor should be put in this situation, choosing between a patient at serious risk of death and needless exposure to infection.

Guidance from the GMC does offer some reassurance, stating: ‘We do not expect doctors to leave patients without treatment, but we also don’t expect them to provide care without regard to the risks to themselves or others.’ But that still leaves many doctors in an appalling dilemma. Many hundreds have told successive BMA tracker surveys that they have experienced shortages of filtering face piece 3 masks/respirators. Do they refuse to treat, potentially causing harm to patients and more pressure on, and resentment from, colleagues?

The doctor was the first to use the BMA’s new 24-hour opening hours for urgent COVID19-related enquiries. Provision of the roundthe-clock availability will be kept under review according to demand. Usually it is 8am to 8pm Monday to Friday, and 9am to 5pm on Saturdays and Sundays.

By being there, when he was needed, in the middle of the night, the BMA employment adviser was able first and foremost to provide reassurance that the doctor was not alone, and would be supported.

He could also put forward a strategy. The BMA has designed a series of ‘escalation letters’,

enabling doctors to highlight the lack of PPE with their line managers, then their medical directors, and then, if necessary, to indicate why, in line with GMC guidance, they were no longer able to undertake patient treatment.

The advantage of this approach is that it not only provides documented protection for the doctor, but a constructive and serious argument to the employer to take action.

The BMA also swiftly took the matter up with the employer. Another adviser wrote to the medical director, underlining the strong concerns the BMA had. A junior doctor representative had previously been to the same person and was told that the hospital was aware of the problem but could not resolve it. But this time, the medical director committed to complying fully with national guidance.

Unfortunately, the assurances given by the medical director did not reflect what was happening on the ground, and the next night, the doctor returned contact having been told that fit testing was still not taking place. It was simply a matter of good luck that she had not been required to undertake an AGP with an illfitting mask that day. Following further advice and reassurance from the adviser on-call that night, the doctor returned to work the next day with one of the BMA’s escalation letters ready to deploy. That same day the BMA had further urgent discussions with the medical director and the infection control lead to ensure national policy was being adhered to. The BMA’s local industrial relations officer has taken up the issue on behalf of all doctors in the organisation to ensure they have access to appropriate PPE. To contact the BMA, call 0300 123 1233, email support@bma.org.uk or talk to an adviser online via the BMA website thedoctor | June 2020 29

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PAUL BLOW

thebma writing competition 2020

Dousing the flames ‘Sorry’ may often be the hardest word to find, but there was no shortage of entries to this year’s BMA writing competition.

And what a powerful word it is too. It provoked a huge range of memories – from the patients and colleagues they felt had been wronged, to the way ‘sorry’ can be a habitual statement for life’s inevitable shortcomings.

For the winner, Clackmannanshire GP Gyda Meeten, ‘sorry’ was not just a way of defusing a very difficult consultation but of finding out the real story behind her patient’s anger. Her skilful building up of the tension and atmosphere, and raw honesty about her feelings and misgivings, was what led the judges to award her entry first place in what was a very strong and competitive field.

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Dr Meeten will receive £250 in John Lewis vouchers as her prize, as well as a framed copy of the specially commissioned illustration by the renowned illustrator Paul Blow.

Five runners-up will each receive £100 in John Lewis vouchers, plus a framed copy of their illustration. They are: London GP Alice Bell, former GP and freelance medical writer Louise Wiseman, South-east Scotland ST5 in anaesthesia and intensive care medicine Claire Adams, London clinical fellow in respiratory medicine Revati Naran, and NHS Practitioner Health Programme clinician and therapist Caroline Walker.

Their work will be published in the weeks ahead.

The judges – most of them doctors with a strong interest in medical writing – would like to thank all entrants for another excellent competition.

08/06/2020 10:22

thebma writing competition 2020

A GP consultation was spiralling angrily out of control, until one little word changed the temperature. By Gyda Meeten, the winner of this year’s BMA writing competition

M

erely five minutes in, the consultation had ‘I’m sorry.’ gone seriously awry. Her words rushed The words were out, before I could phrase them towards me, a wildfire of rage. Every inch of more elegantly. her, from expensive-looking black high-heeled boots The fiery tirade stopped. She looked me full in to honey-coloured highlights, was making it clear I the face. was the worst GP she had ever come across. I began ‘Sorry’ hung like a weight in the still air between us. mentally drafting the complaint response.

But then, in that moment, the dynamic between I had challenged her alcohol intake, suggested us shifted. We were no longer doctor and patient. We this was contributing to her mood swings. I had became merely two women, having a conversation. ostentatiously totted up her red wine She began telling the story of on my laminated unit calculator and a small, shy girl who loved books, turned it to show her the bad news. who watched her father drown ‘Taking a ragged breath, Technically I was absolutely right, sadness in vodka, losing him for I struggled to control my days, drunk or hungover. And then but I couldn’t have predicted the fight or flight impulse’ frightening turn things had just taken. she cried, remembering how she How had I misread the situation had held her father’s hand in a white so significantly? After all, was I not hospital room as he drowned in the the ‘nice new GP’, rapidly building a blood pouring out of oesophageal reputation for being ‘good at mental health’? varices into his lungs.

Taking a ragged breath, I struggled to control I’d had no perception of what pain lay beneath the my fight or flight impulse. Just moments earlier, ‘too much red wine’ I had so confidently, carelessly thinking we were establishing a pleasing rapport, diagnosed; no comprehension of her terrible, latent I had been doggedly moving down my tick list of fear that she would end the same way. All I saw was items constituting a ‘good consultation’, diligently rage, all I had felt was hostility. addressing lifestyle issues that might be contributing But that blurted, instinctive ‘sorry’ turned me from to her psychiatric distress. Now suddenly I was free authority figure to human being. By acknowledging falling. Failing. [GP communication expert] Roger that I had got something wrong I had unwittingly Neighbour hadn’t prepared me for this. opened a door for her to walk through.

There was a choice facing me, and like most That one unremarkable word became the key to decisions in a 10-minute GP consultation, a split working together to support the fragile mental health second to deliberate. hidden by the glossy exterior.

Should I stay calm and address the In the years that followed, I was ranting? Or should I square up to her, privileged to walk alongside her as she given that I was at least four inches ‘That blurted, instinctive navigated the long shadows of that taller, had the big chair, the letters early trauma. “sorry” turned me from after my name? Even if my grey roots I have regrets about many authority figure to were showing and my boots were consultations since those days of human being’ more scuffed than stylish, I had the being the ‘nice new GP’. I’m sure I’ve moral authority. No one was checking missed many hidden stories over how much red wine I got through in the years and sometimes dealt badly a week. I could demand she stop using that tone with with conflict but I have never regretted saying sorry me, hand her a copy of the practice leaflet detailing that morning or the years of connection which were our response to aggression towards staff and usher unlocked by that small, simple word. her out of the door.

Gyda Meeten is a GP in Clackmannanshire thedoctor | June 2020 31

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