The Doctor, October 2021, issue 35

The magazine for BMA members

thedoctor

Issue 35 | September 2021

Fighting back

The doctors taking on the anti-vaxxers

On the grounds of race

The surgeon discriminated against by the GMC

Masked frustration

Lives put at risk by flouting of face cover rules

In Kabul, in danger A doctor’s life in Afghanistan

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In this issue 3 At a glance The BMA launches the Support Your Surgery campaign to help GPs

4-7 Inside Kabul A doctor in Afghanistan speaks of the daily struggle for safety

8-10 Masked frustrations People failing to wear masks in healthcare settings are causing stress and risk to doctors

11-13 Fighting back Doctors facing abuse for promoting vaccination have found ways to tackle it

14-15 Defences under strain The first line of defence against COVID, it is time health protection teams were put on a firmer footing

16-19 A fight for fairness A surgeon faced years of turmoil when the GMC racially discriminated against him

20-21 Sexism exposed Sexism is a significant barrier to career progression, say a large majority of women doctors in a BMA survey

22 Your BMA Why all doctors should be given the chance to develop their leadership skills

23 On the ground Helping a doctor visit a seriously ill family member thousands of miles away

Welcome Chaand Nagpaul, BMA council chair As with many of you I have watched the scenes of chaos and conflict unfold in Afghanistan in recent weeks with great sadness.

In this issue we share the stories of doctors and organisations working in the country, as well as the reflections of an Afghan refugee doctor now living and working in the UK. The fear and uncertainty in these first-hand accounts is palpable and their stories are truly difficult to read.

As we see thousands of Afghans arrive in the UK, it is important our association continues to fight for the rights of refugees and asylum seekers to access health services in the NHS. The BMA also provides a range of support for refugee doctors and, at a time when the world is experiencing increasing rates of forced migration, their unique perspectives and skills are hugely valued.

This month we speak to Omer Karim – a consultant urological surgeon – who has won a landmark case in which a GMC fitness-topractise investigation has been ruled to be discriminatory. We are supporting Mr Karim’s legal case following the GMC’s decision to appeal. It is a decision I believe to be deeply flawed and one that further damages the confidence doctors have in the regulator. We are calling for an urgent and independent review of the GMC’s referral process to shine a light on its proven inequities so change can be made.

There is also an important feature on the BMA’s recent Sexism in Medicine report, which highlights that 31 per cent of female doctors face sexism on a daily or weekly basis, and what we plan to do to tackle this.

We look at how mixed messaging from the UK Government is contributing to a rise in patients not wearing masks in healthcare settings. In Scotland and Wales it is a legal requirement, but in England and Northern Ireland, doctors are left in the invidious position of being expected to enforce mandatory mask wearing without recourse to any legal obligation. We warned about this prior to ‘Freedom Day’ and will continue to call for the Government to take responsibility.

Finally, we cover the work of public health doctors trying to protect the nation’s health in a specialty cut to the bone, while private companies are paid billions for the failed Test and Trace service.

Read the latest news and features online at bma.org.uk/thedoctor Keep in touch with the BMA online at twitter.com/TheBMA

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instagram.com/thebma

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AT A GLANCE GPs and their colleagues are unfairly bearing the brunt of patient anger when their appointments are being handled differently because of the pandemic. The BMA has produced a range of materials to boost understanding and sympathy.

Why are things different?

To keep you and everyone else safe appointments are being triaged. This helps give you the type of appointment you need: – To be seen in person – A phone consultation – A video consultation – Help from your local pharmacy If you need to be seen face-to-face you will be.

Why do receptionists ask such personal questions?

Receptionists are a vital part of the practice team. Their questions are to ensure that you are seen by the right person at the right time, and all answers are kept confidential.

Why am I seeing someone who is not my GP? Not everyone needs to see a GP. Many practices now offer appointments with other healthcare professionals, including nurses, pharmacists, physiotherapists, physician assistants, mental health workers and paramedics. This ensures you see the right person for your condition as quickly as possible.

Where else can I get help?

Visit www.nhs.uk for advice on how to treat common symptoms or contact www.111.nhs.uk or dial 111 to speak to someone who can help.

In a life-threatening emergency always call 999.

GP SURGERY

Find out more about the campaign bma.org.uk/supportyoursurgery bma.org.uk/thedoctor

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INSIDE KABUL

A Taliban fighter stands guard as Afghans, hoping to leave their country, walk through the main entrance gate of Kabul airport’

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A doctor in Kabul, in hiding from the Taliban, speaks of his country’s devastated health service, and the daily struggle for security.

Peter Blackburn reports

‘W

E ARE NOT SAFE. If we had a way we would leave in the blink of an eye.’

Muhib Shinwari is speaking to The Doctor from a house in Kabul where he is in hiding – too scared to go to work in a country which needs his life-saving skills more than ever.

Dr Shinwari, who is a trainee cardiologist in the local hospital, and his brother, who was assaulted by the Taliban in the streets of the capital days after they retook the city, take turns to stay awake for three-hour shifts, watching the doors and windows trying to keep themselves and their mother safe.

‘I told her to keep faith – there will be some possible way for us to get out,’ he says. ‘I said don’t worry. But we are scared.

People are scared.’

Dr Shinwari, who asked for his name and picture to be published in The Doctor, had been training in Beijing, China, until the pandemic hit. Having seen the effects of the disease and the relationship with cardiac problems he decided to fly back to Afghanistan and to offer help in a hospital in Kabul. The health system he found was already bursting at the seams, with a high incidence of TB as well as countless other challenges, but has totally fallen apart since the withdrawal of Western support.

‘It has totally crashed. People are too scared to take regular appointments, most of the specialty doctors have fled the country, we don’t have enough medical supplies and there is COVID. ‘There are people waiting for chemotherapy or for radiotherapy at Government hospitals but there is no system and no Government – nothing is functioning. It’s a crisis – a huge crisis. There are pregnant ladies who want to go to public hospital but there are no duty doctors. It might be a nurse alone handling a delivery... I am afraid if things get worse with this fourth wave of COVID it will just be impossible. We need to look into this immediately, if not the outcomes will be unimaginable – a lot of people suffering.’

Rapid onslaught

He says: ‘The day they took over I was in the CCU [critical care unit] doing my work. It was 11am and then people were running and saying “they are here”. The duty nurse said to me: “They will not allow me to work”.

‘I changed my clothes and told them I am leaving because I am afraid of the consequences. My home is 10km from the hospital and I had to walk because there was no way to get through on the road. Everyone was running – the officials were all running to the airport. It was the most difficult day I have witnessed in my life. I thought everything was done – I didn’t know if I would get home alive. There was aerial firing.’

Dr Shinwari has accepted an offer for specialty training in interventional cardiology in Beijing, but has no idea when – or even whether – he will be able to take up that post. In the present, however, he is sure he cannot go back to the hospital.

He says: ‘If there is no Government you don’t know who the security are. People have come from every part of

Dr Shinwari was working on the wards when it was announced the Taliban were heading for the city. ‘We were thinking it is impossible – they cannot reach, it will take weeks or months. But it was days. Hours.’

‘People are too scared to take regular appointments, specialty doctors have fled the country’

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SHINWARI: ‘We are scared. People are scared’

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‘What is important and what we will communicate to everyone is that we have neutrality’ Afghanistan with guns. They could shoot me. I want to go and help but if it costs my life that is too much. It is better to be on the safe side.’

Every aspect of life in Afghanistan is difficult. There is the endless uncertainty which never leaves the mind or the pit of the stomach and then the practicalities such as having minimal access to internet, intermittent power and the ATM machines sit idle, and useless, dispensing nothing.

‘It’s not easy to handle all this trauma,’ Dr Shinwari says.

‘If I could get away I wouldn’t stay. I’m a professional but nothing is worth your life or your mental health.’

Shortage of supplies

WAILLY: Dialogue with the Taliban

The individual anecdotes are painful – and yet it is clear each individual story could be told through a thousand other similar stories. The volume of tragedy is heartbreaking.

Late last month, the WHO (World Health Organization) warned there were only enough medical supplies left in Afghanistan to last a week, with 500 metric tonnes of

medicines and supplies stuck in Dubai, unable to be delivered to the chaos at Kabul airport.

The WHO and UNICEF have, in response to the situation, urged the establishment of a ‘reliable and robust humanitarian air bridge to send in supplies’.

Doctors and staff from MSF (Médecins Sans Frontières) have continued to work in some of the hardest hit areas of the country, providing emergency, paediatric and maternal healthcare. The organisation works in one hospital in Kabul and one in Helmand province, previously with the support of the Afghan Ministry of Public Health. It is a significant role with staff providing 130,500 outpatient consultations, performing 6,990 major surgical interventions and helping to bring 36,300 babies into the world.

Life has becoming increasingly difficult for doctors working for the organisation, however. Since May, when violence in Afghanistan surged the consequences have been dire with patients staying at home rather than going to hospital, many staff unable to get to work and a significant increase in war wounded – all while the country has seen a fourth wave of the COVID-19 pandemic. During just two days at the end of July MSF treated 70 war-wounded patients.

Medical neutrality One doctor working for MSF says: ‘The conflict leads people to think 10 times if they really want to make the journey. They delay until they can’t wait any more. From a medical perspective that’s almost too late.’

The Doctor understands there are huge concerns among staff working in the country – from people being unwilling to leave their homes to access medical care to huge staffing shortages due to the same reason. And there are significant issues around supply of equipment and medicines. There are also grave concerns for the well-being of staff who have continued to work under the pressure of conflict and COVID-19.

And with Western troops having withdrawn from Afghanistan perhaps the primary issue for doctors has moved from dealing with the results of conflict to worrying about their own security and the great uncertainty of the new regime and what it means for healthcare.

Yves Wailly, MSF’s medical officer, tells The Doctor MSF has been in discussions with the Taliban and is hopeful the organisation can continue with its work.

He says: ‘We have always had those open conversations with them. For us what is at stake and what is important and what we will communicate to everyone is that we have neutrality. We have medical principles.’

Mr Wailly says the problems are exacerbated by the COVID-19 pandemic, with many anecdotal reports that there have been surges across the country – but staff have to take official statistics ‘with a pinch of salt’. Mr Wailly says it is ‘very difficult to answer what is happening on the COVID front’ but that medical centres are seeing people present later with much more complicated disease.

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Women in danger A statement co-signed by BMA medical ethics committee chair John Chisholm, BMA international committee chair Kitty Mohan and senior leaders from a number of medical organisations, described ‘deep concerns regarding the unfolding humanitarian crisis in Afghanistan’ and urged all involved in the conflict to ‘respect the human rights, including the health-related rights, of all in the country’.

It says: ‘As representatives of medical organisations, we are deeply concerned about the access to healthcare for women and girls in the country. Over the last 20 years, significant progress has been made to reduce the remarkably high maternal mortality rates in the country.

Our organisations fear that these efforts will have been in vain. We also fear for the safety of female healthcare workers, violence and sexual violence are well-documented tools used by the Taliban to suppress women and girls.

Midwives in Afghanistan are already reporting having meetings with male colleagues banned and female surgeons feel abandoned by the West and expect to be banned from working.

‘While we welcome the decision of the UK Government to resettle 20,000 Afghan refugees, with a particular focus on women, we believe this figure should be increased and the process expedited to bring more people to safety as soon as possible. We are concerned about the speed of the process and the potential for many Afghan refugees to bma.org.uk/thedoctor

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be abandoned if this number is not increased. We also believe steps should be taken to provide medical training places for those now unable to complete their training in Afghanistan.’

For many Afghans the events of recent weeks will bring a sense of great déjà vu.

The conflict, the uncertainty and the fear are all emotions previously experienced in great quantities.

Concern for family A doctor who does not wish to be identified, who also spoke to The Doctor, fled Afghanistan in 2011. He had worked with Western organisations – military and NGOs – and was the victim of attempted kidnappings while working at a private hospital in the country.

‘When your life is at risk, you have to leave,’ he says.

He is now a working as a GP. ‘It’s quite nice – I’m very grateful.’

Reflecting on recent events in Afghanistan, he says: ‘It is really hard. For the first few days I was in a shocked state.

I was not able to concentrate well. It happened so randomly, so fast.

‘I was thinking about my family and the other people of Afghanistan. Especially my brother and my brother-in-law who are the two members of my family who were working for the Government.

‘Once the Taliban came my family went to the capital and moved houses. Otherwise we were thinking someone would definitely come asking for me or my brother. They are all in Kabul at a location that is unknown. They are hiding.’

He hopes some of his family members will be eligible

for UK resettlement schemes.

But that could be a ‘timetaking process’ and they may not all be eligible.

‘They have to come out of Afghanistan and go to Pakistan or somewhere else,’ he says. ‘It is really difficult – it is a tough time.’

His worries extend beyond his nearest and dearest.

He says: ‘I hear from friends who work as doctors that they were told by the Taliban there is no salary to pay them so they can work free of charge until they establish a proper government… And sure, many people are scared to go to work. People don’t trust these people. They are human beings but they are like animals.

‘Our relatives and friends say they are searching houses every night for people who worked for the Government.

Those people are their enemies – how could they forget them? There is no reason to trust these people.’

He adds: ‘In the past we didn’t have a good healthcare system but on top of that with the coming of the Taliban the hospitals are not running properly and the wellbeing of patients is definitely in danger.’

MOHAN: Human rights must be protected

‘It happened so randomly, so fast’

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LANGHOR: ‘Misinformation has contributed to the way people behave’

W

e’re barely out of summer and it’s busier in Den Langhor’s emergency department than the worst winter peak she has ever experienced.

It’s bad enough with rising COVID cases, an alarming RSV (respiratory syncytial virus) and long-untreated conditions turning into emergencies.

But now increasing numbers of patients are discarding their face coverings or treating them as a civil liberties issue.

In Dr Langhor’s department in north-west England, there are frequent Tannoy announcements that face coverings are still mandatory throughout the hospital.

Yet, she regularly has to remind people about the rules.

‘Most people put their masks on when they walk through the door, but some remove their masks in the waiting room,’ says Dr Langhor, consultant in emergency medicine. ‘The majority are compliant when you point out the rules, but I do find it incredibly frustrating when people are not taking the correct precautions to keep those around them safe.

‘I work with patients from zero to over 100 and I work with clinically vulnerable people every single day.

They might have the option to avoid going to bars, restaurants, and supermarkets but they do not have a choice about whether or not to attend a healthcare facility if they’re unwell. We owe them respect and care.’

Mixed messages At the time of writing, it remains a legal requirement for people to wear a face covering in healthcare settings – and other indoor public spaces – in Scotland and Wales, unless they have an exemption.

In England and Northern Ireland, face masks are still mandatory in healthcare settings – but that rule is not legally enforceable. Here, as restrictions have eased and face coverings have become a matter of personal choice in other public spaces, the messaging has become muddied. And since ‘Freedom Day’ on 19 July, some patients have become more assertive.

Doctors in Northern Ireland have reported rising numbers of patients refusing to wear face coverings and to have a COVID test in hospital before assessment or admission. A number of GP practices have told the BMA they are being threatened with legal action under the Equalities Act for asking patients to wear a face covering.

Dr Langhor believes the absence of clear messaging on the guidelines in England is making matters worse – especially as misinformation is still vocal and rife. bma.org.uk/thedoctor

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‘Patients are hearing messaging that the previous COVID regulations have now been cancelled. They’re not reading the small print and the Government has not made any reasonable attempt to publicise the fact that, within healthcare facilities, the rules have to be different.

‘Meanwhile, we’re seeing people who don’t believe us ‘Some people when we tell them they’ve got COVID remove their because “COVID’s not real” – even masks in the when they have breathing difficulties. waiting room’ All the misinformation, mostly on social media, has unfortunately contributed to the way people behave.’

By contrast, strong statements on face coverings in Scotland have spared healthcare workers this tussle.

First minister Nicola Sturgeon has explicitly linked them to the need to avoid ‘shielding by default’ for the most clinically vulnerable.

Jon Carter is an emergency medicine consultant in south-east Scotland where patients have largely been compliant, even if they have to be handed a mask at the door.

‘I don’t know if it’s because we are a smaller country and have a different sense of identity, or if it’s just easier for Nicola Sturgeon to access the Scottish public with her tweets and broadcasts,’ says Dr Carter. ‘But I do think the Scottish Government has been clear in explaining the rules with their broadcasts.’

Publicity campaign Some hospitals in England have anticipated confusion and headed it off early. At David Strain’s hospital in the south-west, where he is clinical lead on COVID services, they acted fast to keep control of messaging around face coverings.

New artwork explaining masks are still mandatory to protect the most vulnerable is displayed on every TV screen in the hospital and on banners at the entrance where volunteers hand out fluid-resistant surgical masks.

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were being dropped in most public spaces, we had that conversation with our management team,’ says Dr Strain. ‘It had to be new artwork – not just the same “Hands, face, space” – in case people thought it had just been left up there. The artwork was on every single screen in the hospital by that evening. And, because it’s seen as the norm, we’ve not had any problems at all with people saying no.’

Dr Strain is in no doubt about the continuing need for masks as rising COVID cases in his area converge with winter pressures such as flu.

‘Vaccination is preventing people from dying, for the most part, but it’s not stopping transmission as much as we originally hoped, so masks are a good way of keeping infection levels down,’ says Dr Strain. ‘I hope mask-wearing and some degree of physical distancing this winter will be enough to stop us ending up in another lockdown.’

Moral dilemmas NHS England gave GPs the option of denying face-toface treatment to patients who refuse to wear a face covering in a directive in August 2020. Many doctors would baulk at such a draconian step.

But, to deny themselves this option leaves them shouldering all the risk and the responsibility for protecting others.

So, if a patient with suspected COVID refuses to wear a mask, they are treated as if they have the virus.

Dr Langhor’s hospital has six negative-pressure isolation rooms where they could be seen by staff wearing FFP3 masks – but not every facility has this option.

For GP Alice Bell, things were much easier before when the law was clear and staff in her London practice

‘If a patient ... starts to cry during the consultation, it is very difficult to enforce that they wear a mask whilst they’re crying’

BELL: ‘If someone without a mask infects me, I could infect the whole workforce’

STRAIN: No doubt of need for continued face coverings

‘Masks are a good way of keeping infection levels down’ could insist on mask-wearing. Now, despite clear signage in reception in English and Turkish about face coverings being mandatory, patients are increasingly coming into the surgery without one.

Staff in reception have a supply of masks and ask visitors to wear one, and the majority of patients do.

But ambiguity around the rules in patients’ minds exposes the doctors to moral dilemmas, as well as physical risk.

Despite unprecedented workloads, GPs are still facing unfair criticism in the media and, for Dr Bell, the need to build bridges with patients can sometimes take precedence – even at the cost of her own discomfort.

‘If a patient is struggling with mental health problems, which unfortunately is more rife than ever, and starts to cry during the consultation, it is very difficult to enforce that they wear a mask whilst they’re crying. GP surgeries are meant to be familiar, safe spaces.

‘I feel in a very difficult position ethically because of my duty of care to the patient in front of me, and the need to build rapport so we can communicate well.

But, equally, I have a duty of care to everyone else in the surgery, and if someone without a mask infects me, I could infect the whole workforce.’

Dr Bell still wears a mask in public even when it’s optional. ‘Wearing face coverings in healthcare settings is a constant reminder that this pandemic is still ongoing, even if people can behave more normally outside,’ she says.

Few doctors seeing COVID patients, in fact, can afford themselves the luxury of ‘living normally’ outside the workplace just yet.

‘At the very start of COVID, even before the first lockdown, I cut myself off from society,’ says Dr Langhor.

‘I stopped going to the gym, to the supermarket and all public places: I didn’t visit my family, I didn’t visit friends.

Because all I could think was, I could be carrying COVID, I could pass it to someone and they might die. I don’t think that worry is going to go away.’

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PAUL HERRMANN

‘I’m not going to let people spread misinformation and cause harm’

KELLY: Reports online abuse to Twitter

FIGHTING BACK Doctors trying to save lives by promoting the benefits of the COVID vaccines are being subject to online vitriol. Tim Tonkin reports on those who are undeterred, and hears about a network of volunteers who support doctors under attack

‘A lot of the abuse is to try and shut you up’

‘C

ontact me again and I will take u to court personally for crimes against humanity you slave Nazi bastards’ ‘Go f**k urself with ur poisonous cocktail which is killing people’ ‘Why would I come for an untested, experimental, killer vaccination?’

These are just some of the responses GP practices in London have received from patients after simply sending out text reminders about how and where to get COVID vaccinations.

Since the beginning of the vaccine roll-out there have been increasing reports of doctors and other healthcare staff facing harassment and

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abuse from those sceptical or outright opposed to COVID vaccinations: colloquially known as anti-vaxxers.

While this harassment can take many forms including text, email, written letters and even direct confrontation, a considerable portion of it occurs online via social media.

During the pandemic, platforms such as Twitter have afforded medical professionals with an opportunity to engage with a large audience and highlight and promote the importance of getting vaccinated while dispelling misinformation regarding vaccines.

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WOLYNN: ‘These comments are intended to run you ragged and deplete your resources’

‘You can’t let these people win’

has been shocking and, in some cases, led to them suspending or leaving their social media accounts.

Kent specialty trainee 7 in intensive care medicine Samantha Batt-Rawden announced on 8 August she was taking time off from Twitter after receiving dozens of abusive messages relating to COVID. In one of her last tweets before suspending her involvement with the site, she shared a recent message she had received where the sender referred to her as a ‘sub-human animal’ and urged her to take her own life.

‘Do we really deserve this?’ she wrote.

‘This is what NHS staff are facing, along with doctors and scientists around the world.

‘We are trying to get out correct information on the vaccines and save lives. Don’t know how much more we can take.’

Bogus legal threats It is an experience that Manchester-based consultant obstetrician Teresa Kelly can unfortunately relate to all too well.

Speaking about one particular experience, Dr Kelly explains how she had been targeted ahead of an online talk on vaccination in pregnancy she had been scheduled to lead, resulting in the event organisers receiving a number of anonymous threats from the public.

‘The threats warned that people would be “listening” to the event, including medical lawyers, and that if I said that the vaccine was safe, they would look to prosecute me,’ she says.

‘In the end there was no trouble at all, and I think it was just a tactic to try and put us off holding the event. How can you be prosecuted for promoting national guidance? [The threats] made me more determined to go ahead with the

meeting because you can’t let these people win.

A lot of the abuse is to try and shut you up and I’m not going to let people spread misinformation and cause harm.’

Abuse received by Dr Kelly on Twitter has included everything from general profanity and comments about Dr Kelly’s personal appearance, to calls that she be struck off and insinuations that she is being paid by an unspecified individual or organisation to promote a ‘harmful’ vaccine.

After contributing to a local TV news piece on vaccinations in June, Dr Kelly received so much abuse that her trust, out of fear for her safety, urged her to consider temporarily leaving Twitter.

‘There’s been quite a bit of abuse on social media if you promote anything around the vaccines, particularly in relation to pregnancy,’ says Dr Kelly. ‘I was added to a Twitter list of people guilty of cruelty against children. I think I later posted that “Twitter hate’s really strong today”, and one of the responses was “you deserve every bit of it, murderer”.’

She reports every account that sends her abuse to Twitter – an action that she says sees some of them get removed.

She says it can be difficult to know how to respond to harassing comments pushing false information. She points out that on the one hand, ignoring it runs the risk of someone else reading and believing it, while challenging it could end up amplifying the responsible individual further.

‘I think that social media companies need to take some responsibility,’ she says. ‘They’re letting people who are promoting national guidance around vaccination be abused repeatedly.’

Tackling harassment Knowing how to best respond to online harassment is a challenge for many healthcare professionals even if it is coming from one or a few accounts.

In some instances, however, those promoting vaccines have found themselves coming under overwhelming, coordinated attacks, an experience that can take the phenomenon of online harassment to a whole new level.

Pittsburgh-based paediatrician Todd Wolynn and his colleagues found themselves to be the targets of such an attack back in 2017, after Dr Wolynn’s practice posted a short video to YouTube promoting uptake of the HPV vaccine.

Over four days, Dr Wolynn’s place of work, Kids Plus Pediatrics, saw hundreds of negative postings aimed at its Twitter and Facebook

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accounts in addition to negative reviews about the practice being posted on Yelp and Google.

The harassment finally came to an end when dozens of people from pro-science backgrounds came to the practice’s support online.

The experience inspired Dr Wolynn and his colleagues to found Shots Heard Around the World, a global network of volunteers dedicated to supporting those being bombarded with online harassment from anti-vaccine activists.

‘If they [Shots volunteers] see a vaccine advocate – it doesn’t even have to be a healthcare professional – coming under organised attack from the anti-vaccine community, we will contact that person and, if they request it, come to their aid,’ explains Dr Wolynn.

‘The anti-vaccine community is very coordinated in these attacks, but they only attack in any kind of coordinated large-scale form against [pro-vaccine] messages that are resonating. One of the strategies is to overwhelm you with multiple comments from one or more person. These comments are intended to run you ragged and deplete your resources so that you can’t put good information out there.

‘They’ve [also] been able to weaponise social media by creating reputation harm and that’s a major issue, and they’ve been really empowered by these social media platforms that don’t hold them accountable.’

Stand by your posts Now operated by the nonprofit organisation The Public Good Project with a dedicated staff supported by 1,500 vetted volunteers based around the world, Shots Heard has also developed a toolkit outlining the steps and strategies that can be taken to prepare for or respond to harassment directed at Facebook profiles.

With the internet and social media an excellent way of engaging with people, Dr Wolynn argues that it is important for healthcare professionals to distinguish between those who have genuinely held concerns about vaccination, and those who are simply looking for a fight.

‘If the questions you are getting [about vaccines] are in good faith, even if they are very misguided, then you should engage them,’ he explains.

‘As soon as you realise it’s not in good faith, it’s absolutely imperative that you don’t engage. bma.org.uk/thedoctor

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As quickly as you can, first ban or block them and then delete or hide their comments.’

Dr Wolynn adds that one of the most important aspects of dealing with online harassment for medical professionals if willing, is to be prepared and to stand by any posts that may have led to them being attacked, and not delete them.

‘Their goal is to silence you and to get you to pull down your post,’ he says.

‘If you know you’re going to post something that’s likely to receive an attack there are steps you can take on your social media platforms such as stopping reviews and poster comments on the post in question. This can nullify or pre-empt some aspects of these attacks.

‘What we’ve found is that if you follow those steps and stand by your post you can become somewhat immune to future attacks.’

Speaking in a personal capacity, and as someone who themselves has faced abuse online, immediate past chair of the BMA medical academics committee and board of science member David Strain says he condemned the harassment of healthcare professionals in the strongest possible terms.

‘Over the last 18 months researchers and health care workers have worked at unprecedented pace and intensity in order to develop and deliver a vaccine. This vaccine has, quite literally, saved thousands of lives and is allowing life to return to normality.

‘It is appalling that these same people are now being targeted by the very people that they have worked to protect. We, at the BMA, will continue to support any clinical academic, doctor or medical student who has been affected by this, irrespective of whether they are members, through our wellbeing hub.’

BATT-RAWDEN: ‘We are trying to get out correct information on the vaccines and save lives’

‘As soon as you realise it’s not in good faith, it’s absolutely imperative that you don’t engage’

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Health protection teams were the first line of defence against COVID. Doctors say that, after years of funding and staffing cuts, the specialty must at last be put on a firm footing. Tim Tonkin reports

Defences under strain C

OVID-19 is the greatest public health crisis the world has faced in a century. It has posed an unparalleled challenge to health services around the world, including the NHS. Among the first parts of the health service in the UK to encounter and react to the pandemic early last year were the HPTs (health protection teams) of PHE (Public Health England).

It was these multidisciplinary and regionalised units which sought to address and counter the ever-rising swell of infections during the early months of 2020.

Much like the rest of the health service, the effect on staff in these teams during the past 16 months has been enormous, yet for those ‘The existing working in conventional parts of the NHS, the HPTs became work of HPTs is often poorly understood.

Comprising 18 organisations, each covering overwhelmed’ different geographical regions of England, HPTs are truly multidisciplinary medical outfits, consisting of doctors, nurses, allied health professionals as well as staff working in administrative and surveillance roles.

Around one third of all public health consultants in England work in health protection, with this area of public health itself divided into three core areas of responsibility.

These include communicable disease

control, which in the pre-pandemic era would have seen HPTs undertake contacttracing work in relation to person-to-person transmissible infections, such as meningococcal disease and blood-borne diseases, such as hepatitis B and human T-cell lymphotropic virus.

Overwhelmed Another function is responding to environmental hazards to health including incidents involving the accidental or deliberate release of chemical and radiological materials.

Teams are instrumental in developing emergency plans, improving community resilience and responding to major incidents that affect health, with each of these areas of responsibility seeing HPTs work with a wide range of organisations, such as emergency services, local authorities, Environment Agency and Met Office employers and schools.

However, when COVID-19 began to take hold in the UK at the beginning of last year, HPTs and their staff were among the first parts of the health service to bear the brunt of the new pandemic.

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GETTY IMAGES

Initial work included assisting in the repatriation, and subsequent quarantining, of British citizens from China.

Speaking anonymously to The Doctor, one public health consultant explains how the efforts of teams to control the spread of infections through contact tracing of confirmed cases soon became impossible as the virus took hold.

‘Once it [the coronavirus] began to be transmitted within the UK in late February and early March, all of our efforts were diverted into contact tracing and following people up to make sure they acted appropriately, and I think we got advice on self-isolation spot on very early on,’ the

consultant says.

‘The big problem came by the second or third week of March 2020 where the existing HPTs, which had been completely repurposed to coronavirus, became overwhelmed.’

Redeployments The implementation of the first national lockdown in the UK saw the focus of HPTs, working in collaboration with public health services at local authority level, shift from contact tracing to developing guidance and advice on personal protective equipment for NHS staff.

As 2020 progressed, the demands of the pandemic saw the vast majority of public health specialty trainees being deployed to HPT roles.

While redeployments of this kind were not limited to doctors in training, the sole focus of battling COVID has prompted concerns with how some trainees’ experience of working in a public health role will have been narrow in scope.

Speaking truth to power As if tackling a pandemic was not demanding enough, the revelation, abruptly announced bma.org.uk/thedoctor

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in September last year, that PHE was to undergo a restructuring process has presented a further challenge to staff working in HPTs. With PHE set to be transformed into the UK HSA (Health Security Agency), whatever new form that HPTs take, two important aspects will be how they are funded, staffed and resourced and whether the doctors staffing them will be empowered to be truly independent in the way they operate.

‘The biggest single issue that we’ve had is, as with much else, public health has been really run down in terms of funding and staffing,’ says another HPT consultant speaking anonymously to The Doctor.

‘Public health has been really run down in terms of funding and staffing’

‘Next to being properly funded and staffed is [having] the ability to have a professionally led public health response which can be truly independent and speak truth to power, and where individual consultants within the system are free to speak out and advise without political constraint.’

Speaking about the challenges faced by HPTs, BMA public health medicine committee co-chair Penelope Toff says the pandemic had demonstrated how essential the knowledge and experience of these teams were in responding to a health emergency such as COVID. She says: ‘HPTs formed the backbone of the public health response to COVID-19 in England during 2020. This feat is all the more impressive when we consider both the historic underinvestment these highly specialised teams have endured, the rapidly escalating scale of the pandemic and the disruption later imposed on them by the Department of Health’s decision to overhaul PHE. ‘The pandemic has shown how coordination at local and national levels is critical to protecting public health and, along with the wider BMA, we would strenuously urge that these teams and their staff are given the resources and support they need to form a central part of the future national HSA.’ thedoctor | September 2021 15

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SARAH TURTON

‘Having the investigations hanging over me meant I felt like a prisoner’

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SARAH TURTON

Surgeon Omer Karim suffered years of turmoil when the GMC racially discriminated against him. The BMA, supporting Mr Karim, says it is time for the GMC to accept independent scrutiny. By Peter Blackburn

A fight for fairness ‘L

ife-changing.

Devastating.

Catastrophic.’

Omer Karim is doing his damnedest to hold back his emotions as he tries to explain the brutal effects a lengthy – and, ultimately, discriminatory – GMC FTP (fitness-topractise) investigation has had on his existence.

Doctors sometimes speak of the instant, nauseating terror felt when they receive a letter or email with that dreaded three-character heading: GMC. They tell of that stomach-tightening anxiety and panic accompanying a career flashing before their eyes and premonitions of their life crashing down around them. These are concerns felt even more gravely for doctors from minority ethnic backgrounds – who are more likely to be referred to the GMC by their employer.

For Mr Karim, those premonitions were not blown out of proportion.

He ‘lost everything’.

Mr Karim was a consultant urological surgeon at bma.org.uk/thedoctor

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Heatherwood and Wexham Park Hospitals NHS Foundation Trust, (now the Frimley Health NHS Foundation Trust). During his time there the trust made several investigations into his conduct, eventually referring him to the GMC. After almost four years of investigations, the GMC subjected him to an FTP tribunal. That tribunal was to determine that Mr Karim had done nothing wrong.

But the process was lengthy and painful. The GMC had first received allegations of concern against him in 2013 and he was officially referred in 2014 but the final FTP hearing – he had been subject to an interim orders process in the meantime – did not take place until April 2018. In the meantime, Mr Karim lost his

Mr Karim sold his family home of 20 years and his daughter left her private school which helped with costs.

Life on hold Mr Karim, an acknowledged authority in robotic surgery for prostate and kidney cancer, also had to give up teaching roles across the world and was unemployed for five months before taking locum shifts at a south-coast hospital trust miles away from his home, living in a Travelodge when on call.

‘Every family holiday we went on we were constantly wondering whether we would be able to do something like this next year,’ Mr Karim says.

‘We were constantly answering emails from my

‘I was mistreated by the very organisation supposed to be looking after me’ private practice and felt forced to leave his trust through a settlement agreement to be able to work elsewhere in the NHS. On top of that

lawyers and my daughter has lived with this as a huge part of our lives from the age of 15 onwards. Having the investigations hanging over me thedoctor | September 2021 17

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OMER KARIM

KARIM: Operating, and training other doctors

meant I felt like a prisoner.’

Mr Karim argued that, while the investigations into his conduct continued for years, similar complaints against a white colleague were quickly dropped. In August 2018, he brought claims against the GMC, including a claim of direct race discrimination, and an employment tribunal found in his favour.

In June of this year the tribunal judgment said it was concerned there was ‘a level of complacency about the operation of discrimination in the work of GMC or that there might be discrimination infecting the referral process’.

The judgment also said the GMC was ‘looking for material to support allegations against Mr Karim, rather than fairly assessing matters presented’.

At the FTP hearing in 2018, the GMC failed to disclose evidence which it considered not relevant to the allegations against Mr Karim.

Facing prejudice is not a new experience for Mr Karim, who was one of the only minority ethnic boys in a

grammar school in the North West. ‘In the NHS it is subtle,’ he says. ‘You applied for jobs and didn’t get shortlisted. If you have a foreign-sounding name you perhaps miss out.’

He adds: ‘In this country, to achieve the same as your white colleagues you have to be better than them. You have to be above everyone just to get the same treatment.’

But experiencing discrimination from his regulator – a body which is supposed to support patients and doctors – was even more galling. ‘I was mistreated by the very organisation supposed to be looking after me, and it was vexing that, the GMC questioned the credibility of their own witnesses,’ he says.

Amazing support It is not the first time the GMC’s actions have come into question of late. The BMA is supporting a legal case by the family of Sridharan Suresh, a consultant anaesthetist who took his life within hours of receiving a GMC letter.

Dr Suresh’s widow, Viji Suresh,

says he was left feeling alone and unsupported.

Mr Karim tells The Doctor he doesn’t think he would have survived his ordeal had he not had such ‘amazing support’ from family, colleagues and friends. Mr Karim’s case has been hailed as a ‘landmark’ moment. Doctors from minority ethnic backgrounds are already disadvantaged by being referred by their employers to the GMC more than twice as often as their white counterparts – as revealed in the GMC’s own Fair to Refer report, published in 2019.

However, BMA council chair Chaand Nagpaul says the tribunal ruling raises a further ‘significant concern’ that ‘not only do minority ethnic doctors find themselves referred to the GMC more often, but that they can then face further discrimination from [the GMC itself]’.

Dr Nagpaul says: ‘The profession already feel they are working in exceptionally challenging environments – environments that are unfair

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9 in 10 doctors

go into work every day worrying they will make a mistake because of system pressures

for them to work in with too few colleagues, a lack of beds and facilities and capacity nowhere near to meeting demand. Our own studies have shown that nine in 10 doctors go into work every day worrying they will make a mistake because of

one manifestation of this unequal, unfair existence, and it pervades every area of the system.’ He adds: ‘The GMC has always maintained their [investigations] once the referral has been made are fair but Mr Karim’s case challenges that claim directly. This

‘The judgment said the GMC was “looking for material to support allegations against Mr Karim, rather than fairly assessing matters presented”’ these pressures.

‘These pressures are compounded for ethnic minority doctors who suffer twice the level of bullying in the workplace, they feel less confident to speak out about safety concerns due to fear of recrimination or it affecting their careers, on the back of already being disadvantaged with poorer career progression.

Many feel isolated and without support from their employer and managers. When you add all of that together they are less likely to feel able to challenge or to defend themselves and can become soft targets for blame. The GMC referral is bma.org.uk/thedoctor

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example will resonate with the views and experiences of so many other ethnic minority doctors who have felt similarly unfairly treated.’

‘Serious misjudgement’ The GMC is appealing the outcome of Mr Karim’s case, arguing that ‘the tribunal wrongly concludes that disproportionate referrals to the GMC by employers constitutes evidence of direct discrimination in Mr Karim’s case’, and also that the case of the doctor with whom Mr Karim was compared differed in key respects.

But doctors from minority

ethnic backgrounds told The Doctor they felt the GMC’s refusal to accept the ruling – and to take the opportunity to look at their own processes – ‘crystallised’ worries that the GMC treats doctors from minority ethnic backgrounds differently.

Dr Nagpaul says: ‘The GMC should acknowledge there is a desperate need to ensure their own processes are fair and be open about the fact that they may not be. While the GMC also suggests that this is a problem of workplace referrals, we know that GMC employment liaison officers often provide advice on referrals for disciplinary action. The right thing – the moral thing – to do is to allow proper, independent, scrutiny of their processes and for the GMC act on any recommendations for change.

Given the devastating impact a GMC referral can have on doctors it is imperative that its investigations treat all doctors equally and fairly.’

The BMA is calling for a full, independent, review of the GMC’s FTP processes.

NAGPAUL: GMC processes must be independently scrutinised

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Sexism exposed The majority of women doctors say sexism acts as a barrier to career progression, with significant numbers saying they have been assumed to be more junior than they are or lacking in clinical skills.

Tim Tonkin reports on a landmark BMA survey and the action that needs to be taken

A

‘Even for one person to have an issue in relation to their gender in the workplace is one too many’ 20

s with many forms of discrimination, the existence of sexism is largely undisputed, yet understanding its prevalence, how it manifests and what effect it might be having on the medical profession and health service can be far harder to quantify.

It was partly this fact, as well as her own experiences of sexism in the workplace, that led to one junior doctor, Liverpool-based specialty trainee 1 in emergency medicine Chelcie Jewitt, to speak out on the issue of gender-based discrimination and urge other doctors to come forward.

Dr Jewitt’s efforts to shed light on individual experiences and gain a greater sense of what might be happening on a wider scale, led to the BMA conducting a survey earlier this year.

The study, the results of which were published last month, canvassed the views of more than

2,500 men and women, working in all parts of UK medicine, from various branches of practice and at different stages of their careers.

When asked how frequently on average they experienced sexism at work in the past two years 31 per cent of women doctors said they had experienced it on either a daily or weekly basis, with just 9 per cent saying that they had experienced none.

The number of women reporting witnessing sexism in their workplace during the same period was even greater, with 37 per cent saying they had observed such behaviour on a daily or weekly basis.

Gender also appears to influence the way in which seniority and clinical experience are perceived by patients and other doctors.

While 89 per cent of men responding to the survey said they felt they had not been assumed

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JEWITT: Response to survey has been powerful

to be in a more junior position owing to their gender, only 15 per cent of women said the same.

Similarly, 82 per cent of men said that they did not feel their clinical ability had been doubted or undervalued because of their gender, compared with just 24 per cent of women.

Career barriers

‘If we want to eradicate sexism, we all have a part to play’

While there is an obvious and immediate effect of being on the receiving end of a sexist comment or interaction, the survey sought to determine whether gender discrimination might also affect professional development and career paths.

When asked whether sexism acts as a barrier to career progression, 79 per cent of women and 46 per cent of men told the BMA that they believed it did to either a ‘great deal’ or a ‘fair amount’.

Asked to what extent their gender had affected career progression, just 2 per cent of women felt their gender had had a significantly positive effect on their careers, compared with 10 per cent of men.

By contrast, 22 per cent of women responding to the survey felt their gender had had a significantly negative effect on their professional lives, while just 3 per cent of men felt the same.

Responding to the study’s findings, Dr Jewitt says that while many of the figures and personal anecdotes submitted to the survey have been harrowing, many have sadly not come as much of a surprise to her.

‘Even for one person to have an issue in

men women 82% of men said they did not feel their clinical ability

had been doubted because of their gender, compared with 24% of women bma.org.uk/thedoctor

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PATEL: Findings have been appalling

relation to their gender in the workplace is one too many; the fact that there are literally thousands of respondents to this survey is really powerful,’ she says.

Concerning what lessons can be learnt or actions taken as a result of the survey, Dr Jewitt says she hopes more doctors will be willing to speak out about their experiences of workplace sexism, adding that sharing such experiences would further highlight the issue, and demonstrate that people are not alone.

‘There is safety in numbers, however, so having a support network around you should hopefully make people feel more confident and supported in highlighting any issues they experience.’

BMA action In light of the results of the survey, the BMA will now seek to develop recommendations to address the unacceptable experiences that have been raised.

These measures will, in turn, be shared with appropriate partners and stakeholders who will be encouraged to report back on progress made.

Responding to the survey, BMA representative body acting chair Latifa Patel says many of the findings it uncovered are appalling, adding that the BMA will seek to do everything possible to lobby against sexism in medicine and society.

She says: ‘It is appalling that we are seeing these statistics, hearing these stories and talking about these inequalities in 2021. The report makes for shocking reading and there is no place for sexism in society. If we want to eradicate it, we all have a part to play. It’s going to take a concerted effort, and it won’t be quick to fix, but sexism must stop.’

To find out more, visit bma.org.uk/ sexisminmedicine or call the association’s free and confidential helpline on 0330 123 1245 thedoctor | September 2021

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Your BMA All doctors should be given the chance to develop their leadership Headline text to go in skills, and be involved in the decisions that affect them Since taking my position as interim BMA representative body chair in June, it has become increasingly clear to me what an exciting opportunity it is to have a junior doctor take up a position of leadership.

I write this column as the first new mum, first woman of colour and first junior doctor to hold the role in our association’s history. Yet I know that all of these characteristics are common in our profession. Just not in our leadership.

Diversity in leadership is as important as diversity on the ground. Most of us share the principle that our workforce should reflect our society as best it can – so why should leadership be any different? This isn’t about me. Or the BMA. It’s about all positions of leadership in medicine and healthcare.

All junior doctors are clinical leaders. Out of hours we lead the clinical decisions in hospital and make those senior decisions. Though, of course, our consultants are available if we need them. This is sometimes overlooked but those experiences are a hugely valuable resource for the NHS and organisations such as ours.

For assessment purposes, ‘leadership and management’ feel like tick-box competencies loosely achieved as part of the annual review of competency progression process – a rota managed here or a training session attended there. But we are already showing leadership during every shift and I think we should be encouraged to build on that and find a place in each and every room where decisions are made about our careers.

I am fortunate enough to have a TPD (training programme director) who supported me on my leadership journey. I took an OOP (out-of-programme) experience and spent a year working with the GMC through the Faculty of Medical Leadership and Management. I gained understanding of leadership and working in a large organisation, one we are all linked to.

For the last decade I’ve also been involved in the BMA. I’ve gained an incredible amount of leadership and management training. But this has all been on my own time. On annual leave and rest days alongside training.

Now, however, my TPD is again supporting me. All chief officers in my role at the BMA continue their clinical

@drlatifapatel frontline jobs. For me, however, as a new parent with caring responsibilities and of course being unable to train at less than 50% it wouldn’t be possible to do both. I am therefore being granted another OOP. This sort of route isn’t for everybody but I do believe opportunities such as these should be available to more of us and not only supported but encouraged.

The reality is that our day-to-day working lives are demanding, stressful and exhausting. It isn’t always realistic to have significant leadership experiences while in a training post. If our assessors really want us to learn to lead and manage should there not be a specific OOP for management and leadership? An OOPML perhaps?

One of the mantras I believe in most is ‘no decisions about us, without us’. And it is with good reason. Having a diverse leadership in the rooms where decisions are made would ultimately result in them being better.

Beyond that, we are at a crucial moment in the NHS and society. We face issues which will affect our work and life in the coming years. Why shouldn’t those who will be delivering those services participate now?

Your BMA 2021 annual representative meeting will be the first chaired by a junior doctor in our history. I know it won’t be the last!

What do you think about leadership and management training? If you’re a trainee how have you found accessing leadership and management experience?

If you’re a supervisor or a training programme director do you support those sorts of experiences? How do you think we can encourage leadership to be more diverse as a system in an organisation? Email RBChair@bma.org.uk Dr Latifa Patel is acting chair of the BMA representative body The BMA annual representative meeting took place on September 13 and 14. News can be found at bma.org.uk/what-we-do/annual-representative-meeting

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

An employer’s lack of flexibility with leave entitlements has highlighted the need for compassion with staff whose family may live thousands of miles away A junior doctor was desperate to visit her family in south Asia. A close family member was very seriously ill, and there had been no chance to visit since before the pandemic.

One of the main problems was quarantine.

Anyone visiting would need to quarantine for two weeks in the Asian country, and then for a similar period on returning to the UK. So, any leave would need to be four weeks, plus a meaningful amount of time to acclimatise, travel and spend time with family.

The doctor applied for seven weeks’ leave.

The trust’s policy seemed to allow a good deal of flexibility, specifically referring to destinations which required double quarantine and suggesting ways in which the time could be made up, such as unpaid leave. While annual leave requests could be rejected for operational or service reasons, there was at least a framework in which to work. However, the doctor’s service said it had its own local policy which only allowed for two weeks’ maximum leave. It could not provide the trust policy to the doctor. Fortunately, she had the support of a BMA employment adviser. First, the adviser contacted the service manager, who refused to budge, so she took it up with HR, making the argument that the leave was there to be taken, that there were strong compassionate grounds,

bma.org.uk/thedoctor

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and that the trust’s own policy at least required proper consideration.

It took a month, during which time the trust slowly increased its offer until it finally came up with five weeks’ annual leave and two weeks unpaid. The doctor by this point was stressed, as it was only a few days before she was due to fly.

As well as benefiting from the insight and persistence of the BMA employment adviser, the doctor was also supported by her consultant and training programme director, who said the gaps in service could be filled in the circumstances.

The pressures on doctors with family commitments thousands of miles away has never been greater. Another doctor, a consultant originally from India, recently wrote a blog for the BMA where she asked: ‘Where do the boundaries lie for me and others between love and duty to my work as a doctor, to the NHS which is overburdened right now, and to the love for my family, in my motherland?’

Thousands of NHS doctors have family overseas and it is vital the NHS supports them and responds to requests with sensitivity and compassion. With the BMA’s help, this doctor was able to write to the adviser a few weeks later to thank her and speak of her relief at being able to see her family. bma.org.uk/yourwellbeing thedoctor | September 2021 23

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