The Doctor, November 2021

The magazine for BMA members

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Issue 37 | November 2021

WE NEED IT TOO The global struggle for vaccine fairness

The eye of a Twitter storm How to stay afloat on social media

A cruel wait COVID a further setback for ailing cancer services

Punished for doing their jobs Doctors working under a dictatorship

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In this issue 3 In the news A GP comes to the rescue of commuters

4-7 The best of tweets, the worst of tweets

Safely navigating social media

8-11 Punished for doing their jobs Maintaining medical neutrality under a military dictatorship

12-13 Reasons to be hopeful Sharing best practice in tackling inequalities

14-17 A long wait to get better A lack of staff, equipment, and now the COVID backlog have left cancer patients waiting longer

18-20 Vaccines: a question of justice The moral obligation to ensure the world’s population can access COVID vaccination

21 On the ground A pregnant junior doctor suffers an appalling lack of support at work

22 Viewpoint Should white coats make a comeback?

23 Your BMA Solidarity in the face of attacks on doctors

Welcome Chaand Nagpaul, BMA council chair The ability to speak freely and openly is a crucial aspect of medicine and the rise of social media platforms and communities such as #MedTwitter afford doctors a platform to engage with their colleagues and the public.

As well as facilitating the exchange of ideas, however, social media also has a darker and detrimental side. In this edition we hear from a number of doctors about the benefits and downsides of participating in online forums, and what to consider before taking part.

While the struggle against COVID-19 goes on, many countries, such as the UK, have been able to administer millions of vaccinations to their populations. This medical success has not, however, been replicated in the developing world where, despite adequate supplies, distribution of vaccine doses often remain inequitable.

We hear more about the desperate situation facing countries such as Uganda and South Sudan, and the BMA’s call for high-income countries to immediately begin sharing their surplus vaccines.

One consequence of the pandemic has been the ruthless exposure of the numerous health inequalities that blight our society. Fift y years on from Dr Julian Tudor-Hart’s theory of the inverse care law, which posited that good medical care is often least accessible to those most in need, the BMA has produced a health inequalities tool kit. Drawing on case studies and example of best practice, the toolkit aims to be a ‘living document’, one that will support doctors and medical students in their clinical work and facilitate the sharing of experiences and ideas towards reducing health inequalities in communities.

Difficult decisions are part and parcel of medical practice.

Following a military coup in their country in February this year, doctors in Myanmar have been placed in an almost impossible position of deciding whether to continue to strike in support of the prodemocracy movement – or return to work to treat their patients. We hear from one doctor who has set up a charity to provide support and training for colleagues in her home country.

Disparities in cancer survival rates between the UK and other comparable nations is a lamentable yet unfortunately not a new phenomenon. With the effect of the pandemic on the NHS, latest figures show targets for cancer waiting times have been missed. In an effort to understand these shortcomings, The Doctor has spoken to several leading figures in cancer care to understand the challenges and what can be done to address them.

Read the latest news and features online at bma.org.uk/thedoctor

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Keep in touch with the BMA online at twitter.com/TheBMA

instagram.com/thebma

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IN THE NEWS GETTY IMAGES/FINNBARR WEBSTER

GPs rush to aid of passengers after train crash GPs ARE CENTRAL to the health and wellbeing of the communities they serve, but this service is not always confined simply to the day-to-day care provided in surgeries.

The derailing of a passenger train near Salisbury on 31 October prompted a huge response from the emergency services, but the incident also saw six doctors, including five GPs, play a crucial role in the medical response.

Among them was Phil Lucas, a GP and a medical officer in the RAF who also volunteers for BASICS (British Association for Immediate Care), an organisation which seeks to support the emergency services during major incidents.

Dr Lucas had just been about to sit down for dinner at his home in North Wiltshire when word of the derailed train reached him at about 7.15pm.

Within minutes he and a fellow GP colleague had grabbed their emergency medical gear and were on route to the scene armed with very little detailed information about the crash.

‘While we were travelling, I heard on the radio that a major incident had been declared, and that there were potentially 100 casualties,’ he says.

‘By then I was in communication bma.org.uk/thedoctor

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with another GP working in the [ambulance] control room at Exeter.

‘We were incredibly fortunate,’ he adds.

‘When I was driving down to the scene, I was genuinely expecting 20 to 30 fatalities and perhaps 100 significant injuries.’

Arriving at the scene of the incident, Dr Lucas and his colleague were debriefed by other emergency services teams. They learned that one person who had sustained serious injuries was being attended to at the scene of the crash by an anaesthetist.

They also discovered that another doctor, a local GP who lived nearby, had guided a large number of passengers to a nearby church, which was now serving as a triaging area.

On arrival at the church, Dr Lucas and his colleague found three other GPs working alongside ambulance and air ambulance paramedics who were busy dividing passengers into groups of those who did and did not believe they required care.

Most of the injuries were fortunately minor consisting of bumps, sprains, falls and grazes although Dr Lucas noted he and colleagues encountered cases such as that of a three-week-old child thrown from a buggy during the derailment, as well as

LUCAS: Ability to stratify risk really important

the mental effects the crash had had on some passengers.

‘The passengers were fantastic,’ says Dr Lucas . ‘They were very patient, and some passengers were able to help out others. The vicar and the church staff immediately got tea going and were constantly going round helping. Everyone was just so enthusiastic.’

In assessing injuries and speaking to passengers, Dr Lucas said he and his GP colleagues were able to further contextualise injuries in relation to any pre-existing health issues a patient might have, thus prioritising those needing further medical care.

‘As GPs it’s all about trying to do what’s best for the patient,’ says Dr Lucas.

‘I had 86 people in that church and as clinicians we assessed 22 and sent 12 to hospital. That versatility and ability to stratify risk is really important.’

‘It’s all about communication.

Everyone having an understanding of what’s happening, speaking with multiple agencies on the scene and understanding their point of view and then taking that information and communicating it with the ambulance control centre who in turn are speaking to the hospitals.’ thedoctor | November 2021 03

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help n a c , t share be s d s t n i a t t a c , r Twitte learn, conne o backfire s ls ted doctor tion. It can a ost unexpec a inform , and in the m nd hears y ly la horribl nnifer True ating it safe ig e ways. J dvice for nav a users’

The best of tweets, the worst of tweets

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trauma beds in their large acute hospital, an hen Rosie Baruah first joined Twitter, algorithm (with illustration and invitation for she used it simply to check up on questions) on an approach to low bone density travel and transport and practical and pharmacologic therapy for osteoporosis things such as that.

– and a jokey flow chart attempting to explain She didn’t start engaging with it actively what a senior house officer is (or was). until she became chair of the Women in Intensive Care Medicine group – when she quickly saw its potential.

Pile-ons ‘Becoming more active in the medical It’s clear that many medics are deriving Twitter universe, it became clear to me that pleasure, comradeship and even learning it’s a real-time means of communication with from taking part – and even those who do peers, it’s public and accessible in a way that not actively tweet themselves can follow no other medium really is. And despite the the conversation simply by searching on the tight character limit, you can have really quite hashtag. But there is also a negative side to meaningful conversations social media – doctors have on Twitter – it’s brought me found themselves subject opportunities I wouldn’t have ‘It’s brought me opportunities to abuse for expressing had otherwise,’ she says. sentiments unpopular in some I wouldn’t have had otherwise’ If you go to Twitter and quarters, such as promoting search on #MedTwitter at any vaccinations, or maskpoint, you’ll find posts from (mostly) doctors wearing. Some have also faced strong criticism from around the world. A quick check on Friday from other doctors and their supporters – 22 October at 10.30am found tweets ranging sometimes called a ‘pile-on’ where people from a UK doctor commenting on a lack of can be subject to a barrage of tweets taking 04 thedoctor | November 2021

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TONY MARSH BARUAH: ‘You can have really quite meaningful conversations on Twitter’

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‘I will not interact with people who have been vexatious’

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NEIL TURNER

some sort of ethereal beings who are here to issue with their points. Still others have faced be heroes and burn themselves at some sort of criticism for expressing their views in public, altar. I think there’s a feeling that it’s a higher and some have even been threatened with calling, but really, it’s a job. And so I think it’s reports to the GMC, or to their employers, on important to show on social media I work really the basis of what they have tweeted. hard, I try my best, but when I’m done, I’m So how do you ensure that you get the best done. I have good holidays, family, dogs.’ out of #MedTwitter – and avoid the pitfalls?

Partha Kar is no stranger to Twitter controversy. A consultant in Portsmouth, a A row about pancakes national co-lead on diabetes, and director of The fourth part of Twitter, according to equality, medical workforce, with NHS England, Professor Kar, is the debate. ‘I will pick up Professor Kar is a big supporter of the social topics which I will challenge or push and talk media platform, but his openness has, on about,’ he says. ‘I’ve learned along the road occasion, brought disapproval. how to do it in a way that you don’t create a ‘Twitter is a really nice complete firestorm around forum for continuous ‘If you put something on you, which is what a lot of professional development, at people are afraid of.’

Twitter that you wouldn’t say least for me with such a busy A lot of it depends on how to somebody in real life, then you life,’ he says. ‘I’ll see a paper you frame a tweet, he says. are in trouble’ mentioned and I’ll earmark For example, if you tweet it for reading later. Also, in my [national] role, something in anger, perhaps at the end of a it gives me a really good insight into at least long shift, and make generalisations about one sector of the population we serve – with something, there will be ‘a truckload of people diabetes, it gives a good idea of the issues who take offence’, depending on the topic. that people are talking about: is it services, is Whereas if you put the same point across in it technology, is it self-management – what a more considered way, perhaps linking to a resonates and what doesn’t? The third thing blog or some data, then you are encouraging KAR: Unexpected is the human side – I’m a big fan of trying to people to think about something rather than controversies can arise deconstruct the whole ethos that doctors are respond defensively.

He has no regrets about any of his Twitter activity, he says, although he recalls getting a lot of push-back after putting out a picture of himself having breakfast.

‘I was having waffles or a pancake, I can’t remember. And a lot of people commented that they couldn’t believe the national lead for diabetes is promoting pancakes or whatever.

It started with a genuine angry tweet and my mistake was responding to that because as soon as I did, lots of other people jumped in and it escalated way out of control,’ he says.

What he has learned, he adds, is that you don’t have to respond to everything – but also that you need to think about the potential effect of what you tweet. ‘If you put something on Twitter that you wouldn’t say to somebody in real life, then you are in trouble. That’s the basic bottom line.’

Self-imposed rules Dr Baruah tweets often about gender equity and unconscious bias which are topics that can attract a lot of abuse and sexist responses. She follows self-imposed rules for her interactions 06 thedoctor | November 2021

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on Twitter. ‘I’m fully identifiable by my Twitter handle and bio, so people know who I am, which technically puts me at more risk of being identified, but I think that, paradoxically, by being open about who you are, people can’t threaten to “out” you,’ she says.

She is very limited in how she interacts with anonymous accounts. ‘If they are being what I’d consider reasonable, then I would interact with them, but I will not interact with people who have been vexatious in any way – not just abusive, but snide, or mean-spirited.’

A lot of people feel ‘entitled’ to a response, but she doesn’t buy into that, says Dr Baruah – who will, if necessary, ‘mute’ or even block accounts if they are abusive.

Having said that, she is certainly up for challenge. For example, she noticed that a panel drawing up a COVID guideline for one of the intensive care societies was made up of one woman and 18 men.

‘I retweeted it pointing out the lack of female voices and the great thing was that the organisation tweeted right back saying that they hadn’t noticed, that this wasn’t an excuse, and they would try to do better.’

There were some responses, she says, telling her that she was being unprofessional, and that they were simply choosing the best people for the job, and anonymous accounts asking why she hates men. ‘It doesn’t bother me because it’s only some guy behind a keyboard who’s not even brave enough to put his name to it – but there was positive response from the people who matter.’

intended to help staff talk to the families of very ill patients by telephone at a time when hospital visiting wasn’t allowed. ‘One of my colleagues put it on Twitter and I thought I’d put it on my page as well – it just felt like a good way of getting it out there. But then my phone just started pinging [because of Twitter notifications that someone had interacted with the tweet]. I was really quite overwhelmed by it, especially as I was coming down with COVID myself at the time.’

She drew up the guide, she says, in response to what other healthcare staff were saying on Twitter in terms of needing help with communication and based partly on a similar resource being used in Italy. Having ‘It’s allowed me many platforms to come up with the text, she Invaluable tool talk about things I care about’ asked her brother to help with She has had professional a user-friendly design. opportunities as a result Responses were of Twitter interactions, overwhelmingly positive, says Dr Field-Smith, particularly on gender equity, including being who works at the West Middlesex University invited by a research group to speak at a Hospital, with many other healthcare staff conference in Toronto (pre-COVID). asking if they could use the resource. ‘I don’t ‘I have the expertise to participate in that think that would have happened without group, but they wouldn’t have known to ask Twitter.’ me without Twitter,’ she says. ‘It’s allowed me many platforms to continue talking about The BMA has produced advice on using Twitter things I really care about.’

Palliative care consultant Antonia Fieldand other social media platforms; visit bma.org.

Smith found Twitter invaluable to disseminate uk/socialethics a communication aid she and colleagues The GMC has also published guidance on developed near the start of the pandemic. using social media. Search for ‘doctors’ use of The colourful one-page prompt sheet was social media’ at www.gmc-uk.org bma.org.uk/thedoctor

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FIELD-SMITH: Overwhelmed by response to communication tool shared on Twitter

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Medical students at the funeral of their colleague Khant Nyar Hein, shot dead by security forces in Yangon, Myanmar, in March, after security forces fired on protesters

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GETTY IMAGES/ANADOLU AGENCY

Professor Griffiths and Dr Lwin, with delegates at the BSI meeting in 2020

Doctors in Myanmar get arrested and persecuted for nothing more than wanting to care for their patients. Seren Boyd hears about the lives of doctors battling to maintain medical neutrality in the face of a repressive dictatorship

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hey were among the first to take to the streets was the day Aung San Suu Kyi’s National League for when the military junta seized power in February. Democracy was due to be sworn into office, after a Doctors joined hundreds of thousands of others landslide electoral victory the previous November. in peaceful pro-democracy protests, from Dawei Between 1 February and 31 August, 26 health to Mandalay. workers in Myanmar were killed, 38 injured and This time, in contrast to the 1988 uprising, they 199 arrested, according to the Humanitarian Data had witnesses worldwide, thanks to social media. The Exchange. There were 56 military occupations of hashtag #WhiteCoatRevolution went viral. hospitals and 87 military raids on hospitals.

Inevitably, when Myanmar’s military, the Tatmadaw, launched its brutal crackdown with mass arrests Doctors in hiding and live ammunition, health workers were among Dr Lwin has watched in horror at the tragedy unfolding the casualties. in her homeland.

Doctors were detained for striking: the generals In February last year, just before the UK’s lockdown, cynically accused them of ‘killing people in cold blood’ she had attended Myanmar’s first ever international by leaving their posts. When they tended to injured dermatology meeting which drew 250 doctors and protesters, they were shot at. nurses from across the country.

Many saw their names in the Tatmadaw’s regular It was the fruit of a close partnership between lists of ‘traitors’ on state media and went into hiding. some of Myanmar’s leading doctors, the pre-coup Perhaps most brutal of all was what happened to civilian government’s Ministry of Health and Sports, those who eventually ended and the Burma Skincare their strike to tend to the long ‘One doctor couldn’t sleep Initiative, the charity Dr Lwin queues of patients snaking during her strike, knowing that she and founded with Chris Griffiths, around hospitals and clinics. professor of dermatology at her family could be a target Then, the CDM (Civil Manchester University. for the military’ Disobedience Movement) and After the coup, every one social media turned on them. ‘If you’re not engaging of those delegates went into hiding. in the CDM, some people assume you’re pro-military, Dr Lwin has had carefully worded contact with several but life is much more complex than that,’ says Su Lwin, of them, ever conscious of the security risks. a dermatology registrar born in Myanmar, now based ‘One doctor couldn’t sleep during her strike, knowing that she and her family could be a target in London. for the military and that a lot of her patients could In a country where the military has successfully be in a life-threatening situation without treatment,’ employed the tactic of ‘divide and rule’ for decades, says Dr Lwin. medical neutrality, it seems, is dead.

‘But she also felt she had a duty to the CDM, The first of February, the day of the military coup, bma.org.uk/thedoctor

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vaccinated – but it is feared most doses have gone to otherwise the country would go back into the desolate the military. state it endured [under military rule] for 60 years.

Testing rates are known to be abysmally low, while ‘After several months of deliberation, she decided vaccine hesitancy is high, to go back to work, for her especially around juntafamily and for her patients.

‘If she’d taken them controlled hospitals. The But she’s been socially to any clinics while she was doctor leading Myanmar’s punished, with people talking still a doctor, she would have COVID vaccine rollout, Htar about her in abusive terms on been arrested’ Htar Lin, was arrested in June social media.’ and charged with high treason; On her return to hospital, COVID treatment centres have been shelled. she found her equipment had been stolen – and years’ Professor Griffiths says the military has ‘weaponised worth of research materials vandalised.

COVID against their own population’.

Another doctor has been forced to resign, for the ‘They have starved people of oxygen, so people sake of her ailing, elderly parents. ‘If she’d taken them queuing up to refill privately purchased oxygen tanks to any clinics while she was still a doctor, she would have been shot at,’ he says. have been arrested, along with her parents,’ says Dr Lwin. ‘The military are detaining children, even pets.’

‘There is no real support system for management Myanmar’s healthcare system, already precarious, of COVID, neither intensive care nor any proper vaccination programme. General practitioners who has all but collapsed since the coup. Many health have tried to treat COVID patients at home have been workers are operating from makeshift clinics, to avoid arrested. So the military abuse this to suppress and more conspicuous military targets such as state hospitals. Medical supplies are confiscated at border control even more.’

Even before the coup, the UN reported that almost checkpoints for military use. one million people in Myanmar needed humanitarian In recent months, the country has been battling a support, including 336,000 fresh wave of COVID, and most internally displaced people. doctors have been redeployed ‘People queuing up to refill oxygen

to treat COVID patients.

Give something back Officially only 10 per cent of tanks have been shot at’ Despite – and because of – the population have been fully Myanmar’s many challenges, Dr Lwin and Professor Griffiths are determined to press on with their plans with the BSI (Burma Skincare CARE AND SUPPORT: Professor Initiative), albeit with some adjustment.

Griffiths and Dr Lwin at an orphanage in central Myanmar The parlous state of dermatology services in Myanmar, the pressing need and the enthusiasm with which their support so far has been received by colleagues in Myanmar cannot be ignored.

Dr Lwin has strong ties with her homeland despite moving to the UK at the age of 15 to go to school in Wales. She was able to remain in the UK to study medicine at King’s College London through the support of a family friend, teachers and local MPs – and now wants to give something back.

Professor Griffiths had developed a keen interest in global skincare, particularly among migrants, through his involvement with international bodies such as the International League for Dermatological Societies, and through visiting Syrian refugee camps in Lebanon’s Bekaa Valley. Visits to Myanmar with Dr Lwin in 2018 and 2020 only deepened that commitment to humanitarian dermatology.

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Lucy Moorhead and Rebecca Penzer-Hick of the British Dermatological Nursing Group were among the trainers.

‘We were overwhelmed at the number who attended our meetings and the lengths they’d gone to, to be there,’ says Ms Moorhead. ‘We tried to tailor our teaching to the resources they had and showed them how to apply bandages and topical treatments effectively – because that can make all the difference in caring for a dermatology patient. It was the most interested audience I’ve spoken to in over 20 years.’

KNOWLEDGE SHARING: Ms Moorhead at Myanmar's first ever international dermatology meeting

Solidarity

Looking ahead, the BSI and colleagues in Myanmar want to create a network of community nurses trained in essential emergency skincare, in response to the coup and the COVID crisis. Already they have contact At orphanages, at local hospitals, through Viber with 800 nurses, through THET (Tropical Health consultations connecting them with embattled areas, Education Trust). they were confronted with unmet need: children They are now working closely with the newly formed disfigured by ringworm and scabies, children stigmatised National Unity Government in exile, and providing by genetic diseases such as ichthyosis. educational and clinical support via online media At Myanmar’s three dermatology centres – two in and tele-dermatology. Further ahead, they want to Yangon, one in Mandalay – staff made the best of basic help provide vital infrastructure such as a molecular diagnostic laboratory, as well as funding for research facilities but had limited access to medicine. Away from and fellowships. these centres, access to skincare was extremely limited The near future is uncertain. Dr Lwin and Professor or non-existent. With fewer than 100 dermatologists Griffiths are heavily involved in advocacy on behalf for a population of 54 million, many in conflict zones inaccessible to humanitarian support, it was clear that of Myanmar’s health workers, through THET, joining community-based solutions were vital. an international outcry to which the BMA has added ‘Getting the best healthcare to people isn't necessarily its voice. about having the best doctors Civil war has now been and the best medicines,’ says declared, and many of Professor Griffiths. ‘Often, ‘People are like dry sponges, Myanmar’s medics remain you've got to take the care trapped in no man’s land, desperate to learn’ reviled on either side. Dr Lwin out to people in the poorest believes what her colleagues parts. Our approach is to train there need most are opportunity and solidarity. healthcare workers such as community nurses in basic ‘We are starved of opportunities in Myanmar and dermatology diagnosis and management, particularly for disadvantaged peoples.’ we don’t let them go when they’re presented to us,’ The first ever international dermatology meeting to she says. be held in Myanmar organised by the BSI in February ‘People are like dry sponges, desperate to learn. I’ve 2020 was a promising start. Doctors and nurses from had many messages from people saying how much it across Myanmar devoured the teaching delivered through means to know the outside world is standing with them lectures and practical workstations. Some had travelled for steadfastly, as colleagues and friends.’ two-and-a-half days to attend. bma.org.uk/myanmar

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DOUGLAS ROBERTSON

LUNAN: Life dedicated to the less well-off

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one of us would disagree that health inequalities are important ... but it can often feel very overwhelming, quite nebulous and quite hard – it is easy to say it is someone else’s responsibility.’

Edinburgh GP Carey Lunan knows these issues as well as anyone. Dr Lunan has spent much of her career providing care for those who need it most – from the homeless population to working in a group of practices called the Deep End in Scotland which look after the most deprived populations.

In Dr Lunan’s Deep End practices patients have disproportionately higher levels of mental health and addiction issues, consultation rates are higher and appointment times must be shorter to meet demand and patient enablement scores are lower. All of these issues come, perhaps inevitably, with higher levels of clinician stress. As Dr Lunan says, speaking at an event launching a new BMA initiative around health inequalities, ‘this is the inverse care law in action’.

This year marks 50 years since GP Julian Tudor-Hart put forward the Inverse Care Law, which describes a ‘perverse’ relationship in which the availability of good medical care is often least for those who need it the most.

Half a century on and with the pandemic having only further exacerbated and exposed the health inequalities in society, work in this area could hardly be more ‘timely’, as Dr Lunan says.

Care lottery

Reasons to be hopeful Inequalities have a huge effect on health, but tackling them can feel like a hopeless task. A new initiative shares striking examples of best practice. Peter Blackburn reports

In many areas of the country doctors, and other people from a wide range of public services and charities, have tried to address the unfairness in their communities – but often work has been isolated rather than shared and driven across the UK. Often, access to specialist services, or services tailored for communities that are left out of conventional healthcare arrangements, are a lottery based on little more than local personalities driving the work.

It is for all of these reasons – the overwhelming, nebulous complexity of health inequalities, the sporadic and localised responses and the entrenched need and lack of coordinated response – that BMA immediate past president and former chief medical officer for Scotland, Professor Sir Harry Burns, has led the association’s production of an inequalities toolkit which asked clinicians across the UK to tell the BMA about the initiatives they had seen,

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or taken part in within their local areas, which have helped to tackle inequalities.

This toolkit is intended to support clinicians and medical students working across the UK, not to lay the responsibility for reducing health inequalities at their feet. Neither is it intended as a replacement for campaigning at the BMA to ensure UK governments meet their responsibilities to reduce health inequalities.

But it will allow doctors to see the work colleagues have done – arranged into tiers representing the level of time and complexity involved – in a bid to share best practice and act.

Action not talk Sir Harry is clear about why this work is important. He says: ‘We’ve been talking about health inequalities for some time – and it’s high time we did something about it.’

And for Sir Harry, while doctors must be at the heart of tackling these issues, being among those in communities who know their populations best, health inequalities must be considered as much wider than traditional healthcare. The professor of global public health at Strathclyde University says: ‘We focus as doctors on outcomes like heart disease, type two diabetes, COPD, lung cancer and look at the behaviours that cause them or are correlated with them. But that all comes down to them having an ability to choose to do things differently and the ability to feel control over their lives. If they have that ability, they have that sense of purpose and meaning, sense of control and self-esteem.’

Sir Harry cites the example of Falmouth’s Beacon and Old Hill estate which was a community dominated by drugs, violence and alcohol – with all the accompanying poor life outcomes. In the late 90s two local health visitors decided to act and asked a small group of residents to drive change with them – largely by asking what mattered to the people who lived there. At first it was simple things like gardening and making the streets look more presentable. At one house the front garden had become so overgrown a longforgotten Ford Transit van was found when the gnarly overgrowth was peeled away.

Local teachers, police officers and housing workers all became involved and a host of community projects and building improvements led to massive change.

Crime was reduced by 50 per cent, postbma.org.uk/thedoctor

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natal depression decreased by 70 per cent, child protection registrations reduced by 65 per cent and teenage pregnancies went from 14 per cent to less than 1.

BURNS: High time something was done about health inequalities

Inspiring examples Case studies already embedded in the toolkit include a health inclusion team who target untreated chronic and infectious disease in groups of individuals who have the worst health outcomes, an emergency department team which works with vulnerable adults and repeat attenders and a programme tackling tobacco addiction in hospitals. The toolkit also includes a community chronic pain support group and an educational charity which produces free materials for healthcare professionals.

BMA GPs committee executive team member Krishna Kasaraneni says: ‘The luxury most of us don’t have at the moment is time and space and that’s only got worse through the COVID pandemic. But the toolkit hopefully sets out a framework and provides clinicians and medical students with an opportunity to start looking at areas where things can change.

No individual can fix this on their own but like myself you might notice issues in your own practice and want to address those issues. The toolkit provides you with the different things that are happening and the way of looking at it that can support you with influencing change.’

As Sir Harry says: ‘We need to change the public service attitude. The existing system is all about finding solutions doing things to people rather than with them run by professionals. We need to build networks and allow the citizens to find support, and build strong citizens and healthy communities.’ bma.org.uk/clinician-toolkit

‘It’s easy to say it is someone else’s responsibility’

‘We’ve been talking about health inequalities for some time – and it’s high time we did something about it’

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GETTY IMAGES

A LONG WAIT TO GET BETTER It has been six years since a referral-to-treatment target for cancer patients in England was last met. With a lack of staff and equipment, and now the COVID backlog, it is little wonder that outcomes have lagged behind other countries. But doctors tell Peter Blackburn about some new initiatives which can radically improve patients’ experience

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ne of two people in the UK will be diagnosed with cancer in their lifetime. It is a striking – and well-publicised – statistic, but it is just one of many which grab the attention when it comes to cancer care and outcomes in this country.

Figures cited in a publication earlier this year by the Nuffield Trust show the UK significantly lagging behind other countries. The

five-year survival rates cited for the UK were 85.6 per cent for breast cancer (90. 2 per cent in the USA), 63.8 per cent for cervical cancer (71.4 per cent in Japan) and 60 per cent for colon cancer (70.7 per cent in Australia). While these figures, the most recent that were cited, were for 2010-14, it is not unreasonable to think that the intervening years, during which budgets and staffing have been under exceptional

strain, have seen little relative improvement.

The picture in the UK becomes increasingly concerning when the effect of the COVID-19 pandemic is taken into account. Data for August suggests there were 15,800 fewer people referred via an urgent suspected cancer referral in England compared with what NHS England modelling would have expected if the pandemic

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factors at play too, including a culture among the public of being slow to seek help and, for many, the reality that clinicians often end up becoming gatekeepers of NHS services given the paucity of capacity.

GP Richard Roope, who is also adviser to the Wessex Cancer Alliance, says the problems can be split into three categories: patient factors such as members of the public being ‘more stoic’ and ‘less forthcoming’ in this country, professional factors including the UK having fewer physicians per 1,000 patients than almost all comparable countries and thus shorter consultation times, and process factors.

On those process factors Dr Roope says: ‘As GPs we have

Dr Roope, who works as part of the local RIS (Rapid Investigation Service), also known as an RDC in other parts of the country, adds: ‘Fundamentally, across the NHS, in every sector, demand is outstripping supply. We have sleep-walked into the workforce issues we have got.’

Andrew Millar is clinical lead for the multidisciplinary diagnostic centre at University College London Hospital and is a consultant gastroenterologist and hepatologist. Dr Millar says there are delays throughout the cancer pathway in this country, from the point of the patient recognising symptoms as serious to having those symptoms assessed, and then access

SARAH TURTON

hadn’t happened. And there were five to 10 times more patients waiting six weeks or more for diagnostic tests in England at the end of August 2021 compared with the same month in 2019.

Cancer waiting time figures for England, covering last August, were recently released and show that none of the three primary targets – urgent referrals to be seen by a specialist in two weeks, 62 days from urgent referral to start of treatment and 31 days between agreed treatment plan and the start of treatment – were met.

‘We’ve seen impact across the whole spectrum,’ Cancer Research UK’s head of strategic evidence Jodie Moffat and early diagnosis programme lead tells The Doctor.

‘It’s hard to pin down what the impact will be in terms of outcomes but we are anticipating we will see a negative impact in terms of stage and negative outcomes and we are in a position where we risk cancer survival going backwards.’

‘We are in a position where we risk cancer survival going backwards’

ROOPE: ‘We have less kit than nearly every country in Europe’

Dwindling workforce This is not just about the pandemic, though. That 62day target has not been hit since August 2015. And the data covering the comparisons with other countries looks similar through previous years.

The problems holding the UK’s cancer care and outcomes back are familiar themes to those who work across health and care or who know the sector – with dwindling workforce, lack of capital investment and capacity far outstripped by demand. There are other bma.org.uk/thedoctor

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access to less diagnostics than our colleagues in other countries which means we are flying blind for longer. If you look at the whole area of diagnostics we have less kit than nearly every country in Europe. We are equal bottom with Moldova.’

to secondary care. Dr Millar blames lack of specialists and lack of diagnostic equipment in particular for delays in diagnosis, which he ‘suspects is probably related to the worse mortality we have than some countries’.

It is in this context that the

‘We have sleepwalked into the workforce issues we have got’

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informing and empowering people to respond promptly to signs and symptoms and health professionals being alert to the risk of cancer and being supported to act, including having access to tests and test reports, and pathways that suit the range of patients they see. The charity also wants to see research Ambitious targets and innovation for the future, The second of those stated to ‘fully realise the vision of aims is particularly striking bringing forward the day when ‘We are given that the current figure is all cancers are cured’. around 55 per cent – with the lagging Dr Moffat says: ‘A challenge effects of the pandemic still to behind to achieving early diagnosis be fully felt and understood in other is that there is no one silver the statistics. health bullet. This is going to mean ‘That ambition is probably economies’ investment in diagnostic unrealistic – it is probably equipment, it’s going to unachievable,’ Dr Millar says. need workforce, it’s going to ‘But it is good to set targets. need cross-NHS and crossWe are lagging behind other community working. None health economies and if we of these things are easy, don’t set ourselves these particularly at a time when targets, we are probably there is a lot of pressure in the less likely to achieve system of trying to recover better outcomes.’ from COVID-19. But we must The ambitions may be continue to look forward and ‘unrealistic’, but improvement to bring about the changes is important, regardless, so if needed to ensure everyone any progress is to be achieved with cancer gets the best what are the key areas where SOURCE: OECD, possible care.’ work is required?

Health Care Quality Indicators, Cancer Both Dr Roope and Dr Millar Cancer Research UK has a Care cited in Cancer have been involved in setting manifesto for change which Survival Rates, Nuffield Trust up, and working in, new clinical includes implementing and (online), last updated pathways which aim to address improving life-saving cancer May 2021. Figures many of those problems. are for 2010-14 screening programmes, In Wessex Dr Roope is Five-year survival rates in the UK part of the RIS which is staffed by two GPs, three Breast cancer UK: 85.6 per cent advanced USA: 90.2 per cent nurse practitioners Colon cancer and overseen UK: 60 per cent by a Cervical cancer Australia: 70.7 per cent hepatologist, UK: 63.8 per cent Japan: 71.4 per cent colorectal surgeon and a urologist.

NHS long term plan’s stated ambitions sit – that 55,000 more people each year will survive their cancer for five years or more by 2028 and that 75 per cent of people with cancer will be diagnosed at an early stage, stage one or two, by the same year.

The new pathway has been up and running for six months and allows GPs to refer patients who have serious but not site-specific symptoms which could be cancer, like vague abdominal pain, weight loss or a raised platelet count. In the past – and in many areas of the country still – GPs might have to make three or four referrals for these sorts of patients before eventually finding the right pathway, potentially delaying things by two or three months. Prompt action is key, as Dr Roope says: ‘For every week a diagnosis is relayed you reduce the 10-year survival by one per cent.’

Fast-track referral The Wessex RIS is delivered at significant scale across a wide geographical area and staff have the luxuries of a 35- or 40-minute consultation and licence to order ‘pretty much any test’ in a patient’s local hospital. That means a much more thorough understanding of the patient’s needs, quicker access to diagnostics and a much speedier path to treatment. ‘The feedback we get from patients is amazing,’ Dr Roope says. ‘It is essentially breaking down that primary/ secondary care divide and working as a unified team. It is working well and the patients appreciate it.’

Dr Millar is clinical lead for the North Central London Cancer Alliance – overseeing new pathways like MDCs (multidisciplinary diagnostic centres). The MDC at University College London Hospital allows GPs to refer patients by email if they suspect gastrointestinal cancer. The service provides a fast-track diagnosis for patients who are often

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EMMA BROWN

MILLAR: ‘A challenge to achieving early diagnosis is that there is no one silver bullet’

difficult to diagnose. Patients attending will usually attend the MDC within two or three days of referral and have had diagnostic tests within days which are then followed up by a multidisciplinary team.

Dr Millar says: ‘There’s no doubt GPs are faced with patients who they think might have cancer and they are puzzled as to which pathway to send them to. The GP concern, or gut feeling, is very good. We need to have pathways that allow that gut feeling to be expressed into rapid diagnostics.’

Above all, though, in cancer care and outcomes, as in so many aspects of the NHS, workforce may be the main factor. There are simply too few staff in comparison with the need from patients.

Investment in equipment needs to be accompanied by workforce, primary care needs additional workforce to provide the time and timeliness complex consultations and serious diagnoses require and new ways of working may be capped in terms of their effect bma.org.uk/thedoctor

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if staff are always pulled from existing work where they are also needed.

BMA council chair Chaand Nagpaul said the workforce crisis included a severe shortage of GPs, critical in the early diagnosis of cancer, and yet who were forced to give short consultations where it can at times be impossible to give patients the time to divulge symptoms. He also cited the UK being at the ‘bottom of the league’ when it came to CT scanners and MRI provision.

Workforce barriers The BMA is calling for increased Treasury investment into the medical workforce to fund increases in medical school, foundation programme and specialty training places, alongside investment in the staff and infrastructure to deliver this. The association is also demanding investment in retention initiatives including removing punitive pension taxation rules so older doctors can remain in work flexibly and a duty for the secretary

of state to publish regular, detailed and publicly available health and care service workforce assessments which inform current and future recruitment needs.

The workforce issues are exacerbated by Government policy around immigration, too. Dr Millar says: ‘You do need people to go with kit and the workforce challenge is going to be huge. I’m going to be utterly non-political… obviously if we are able to access trained healthcare workers from other places in the world to run the diagnostics then that would help offset the difficulties.

Of course, we don’t have that because of the circumstances in Britain today.’

The challenges in cancer care and outcomes are huge and the ambitions being outlined are only matched by the obstacles in the way of progress.

However, there is a significant degree of consensus about the path forward among those in positions of expertise – it is perhaps now a case of political will providing the muchneeded support for that consensus.

If there is any sense of hope for future improvement it should be largely grounded in the work professionals are already doing in pockets of the country.

Dr Roope is optimistic, having seen the improvements he, and colleagues, can make.

He says: ‘I am an optimist.

I think what GPs and the profession have achieved in the past 18 months has been awesome. It’s all quite exciting and all targets are within reach if we can get a unified care system.’

‘We need to have pathways that allow that gut feeling to be expressed into rapid diagnostics’

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COVID vaccinations take place at the headquarters of Amref Health Africa in Nairobi, Kenya

B

y the end of December, more than 12.2 billion doses of COVID vaccine will have been produced worldwide, according to the latest forecasts. That’s enough for everyone on the planet to have at least one jab.

Yet, the world map of vaccine distribution is heavily skewed. The UK alone has procured enough doses to vaccinate its entire population three-and-a-half times over. Uganda, by contrast, has secured just 0.44 doses per adult.

According to Bloomberg, it would take just five months to vaccinate 75 per cent of the global population if the world took steps to even out distribution. But at current rates, it will take five-and-a-half years before three-quarters of Uganda’s population are vaccinated.

Meanwhile, the cost of that inequity is being counted in lives lost.

Life on hold

LEONARDO MANGIA

Vaccines: a question of justice Richer countries are stockpiling hundreds of millions of excess doses of COVID vaccine, while their poorer neighbours are desperately short. Who can justify this needless cost in human lives?

Seren Boyd reports

James Eyul and his wife were optimistic when they received their AstraZeneca jabs because of his responsibility for port health at Entebbe International Airport. Dr Eyul had identified Uganda’s first COVID case in March 2020: a person on business flying home from Dubai. The vaccine proved its worth just three weeks later when two of Dr Eyul’s children caught COVID, at the peak of Uganda’s second wave in June. Their teenage brother caught it too: their parents escaped. Their household was a useful test case for the vaccine’s doubters and detractors.

But, as cases rose sharply, vaccines remained in limited supply – and still are. By late-October, only 3.9 per cent of Uganda’s population had received even a single dose.

‘If we had had adequate vaccine in Uganda’s second wave, I believe we could have prevented a lot of severe infection and checked the spread,’ says Dr Eyul.

Five months on, life remains on hold. Schools have been shut for the best part of 18 months; the night-time curfew still stands. Poverty, crime and teenage pregnancy rates have all soared.

Dr Eyul insists his country is well equipped to deal with infectious disease – given the proper tools. He has worked in infectious disease control in camps for displaced people, with the health NGO Amref Health Africa.

His first weeks in the job at Entebbe International in 2014 coincided with an outbreak of Ebola in neighbouring Democratic Republic of Congo. Uganda has lots of experience in tackling outbreaks, including

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‘When the vaccines come, they get used up fast. But then we have to wait several weeks for the next batch’

‘Vaccines are not doing any good sitting on shelves when they could be saving lives right now’

yellow fever and Marburg virus.

‘The distribution system for vaccines in Uganda is robust: the problem is getting vaccines into the country,’ says Dr Eyul. ‘People are lining up to get the vaccines, and when they come, they get used up fast. But then we have to wait several weeks for the next batch.’

Stockpiles and shortages A few short months ago, wealthier nations agreed that global vaccine equity was a moral imperative. In the slogan, ‘No one is safe until everyone is safe,’ they recognised it was enlightened self-interest too.

Today, international comparisons of vaccine procurement and rollout are shocking.

By late-October, enough COVID doses had been administered to fully vaccinate 44.6 per cent of the global population. Yet, while 62.79 per cent of people in HICs (high-income countries) had had at least one dose of vaccine, the figure for LICs (low-income countries) was just 4.51 per cent.

COVAX, the platform set up to help LICs equitably access vaccines at subsidised prices, has shifted its goal of delivering 2 billion doses from this year to next. By April 2021, the UK had distributed the same number of vaccines domestically – 38 million – as COVAX had globally. The issue is not global supply but access and fair distribution.

HICs have secured a disproportionate amount of vaccine doses – far beyond what they need, even after booster jabs for high-risk groups and double jabs for the over-16s – and are hoarding their surplus. In early October, MSF (Médecins Sans Frontières) estimated the size of this stockpile for 10 HICs at 870 million excess doses.

The BMA has written to the prime minister calling for him to be transparent on the number of surplus doses in the UK and to increase and accelerate UK pledges to COVAX. The Government has since announced it will accelerate its COVAX donations to the tune of 30.6 million doses in 2021 by year end.

Arielle Nylander, BMA senior policy adviser for global health, says: ‘People are dying now, so we need to be mobilising the doses that we have now. They’re not doing any good sitting on shelves, waiting for people who might need them in the future, when they could be saving lives right now.’

Time is of the essence – but countries,

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including the UK, have been slow to share.

The UK only started sharing doses in July, when 86 per cent of UK adults had had a first dose. It has committed to donating 100 million doses by June 2022 – yet had shared fewer than nine million doses by September.

Alarmingly, many jabs may expire before they are used – a scenario the BMA believes must be avoided at all costs. A September forecast by data firm Airfinity warned that G7 and EU countries alone could waste 241 million doses due to expire by the end of the year, even after boosters were delivered and donations pledges fulfilled.

Hoarding means that vaccines are being shared with LICs close to their expiry dates and at short notice.

In March, South Sudan, for example, received AstraZeneca vaccine through both COVAX and the African Union but much of it had to be passed on to other countries – and some of it reportedly destroyed – because it could not be used in time. By late-October, only 0.74 per cent of South Sudan’s population had received at least one jab.

South Sudan faces many challenges: most of the nation is inaccessible by road, and severe flooding in some areas recently has hampered distribution. Conflict has fuelled a severe hunger crisis: malnutrition and tuberculosis rates are high.

Often, it falls to NGOs to support vaccination drives, especially in remote areas. Amref Health Africa, for example, is training health workers, setting up mobile clinics, addressing vaccine hesitancy and helping with transportation, as well as lobbying for vaccine equity with its #VaccineSolidarity campaign.

One of its partners is Juba Teaching Hospital where Dr Arecro Richard Makur and her nursing colleague, Suzan Poni Loro, are involved in the vaccination programme, which is focusing on society’s most vulnerable.

Hesitancy about the AstraZeneca jab has been a significant hurdle. ‘Rumours were circulating on social media that the vaccine caused blood clots and infertility,’ says Dr Makur.

‘We tell them it’s safe and that it will protect them from disease, but it takes time.’

She is hoping the vaccine rollout will gather momentum now the single-dose Johnson & Johnson vaccine has arrived in South Sudan, donated by the USA. Ms Poni Loro urges the international thedoctor | November 2021 19

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community to keeping sending them vaccine.

‘We know it works because when we started the vaccine, case numbers dropped. We are very worried that if it rises up again here, people are not vaccinated.’

Knowledge transfer

‘COVAX has been left dependent on the charity of highincome countries’

Meanwhile, the question of expanding vaccine-manufacturing capacity in LICs is hotly debated. Pre-pandemic, vaccine manufacturing was heavily concentrated in the EU, USA and India.

China has becoming the largest exporter of COVID vaccine, flexing its soft power in poorer regions, especially since India’s Serum Institute halted exports during its national COVID emergency.

MSF and the People’s Vaccine Alliance want to see intellectual property barriers removed at the World Trade Organisation, arguing that they block the crucial increase and diversification of vaccine production.

Vaccines developed with public funding in public labs should be considered a public good, they say. There is an acknowledgement, however, that removing intellectual property barriers alone will not solve the problem: transferring technological know-how is vital too.

Moderna has said it will not enforce its intellectual property rights on anyone manufacturing its vaccine during the pandemic – but, as Ms Nylander points out, it has not yet released information on how to produce the mRNA COVID vaccines, including to the new WHO-backed ‘tech transfer hub’ in South Africa.

Some smaller issues could be resolved more easily. Victorine de Milliano, MSF Access Campaign policy adviser, points out that

Number of vaccine doses procured per person USA 2.54

UK 3.58

UGANDA 0.44

pharmaceutical companies are jeopardising COVAX’s ‘humanitarian buffer’ – designed to ringfence vaccine for the highly vulnerable communities including refugees – by insisting NGOs carry liability for any adverse effects from vaccines they distribute.

Whatever their differences, most agree the current system is failing. ‘Pandemic preparedness and response’ will be discussed at a special session of the World Health Assembly later this month: WHO director general Tedros Adhanom Ghebreyesus has called for clear ‘rules of the game’ to ensure ‘such shocking inequities are not repeated’ in future pandemics.

Ms de Milliano agrees: ‘COVAX is built around the parameters of the existing market system of supply and demand, where you see what you can negotiate with industry based on how much money you have. This hasn’t served COVAX well, and has largely left it dependent on the charity of high-income countries. That’s not how you counter a global pandemic.’

Meanwhile, the cost of inequity remains unacceptably high. If surplus vaccines are not redistributed equitably this year, up to five million more lives ‘hang in the balance’, according to former prime minister Gordon Brown, now a WHO ambassador for global health financing.

Dr Eyul in Uganda urges the international community to learn the lessons of the past.

The world’s failure to commit resources equitably to tackle malaria in the 1950s – allowing it to persist in Africa – means malaria remains a global threat.

‘The world should wake up and not let history repeat itself,’ says Dr Eyul. ‘Let’s give the rest of the world vaccines in time. Otherwise COVID will come back, worse than before.’

The cost of vaccine inequity – US$2.3tn in projected GDP losses for countries vaccinating less than 60% of their population by mid-2022 (The Economist Intelligence Unit) – 22% drop in HIV testing and 19% drop in those treated for drug-resistant TB in 2020 (Global Fund survey of more than 100 countries) – 56.6% increase in spending on health care for LICs to cover cost of vaccinating 70% of the population, compared with 0.8% increase for HICs (UNDP) Source: UN Development Programme (https://data.undp.org/vaccine-equity/accessibility/)

Last updated 22.10.2021

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

A pregnant junior doctor suffered from an appalling lack of support at work Frequently in the health service, we are left asking who cares for the carers. Rarely is this better illustrated than in the harrowing experience of a junior doctor who received an appalling lack of support at work.

Having become pregnant, she told her manager that she did not feel comfortable working three consecutive 12-hour oncalls during a weekend in a very demanding specialty, and instead asked to work two of them, with a day off in between to recover. Not only was this refused, but the risk assessment that should have been carried out for all pregnant employees was not done.

On the third of the three on-calls, she began bleeding, and soon after, she miscarried.

And then it happened again.

A year later, with the same employer but in a different department, the doctor told her manager she was pregnant, and requested an occupational health referral given that it was a high-risk pregnancy. All the manager had to do was complete a form, but the referral was never made. Nor was a risk assessment. Believing the referral was on the way, the doctor continued with her rostered on-calls, and on the third 12-hour shift of the week, began to bleed, and once again she miscarried.

The doctor contacted the BMA for help in pursuing a grievance. She was very distressed, and it was traumatic to be reliving what had happened, especially as she found out while her case was progressing that she was pregnant again. The BMA adviser said she would liaise with the employer on her behalf to take on as much of the burden as possible, and the doctor was also referred to the BMA wellbeing support service.

To add insult to injury, the doctor was not

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being paid enough. She had not been taken off sick leave, despite emailing a copy of the relevant certification to her manager, and she was reduced to half pay. She was forced to take annual leave to boost her sick pay.

The BMA adviser was there for her at every stage. She helped review the draft grievance before it was submitted, and represented her at meetings with the trust. Usually, the person making the grievance would attend the investigation and outcome meetings with the employer, but because of the sensitive nature of the case, it was agreed that she could respond in writing and the adviser would liaise on her behalf.

Her grievance was upheld. Her pay was restored to full for the time she was off sick, and she was compensated for the annual leave she had to take. On how she was treated while pregnant, the BMA would have supported the member through an employment tribunal with a discrimination claim, but a financial settlement was agreed through the conciliation service ACAS. The employer also committed to follow the recommendations which came out of the process, including better oversight and help for pregnant trainees, the need for managers to ensure prompt access to occupational health appointments, and a systematic process for managing rotas. The BMA is ensuring the employer keeps its promises.

So, a positive ending. More positive still is the fact that the doctor had a healthy baby boy, a few months later.

To talk to a BMA adviser about workrelated issues, call 0300 123 1233 or email support@bma.org.uk thedoctor | November 2021

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viewpoint

Bring back the white coat?

An age-old symbol was ditched over infection concerns, but the evidence for doing so was not strong Posed by model

Who is the doctor? Was it the neat one in scrubs, with the stethoscope? Or the scruffy chap with the crumpled shirt hanging over his trousers?

I was in outpatients, as a patient, and I was struck by the same thought I often had in the later years of my medical career: if only doctors still wore white coats.

When I was a medical student, I couldn’t wait to put on my white coat. As I grew as a doctor, it gave me not just instant recognition, and a professional look, but a kind of camouflage when you had to spring out of bed and were only wearing pyjamas underneath.

A short history, especially for those who associate white coats only with period dramas and have no direct memory of them. More than a decade ago, healthcare-associated infections were growing, and the Government was under pressure to act. So, in 2007, in came a new policy on ‘bare below the elbow’, and out went the last of the white coats.

But were they really such a terrible infection risk? Actually, the evidence was far from clear. A review commissioned by the Department of Health found contamination in white coats but ‘the majority of organisms isolated were nonpathogenic environmental bacteria or skin commensals probably originating from the wearer’. It continued: ‘Although it has been hypothesised that contaminated uniforms are a potential vehicle for the transmission of pathogens, no studies demonstrated the transfer of microorganisms from uniforms to patients in the clinical situation.’

Another study found no statistically significant differences in MRSA (methicillinresistant staphylococcus aureus) or bacterial contamination between physicians’ white coats

and newly laundered short-sleeved uniforms. It said: ‘Our data does not support discarding longsleeved white coats for short-sleeved uniforms that are changed on a daily basis.’

This appears to have been borne out in the years since. It seems to me that MRSA steadily increased during the years when the use of white coats was in decline. It can’t have helped that doctors were probably taking home more microbes on their clothing, with the risk that hospitals were becoming reinfected from the community. Other measures where there was actually evidence that they reduced MRSA, such as the use of disposable plastic aprons in high-risk clinical areas, could have been more vigorously pursued.

So, it seems there was little or no scientific basis for the ban. Yes, there were some doctors who looked like they had stepped out of a meat market, but such lazy behaviour could be addressed with an effective and hygienic dress code. It might be paranoia on my part, but I do wonder if this was some ploy by those in the non-clinical hierarchy, who wanted to undermine the status of doctors. Other allied health professionals have persisted with their uniforms, as if they are magically microbe resistant.

And, so, who was the doctor in that outpatients’ department? The neat one in scrubs was a physio. The scruffy chap was a doctor, or at least that’s what he told me.

Radhamanohar Macherla, now retired, was for more than 20 years a consultant physician with Barts Health NHS Trust What do you think?

Contact thedoctor@bma.org.uk

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Your BMA An attack on one part of the profession is an attack on us all. Maintaining unity is of vital importance All of us have things that we hold dear and which matter to us as individuals. As doctors and medical students we are driven by our ambition and determination to achieve the personal and professional goals that we set for ourselves in our careers.

At the same time, the very nature of our profession means each of us are deeply committed to protecting life and wellbeing, easing suffering and caring for the countless patients we will encounter during our lives.

It is perhaps not surprising therefore that wanting to make a difference on an issue of personal importance can sometimes be the catalyst to recognising that speaking up for and championing the needs and rights of others is inexorably linked to our own interests and wellbeing.

My own journey to this discovery began more than a decade ago when I first became motivated by a desire to take on some of the injustices I saw around me by becoming actively involved with the BMA. Outraged by cuts to the NHS bursary and the inequitable access to resources in medical schools, I made my first forays into medico-political activism as a medical student. Like many people, my initial reasons for becoming involved with my union were personal ones on issues that, at the time, personally affected me.

However, as I became more deeply involved with the work of my association, and as I began to hear more about the experiences of other medical students and doctors needing the BMA’s help, I realised I wanted to do more.

Hearing about the forms of discrimination they faced and the disparities that existed within the health service and medical profession was what prompted me to continue putting myself forward for election.

As a profession, medicine has often faced criticism for taking a siloed approach. These divisions can manifest through overly focusing on the distinctions between primary and secondary care, between consultants and GPs and between junior and senior doctors.

What I have learnt, however, is that by overly focusing on these differences, we risk forgetting an important reality; that, as doctors and medical students, we are bma.org.uk/thedoctor

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@drlatifapatel united as one profession.

This belief is at the core of your BMA’s ethos, hence the association’s mantra that it exists to care for doctors, so doctors can care for their patients.

We only have to look at some of the issues affecting the NHS today – the unfair and erroneous accusations regarding the role of general practice during the pandemic has led to the shameful scapegoating and persecution of GPs and their colleagues by the Government and the media.

GPs are angry and upset with the way they have been criticised and caricatured, but this anger and indignation should be shared by all doctors – as not only will a fracture in any part of our NHS affect us all, what we are seeing here is an injustice.

In January this year your BMA launched its BAME National Forum of which I am proud to be a member.

The forum’s functions include examining what the BMA can do to support minority ethnic colleagues as well as look at what stakeholder organisations such as the NHS need to do. The forum is a platform for doctors from minority ethnic backgrounds to voice their experiences and contribute to the debate around tackling racial discrimination in our profession and workplaces.

However, examining, confronting and eradicating racism should not be something that is the sole responsibility of ethnic minority doctors and medical students. It is something all of us have a role and responsibility to address.

An attack on any part of our health service is ultimately an attack on all of us in the medical profession.

It not only affects us, as individuals and as a profession, but it affects our patients and the care they receive.

As doctors, all of us should be striving for a fair and equitable system for our patients and for each other.

As always, if there is anything your BMA can do to help you, do let us know. My DMs are always open.

Dr Latifa Patel is interim chair of the BMA representative body thedoctor | November 2021 23

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