The Doctor, issue 26, November 2020

The magazine for BMA members

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Issue 26 | November 2020

COVID’s other symptoms Pay cuts and job losses – a cruel burden for doctors with the virus

Not the right time A massive reorganisation of public health in the midst of a pandemic Out-of-area beds Government mental health target set to be missed Not so freshers The very limited joys of student life

09/11/2020 09:43

thedoctor

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

Email thedoctor@bma.org.uk

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

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

Read more from The Doctor online at bma.org.uk/thedoctor

The Doctor will not publish in December, the next issue will appear in January 2021

The Doctor is a supplement of The BMJ. Vol: 371 issue no: 8268 ISSN 2631-6412

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In this issue 4-5 Briefing

The Government dithers on COVID-19, GPs under pressure and a consultant retention crisis

6-9

Not the right time...

Welcome Chaand Nagpaul, BMA council chair Every day, week and month the disaster of the COVID-19 pandemic grows greater. It has been a chaotic and costly response from the Government and its dithering and inaction has, without doubt, compounded the effects of this disease on the public, the NHS and the doctors fighting against the tide in GP surgeries, hospital wards and from cobbled-together office spaces in their homes.

The BMA has, at every stage of this pandemic so far, been among the loudest voices for a more coherent strategy, for measures which would control this virus and for better protection of the public. We will continue to demand a nearsuppression approach to tackling this virus and for far greater support for the doctors facing great risk every day of their working lives.

In this issue of The Doctor we continue to raise aspects of this pandemic which may affect the daily lives of doctors but are not often given the time and space they deserve in a public debate often dominated by daily and weekly statistics and political infighting. A feature in this issue highlights the devastating effect of long COVID on doctors – for those struggling with debilitating symptoms and, also, those now facing a financial nightmare. With hospitals filling once more it is a very worrying time for doctors and the BMA is calling for central funding and support for the Government to recognise these growing concerns.

The November issue of the magazine also contains an indepth investigation into the Government’s plans to abolish Public Health England – considering its actions and what might happen next with detail on its replacements so far scant, at best. One thing in particular is clear: this country cannot afford for a reform to fail in this area with the pandemic growing again and health inequalities becoming more and more entrenched across the country. The BMA will be engaging with, and heavily scrutinising, this process at every step.

We also tell the tragic story of the suicide of a GP and the professionals demanding better support for practice staff going through the grieving process. We look at life during the COVID-19 pandemic for medical students and assess progress against former health secretary Jeremy Hunt’s pledge to end out-of-area placements for mental health patients in the NHS. bma.org.uk/the doctor

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A massive reorganisation of public health – in the midst of a pandemic

10-13

No end in sight Mentally-ill patients continue to be sent far from home for treatment

14-17

The jobs that COVID crushed COVID has cost some doctors not just their health, but their livelihood too

18-19

Fringe benefits How three junior doctors turned barbers kept their colleagues in trim during lockdown

20-24

Fallen friend GPs who lost a partner to suicide had to maintain the practice while managing their grief

25 If we can beat Ebola...

Nigeria's efforts to overcome COVID-19

26-27 No time to be a student How COVID measures have robbed many students of their university experience

28-29 In private hands The billions given to multinationals in outsourcing the COVID response

30-31 On the ground The BMA helps an overseas doctor through tough times

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ALL TALK: Politicians argued while the ‘R’ rate rose

Delaying the inevitable The sentiments behind Harold Wilson’s infamous ‘a week is a long time in politics’ line have never felt more fitting than in the UK of 2020.

On 31 October prime minister Boris Johnson announced a second national lockdown amid a dramatic rise in COVID-19 infections, hospitalisations and deaths and told the public in England – aside from key workers and those employed in sectors where work cannot be carried out remotely – to stay at home.

Just 10 days earlier Johnson had attacked opposition politicians – calling them ‘incoherent’ in their calls for a lockdown he then called ‘damaging’. And until the hours before the prime minister’s Saturday evening announcement the public were still firmly under the impression that the Government would only take a localised approach in its fight against the disease.

While the prime minister dithered and politicians argued the statistics were becoming ever more stark, the ‘R’ rate was out of control, hospitals in several parts of the country were treating more patients than at their peak during the first wave and doctors were telling the BMA their services could not cope.

Better late than never is a particularly glib cliché when it comes to such matters of life and death but it is darkly relevant in this case. As BMA council chair Chaand Nagpaul said, a second lockdown was the right decision ‘and the only option left, dictated by the exponential rise in the infection levels and a very real threat that the NHS will be overwhelmed if nothing was done’.

Dr Nagpaul said: ‘The BMA has been calling for all decisions about this pandemic to be based on the best scientific evidence available and it is regrettable that warnings from SAGE were not actioned as long ago as 21 September.

‘We know this will be painful for the public, but the alternative of a health service with overfull hospitals unable to treat seriously ill patients would have been devastating.

‘What is vital now is a clear exit strategy. We cannot afford to have a repeat of the first lockdown – which was followed by a rebound surge in infection and impacts on the nation’s mental health – where the economy is made even more fragile and where the NHS and its workers teeter on the verge of collapse because of delays, confusing rules and guidance that doesn’t work.’

The course of action now should be clear. This second lockdown period must be used to create a test and trace system fit for purpose.

It must have capacity, it must be responsive and local public health teams should be given the investment to take over its management, moving away from the messy and costly fragmentation caused by outsourcing to private firms.

GPs work flat out ‘I think most GPs are feeling more and more like frogs in the pot of heating water. Continued unkindness, abuse and complaints largely centred on the inescapable fact we are operating in a COVID environment (thus different).

We’re doing our best.’

These were the opinions of one GP, expressed online last month, in relation to the climate of pressure and under-appreciation felt by many working in general practice.

While the pandemic has by and large seen an outpouring of support and thanks from the public towards the doctors and staff in NHS hospitals, attitudes to GPs have not always displayed such unequivocal support.

The highly contagious nature of COVID-19 saw the majority of GP practices having to change how they work and, in some cases, limit what services they can provide, to protect patients and staff.

Despite doing everything they could to work around the challenges of the pandemic, NHS England and NHS Improvement still saw fit in September this year to write to all GPs and clinical commissioning groups, tersely reminding that practices should continue ‘providing face-toface appointments for those who need them’.

This false perception of general practice somehow not pulling its

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OPEN: GPs have managed a huge increase in appointments

weight in the fight against COVID-19 led to criticism in certain sections of the national press, an action which many GPs felt intensified the suspicion and hostility facing them.

Fortunately, the black and white figures drawn from September GP appointments data have effectively served to demolish any notion that GPs aren’t ‘open for business’ and working flat out to meet the needs of their patients.

Published on 29 October, the data shows not only an additional 6.5 million more appointments in September than in August, but that 4.7 million of these had been face-toface consultations.

The data further highlights that the number of same-day consultations that took place this September was 1.8 million higher than in August and 1.5 million more than in September last year.

It also showed the number of patients waiting more than a week for an appointment falling from 8.3 million in September 2019 to 6.6 million in September this year.

BMA GPs committee chair Richard Vautrey has written to health secretary Matt Hancock to call for more support for hard-pressed practices.

He wrote: ‘At a time where the profession is exhausted and fearful for the future (for both themselves and their patients), it is more important than ever for the leaders of the NHS to show their appreciation and to stand behind general practice.’

Keep in touch with the BMA online at bma.org.uk/the doctor

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HARWOOD: ‘Everything must be done to retain and recruit more doctors’

Consultants under threat from ‘huge workforce crisis’ There are three straightforward facts about the consultant workforce which should send cold shivers down the spines of the politicians and officials in charge of the NHS. It takes six years at least to train a consultant. Almost one quarter (24 per cent) of its workforce is over 55. Six out of 10 consultants in post plan to retire on or before the age of 60.

Without even considering the context of life as an NHS consultant, you see the huge problem pending; large numbers leaving before the next generation starts specialty training.

Context must be considered too, of course; the chronic staff shortages, piling pressure on those already bearing the burden of an ever-heavier workload. They’re not what you’d call retention incentives.

It’s no exaggeration then, as BMA consultants committee chair Rob Harwood warns, that the NHS has a ‘huge workforce crisis’ to deal with, which threatens ‘potentially catastrophic consequences’.

‘We’ve reached a position where every consultant is more precious than ever,’ he said. ‘In the face of an unwavering global pandemic, everything must be done to retain and recruit more doctors as a matter of urgency, not only to help in the fight against COVID-19, but also the immense backlog created as a result of the virus.’

His position is backed by eight other respected medical bodies, including the Royal College of Physicians, the Royal College of Paediatrics and Child Health, and the Royal College of Surgeons of England.

All eight back measures in a new report, Consultant workforce shortages and solutions: Now and in the Future, including calls to address the stagnation in salaries which has seen a 30 per cent real-terms erosion over the last decade, reform of the pensions taxation system, and measures to eliminate gender disparities in pay to encourage retention of female consultants.

Read more content from The Doctor at bma.org.uk/thedoctor

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Not the right time...

A massive reorganisation of public health in the midst of a pandemic, to a tight deadline, with no clarity over vital services. Really? Peter Blackburn asks why

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A

MATT SAYWELL

concerns around the future of all of the other areas t 12.16pm on 16 August an email entered the of public health which do not sit under the health inboxes of all members of staff working at Public protection umbrella, the decision being rushed Health England. It began: ‘Dear everyone, I am and following no significant engagement and sorry beyond words.’ consultation and fears of professionals having their The executive agency’s chief executive, Duncan independence eroded. The Doctor has spoken to public Selbie, was addressing leaked news, published in The Sunday Times, that the 5,500 members of PHE health consultants, directors of public health, academics (Public Health England) staff were now working for an and PHE staff members – and the first issue most raised organisation which was to be disbanded, ‘amid concerns was that of timing. In short, why now – in the thick of the about its performance during the pandemic’. current chaos and crisis?

It was a surprise and a shock to most, although, The Health Foundation’s Tim Elwell-Sutton, a former according to one senior source, those in leadership assistant director and consultant in public health at positions had felt the rumours swirling for several weeks. Thurrock Council, describes the Government’s decision ‘You do not have a situation where thousands of as a ‘risky move’. He says: ‘Whatever criticism there may people in a major organisation be of it you have to be clear that is absolutely key to the that this is not the time.’ pandemic response find out It is an analysis supported they may not have a job in by the evidence of those ‘You have to be clear that a year’s time over Twitter, working for or with PHE, to late on a Saturday night or whom The Doctor has spoken. this is not the time [for major in the papers on Sunday One senior member of staff reorganisation]’ morning. That is absolutely said that while staff were inappropriate,’ consultant in continuing with their work, the public health and BMA public loss of CEO Mr Selbie had led health committee co-chair Richard Jarvis says.

The chief executive’s apology expressed regret that the media had been briefed before staff had been JARVIS: ‘Thousands of people find out given the news – and outlined the stark action the they may not have a job over Twitter’ Government had taken.

It said: ‘The prime minister and secretary of state wish to recreate an organisation with a sole focus on health protection and to bring together our health protection services with the budgets and people of the NHS test and trace programme to create a new national institute for health protection.’

Rushed decision The Government hoped, it added, to ‘boost our unique scientific capability and world leading health protection expertise with much needed new investment’.

The news caused great upset to many of those working in public health and consternation among observers with expertise in the area – with particular bma.org.uk/the doctor

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MATT SAYWELL

ENGLISH: ‘The timing is wrong and there cannot be further changes for the time being’

be the need to merge PHE with NHS test and trace in order to give NHS test and trace access to a wider staff and to give it an organisational structure. That, I think we were expecting but what we weren’t expecting was that the full abolition of PHE would be announced as a done deal at the same time. Especially not before any announcement about what would happen to the parts of PHE that were not going into the new combined function.

‘I’ve never heard the secretary of state say anything other than positive things about PHE apart from when to feelings of a lack of direction and made recruitment he’s quoted as telling jokes about us in the bar in the more difficult.

Commons. There’s no sense currently that we are being And there is, of course, the effect on staff wellbeing formally scapegoated but there is a lot of rumour. It feels and job satisfaction, too. The senior member of PHE more as if we are, if anything, staff, whose identity has ‘There’s huge disruption collateral damage in this been protected so they can reorganisation.’ speak freely, says: ‘Most caused when you abolish organisations And, in his email of 16 of our staff – once they and create new ones’ August, Mr Selbie said: ‘No one recovered from the shock remotely close to our work of of the announcement – are reasonably resigned, I think, to the current situation, they the past eight years, and since January on the pandemic would agree with the headlines that this change reflects expect to be doing a broadly similar job in the future in “pandemic failure” on our part. Certainly, this is not some new organisational structure but are frustrated by what the secretary of state believes or says in public or the uncertainty and disappointed by the implied lack of private.’ appreciation of what they do.’

Dr Elwell-Sutton adds: ‘There’s huge disruption Fragmentation fears caused when you abolish organisations and create new Among the greatest concerns surrounding this decision ones – it’s inevitable that staff will be unsettled, they will is the future of vital parts of public health which are not lose experienced, knowledgeable staff who will move elsewhere, people’s minds will be taken off the tasks and included in the remit of the new organisation. And now, there will be a lot of financial costs as well. Even if what three months on from the announcement, the experts comes next is much better it seems hard to understand and the staff are united in having gained very little clarity. or to see how it’s worth the risk.’

There is indeed a feeling in PHE that the Government came into the pandemic not even aware of the full range A scapegoat? of the organisation’s roles and responsibilities.

The narrative of PHE being a scapegoat – a grand, A senior member of staff at PHE says: ‘A lot of the destructive distraction to draw the eyes of critics away functions not going to the new National Institute from other failings – won’t go away. But, perhaps for Health Protection are acknowledged to be core surprisingly, many of those in positions of power at PHE functions – the work we do on screening, drugs, mental do not believe those were the intentions behind the health, tobacco control, disease registration, sexual move – and while many remain critical of the manner health – all of these things. There’s no suggestion that of the announcement and the lack of a proper process ministers don’t want these functions to continue, it’s there is a sense of agreement that the moves haven’t just that we don’t know what the structures are going been overwhelmingly driven purely by malice or political to be and we don’t know the relative priority of those game-playing. functions.’

A senior member of staff at PHE says: ‘It became The staff member was concerned about obvious that the Government needed to do something fragmentation of services and the separation of health to put NHS track and trace on a proper organisational protection and health improvement. footing. The primary reason for the decision seems to The biggest concern is perhaps that successive 08 thedoctor | November 2020

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MATT SAYWELL

governments do not have great records in this area.

Promises of protected budgets were made when the responsibility for public health moved from the NHS to local authorities but budgets have repeatedly been slashed, with often a severe effect on outcomes.

There is uncertainty over what the Government will do next. A ‘stakeholder advisory group’ and trade union working group have been set up, but members of the group and the former BMA public health committee chair Peter English say there is a lack of detail.

The deadline for restructure – April next year – strikes NAGPAUL: Public health everyone as remarkably tight, given the context and must receive the amount of planning required. A brief consultation the resources document from the Government in September it needs proposed a dizzying range of options, including the A BMA document drawn up by public health doctors devolving of PHE functions to local authorities or representing their colleagues working across the system creating a wholly new organisation for prevention and suggests a future public health system should balance health improvement. meeting short and long-term challenges of responding Dr English says: ‘We would like them to pause what to the pandemic and wider they are doing – it’s rushing health inequalities. It also ahead far too quickly. We outlines the importance of all ‘It’s rushing ahead far too quickly’ would like them to have the parts of public health being consultation but make it not strongly interconnected, have many pre-conditions and the importance of a close definitely to consult widely at partnership with the NHS and social care, the vital role of a time when the key players are not involved in running accessibility of high-quality data and analysis, consistent the pandemic. That means parking it in the knowledge national terms and conditions of service at least that the timing is wrong and there cannot be further equivalent to those of the NHS. changes for the time being.’

Whatever the look and feel of new structures, For staff in PHE, and those in the wider public health community, if these changes are to have any great effect doctors leaders will also demand protection and rebuilding of the rights of public health professionals to they will need to encourage the return of investment remain independent and to express their professional and priority to this woefully neglected, but crucial, area views in public and in meetings in order to properly of medicine. advise the population openly. A senior member of staff Public health medicine has suffered significant at PHE told The Doctor the current plans looked likely reductions in funding over the years – an £850m drop to draw functions closer to Government with in real-terms funding between 2015/16 and 2019/20, according to the Health Foundation and the King’s Fund. less independence.

Ask many doctors for their views on the situation and they’ll say, ‘well, I wouldn’t start from here’. A Need for resources hastily-written apology email to staff, a leaked report BMA council chair Chaand Nagpaul says: ‘It is vital public in a national newspaper, heavily questioned political health receives the resources it needs – the pandemic motivations, beleaguered staff and, not least, a global is evidence enough that having the capacity to manage pandemic. But what is also striking is the determination a pandemic could save thousands of lives. Yet the to make the new structures as effective as possible. The budget for PHE is around £400m compared with the stakes are simply too high. £10bn allocated by Government for the test-and-trace As Dr Nagpaul puts it: ‘We, our patients, and the most programme.’ disadvantaged in our communities, cannot afford for It is crucial the process places genuine clinical another reform to fail.’ engagement and expertise at its heart, from now on. bma.org.uk/the doctor

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Mentally ill patients continue to be sent far from home for treatment, and a government target to end the damaging practice looks set to be missed. Keith Cooper reports

‘We weren’t sending people out of area en masse 10 years ago’

N

ot a single patient from England with acute mental ill health should be in a bed far from home for want of one locally by April, as has been commonly the case in the NHS. This was the widely welcomed target announced by the then health secretary Jeremy Hunt in 2017 to end the pain of separation from families and NHS carers of patients sent to socalled OOA (out-of-area) beds, an increasing practice back then, as an investigation by The Doctor had revealed months beforehand.

With the deadline looming, and as COVID-19 re-tightens its grip

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on the NHS, how likely is it to be hit? And what have trusts done to meet it?

The Doctor analysis of NHS figures and responses from FoI (freedom of

‘Mental health services will not be immune from the acute pressures of winter and the second wave of COVID-19’

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Resources needed The Royal College of Psychiatrists backs calls for extra investment in beds in areas with consistently high numbers of inappropriate OOA placements and persistently high bed occupancy.

‘These priority areas should be given the resources to invest in additional local mental health beds that are properly staffed and resourced, immediately,’ says Billy Boland, chair of the RCPsych’s general adult faculty.

Dr Boland called for dedicated discharge funding for mental health to support patients when they leave hospital. ‘Mental health services will not be immune from the acute pressures of

winter and the second wave of COVID-19,’ he adds.

While the BMA supports NHS England’s plan to boost mental health care in the community as a means of ending OOA placements, it’s also calling for more local NHS beds. Eight out of 10 OOA beds occupied by NHS patients are in private hospitals, which have increased bed numbers over recent years as the NHS cut its supply.

Our analysis shows that the number of patients sent to a bed OOA for want of one locally fell by just 8 per cent in the 12 months to August compared with the same period in 2018.

While these socalled ‘inappropriate’ placements fell in most trusts, they increased in 38 per cent of the 40 trusts for which comparable figures are available.

The number of days patients spent in

such beds – another NHS measure – fell by just 6 per cent in the same 40 trusts.

OOA placements in BSMHFT (Birmingham and Solihull Mental Health NHS Foundation Trust) and DHFT (Derbyshire Healthcare NHS Foundation Trust) – and eight other trusts – doubled in the 12 months to August compared with the same period in 2017/18.

BSMHFT says it has taken several steps to reduce OOA beds through early intervention, including creating an openaccess 24/7 mental health helpline.

A plan to address the complexities of ending OOA placements is still in development.

DHFT says its numbers had risen because no psychiatric intensive care beds were commissioned by the MOLODYNSKI: ‘It’s a result of austerity’ MATT SAYWELL

information) requests indicate it’s almost inevitable that it will be missed and for several years to come.

Thousands of patients are still sent out of area. Almost half (47 per cent) of trusts sent patients out of area 100 or more times in the 12 months to August, show the latest figures from NHS Digital.

Very few of the CCGs (clinical commissioning groups) which fund, and so set, bed numbers plan to increase local bed capacity, responses to FoI requests indicate.

Bed numbers in some areas are also under review after being requisitioned for COVID-19 patients, The Doctor has found.

In the longer term, further reductions are inevitable as dormitory wards for multiple patients are converted to en-suite rooms with recently announced

Government funding.

BMA mental health policy lead Andrew Molodynski says the time has now come for NHS England to lead a coordinated effort to end OOA placements once and for all.

‘Sending patients OOA is a complex but relatively new problem in the NHS. We weren’t sending people out of area en masse 10 years ago,’ he adds. ‘It’s a result of austerity and the gradual but significant reduction in mental health beds over the past few years.’

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SOURCE: NHS Digital

‘Inappropriate’ out-of-area placements in England, 2020 Lincolnshire Partnership NHS Foundation Trust

Derbyshire Healthcare NHS Foundation Trust

305

240

Birmingham and Solihull Mental Health NHS Foundation Trust

Norfolk and Suffolk NHS Foundation Trust

300

245

Barnet, Enfield and Haringey Mental Health NHS Trust

‘Inappropriate’ placements are defined as where patients are sent to a bed out-of-area for want of one locally. This is a sample of OOA placements in England.

340

Devon Partnership NHS Trust

570

Avon and Wiltshire Mental Health Partnership NHS Trust

335

HUNT: Pledged to eliminate OOA placements by April next year

NHS in Derbyshire.

‘We are working hard to reduce the length of time that people spend in our inpatient areas to ensure people are supported within a community setting as much as possible,’ a spokesperson adds.

Responses to FoIs indicate that CCGs are not driving an increase in bed numbers to end

OOA placements.

The majority said they left decisions on bed numbers to the mental health trusts they commission; 21 said they planned to keep bed numbers the same; two to reduce them; and only one, Devon, the area with the highest number of OOA beds in the country, said it wanted to increase bed capacity.

Complex cases Avon and Wiltshire Mental Health Partnership NHS Trust has seen its OOA placements increase by 14 per cent to 335

Oxleas NHS Foundation Trust

320

in the 12 months until August, despite opening a new 18-bed ward in Bristol in 2018.

‘We have continued to see sustained demand with greater acuity and complexity among our patients,’ a spokesperson for the trust says. In anticipation of a likely further increase in demand, the trust has appointed a clinical director for ‘right care’ to build confidence in home treatment as an alternative to hospital care, to lead ‘system change’ and support ‘complex clinical

decision-making’.

COVID-19 itself has been a double-edged sword for hitting the 2021 target, trusts and psychiatrists say.

While reducing bed numbers, it has forced social and mental health care providers to work together like never before to get and to keep patients out of hospital.

‘A lot of our time is usually soaked up by protracted, bureaucratic processes justifying why this patient can leave hospital, leaving lots of them stuck in hospital because social care providers are unable or unwilling to meet their needs,’ a consultant psychiatrist in one major trust tells The Doctor.

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SOURCE: FoI requests of CCGs in England Increasing

1

Decreasing

2

No change planned

21

A further 31 CCGs said they left decisions on bed numbers to the mental health trusts from which they commissioned services.

‘We went through a strange window of a few weeks when we were able to get people into social care without any friction’

‘But we went through a strange window of a few weeks when we were able to get people into social care without any friction.’

This illustrates that ending OOA beds is not simply a bed problem, he adds. ‘It’s a systemic issue,’ he says. ‘In our city, if we don’t take into account the complete dearth of social housing or appropriate placements for complex mentally ill people then we won’t solve anything.’

Srinivas Naik, consultant psychiatrist at LPNT (Leicestershire Partnership NHS Trust), which has not sent a single patient out of area since March, also found a notable improvement in collaboration.

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‘Housing, social care, and the CCG all started changing their timeframes,’ he says.

‘It’s a shame that we had to have a disaster to work out that we could all work together at this level.’

Steps taken by LPNT for COVID-19, including the creation of the urgent mental health care hub to cope with COVID-19, which Dr Naik heads up, has helped keep OOA beds at zero (see box, right).

The BMA’s Dr Molodynski welcomes the efforts of psychiatrists and trusts to reduce OOA placements but calls for a new plan to end them once and for all.

‘It’s clear that further action is needed to end this harmful practice,’ he adds.

‘The pressures of COVID-19, the financial uncertainty faced by the NHS and the country, and the prospect of an economic recession makes it even more important to get a grip on this.

‘We need a more coordinated response from NHS England on beds supply for acutely unwell patients and an immediate moratorium on any further reductions in NHS beds.’

APEXA PATEL

Plans for mental health beds 2020/21 to 2022/23

Ending OOA placements

NAIK: Prepare for fewer beds

Leicestershire Partnership NHS Trust’s efforts to end OOA placements pre-COVID-19 focused on housing, homelessness, and social care.

It commissioned ‘very short-term’ accommodation from Action Homeless in Leicester, a housing association, for people who need extra support before returning home.

An expansion in its home treatment team has reduced informal admissions and helped people leave hospital sooner.

For the pandemic, it set up in April a round-the-clock urgent mental health care hub for people of all ages. This has reduced the proportion of people admitted during a mental health crisis from 20 to 2 per cent, the trust says.

Despite reducing adult acute beds by 40 during COVID-19, it has kept OOA beds at zero by ensuring every admission goes through a consultant psychiatrist.

Patients can be kept overnight at the hub for review by senior psychiatrists.

Consultant psychiatrist Srinivas Naik hopes the measures set up during COVID-19 will keep going. As one of 20 or so trusts to receive a chunk of the £400m to convert dormitory wards, there’s an extra imperative to do so, he says. ‘We are likely to lose further beds because of the designs,’ he says. ‘So we need to prepare as a service to work with fewer beds.’ thedoctor | November 2020 13

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The jobs that COVID crushed 14 thedoctor | November 2020

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One doctor catching COVID-19 while caring for patients has been forced to live on benefits, another faced a battle with employers who tried to wrongly cut her pay. The NHS, having failed to protect doctors from catching the virus, must now offer more support. Jennifer Trueland reports

W

MATT SAYWELL

orking as a locum at the height of the pandemic – in a ward where the wearing of surgical masks was frowned on as it might upset patients – Ellie wasn’t too surprised when she caught COVID-19.

But she didn’t imagine for one moment that, several months on, she would be unable to work, applying for Universal Credit, and relying on grants and family help simply to pay her bills.

Ellie, a GP trainee who was taking a year out of training and working as a locum while she moved across the country, is one of the growing number of doctors affected by long COVID, still suffering debilitating symptoms months after contracting the virus.

Although this devastating syndrome is recognised by the World Health Organization and, last month, by the National Institute for Health Research, that’s still not universally the case in the NHS. While some employers and GP partners are treating it as an occupational exposure issue, providing a measure of financial protection for healthcare workers, others aren’t.

The Doctor has spoken to GPs, consultants, medical academics, trainees and locums from across the UK, who report variable experiences.

All are living with long COVID, all are facing uncertainty, but some are facing a financial as well as a health nightmare. And the fear of the possible implication of COVID, even to the young and previously fit and healthy, is already having an impact on the rest of the medical

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STRAIN: ‘Some people are being left without any source of income’

workforce – at a time when hospitals are filling once more.

‘It’s very scary for doctors,’ says David Strain, co-chair of the BMA medical academic staff committee, who is playing a leading role in the BMA’s COVID work. ‘In the first wave, the younger and fitter doctors and nurses were actually quite confident that because this was a disease particularly affecting older people, they felt that even if they did get it, they would shrug it off really quickly and just get on with things.

This time there is actually a palpable fear amongst all of the trainees and the nurses and the therapists knowing that if they get it, yes, they are less likely to need to be admitted to ICU, but they nearly all know somebody directly or indirectly who has been affected by long COVID. It’s making things like staffing the COVID wards a lot more difficult because people are nervous.’

Occupational exposure

‘They felt that even if they did get it, they would shrug it off really quickly’

At the time of writing, there is still some debate over the status of long COVID and the BMA continues to press for clarity – and a fair deal for doctors.

‘It’s being seen differently by different places,’ says Dr Strain. ‘But what we do know is that some people are being left without any source of income after six months of standard sick pay because it isn’t universally being accepted as a consequence of an occupational exposure.’ thedoctor | November 2020 15

09/11/2020 09:47

The BMA is hearing stories about doctors who are losing their livelihoods, he adds.

‘We are fighting each case as we hear about it and obviously we want to do what we can to help. We think this should be coming with central funding and central support from the Government as part of the COVID response.

‘We are working very hard for recognition that long COVID is a consequence of occupational exposure, particularly the long COVID that came from cases early on in the pandemic when there was insufficient PPE.’ Ellie is as sure as she can be that she contracted COVID while she was working as a locum in an ENT ward in an NHS hospital.

‘A colleague caught it and collapsed on the ward, I helped her, then a week later I developed it as well,’ she says. ‘The trust refused to swab me because I was a locum, but I had all the symptoms and ever since then I’ve had persistent breathlessness and a racing heart with palpitations whenever I try to do anything. All my tests have come back normal, so it’s now suggested that I have a long COVID kind of thing. I’m still having fevers, and it’s been six months.’

Living on benefits As a locum, she doesn’t get any sick pay – and she still has around £40,000 in student debt. ‘I’ve had to get a loan from family just so that I can pay my mortgage. I’ve just heard I will get some money from the Royal Medical Benevolent Fund, which the BMA advised me to contact. This is such a relief.

‘I’ve had to apply for Universal Credit. It’s humiliating, to be honest. That money should be for people who need it, and I shouldn’t need it – although how they expect £400 a month to be enough for anyone, I don’t know.

‘I feel that when I was working in the NHS I didn’t get enough protection – this was at a time when this particular ward would tell you off for trying to wear a mask because it was frightening the patients. There was next to no understanding. They said that ENT isn’t a risky specialty but they’ve clearly never tried to use a tongue depresser on someone with a good gag reflex, because it is.’

Claire, a consultant physician, caught COVID-19 at the end of May. ‘I had been so careful about wearing PPE and washing all my clothes and so on to protect my children, but I had popped into an office at work to speak

to someone, then realised later that one of my colleagues was unwell and I had been exposed. I felt a bit annoyed, but thought, OK, I’ll just have to wait it out until I get better.’

When we speak at the end of October, Claire is still waiting.

‘June, July and August passed and I still felt awful,’ says Claire, who has three children. ‘I also felt hassled by some colleagues. One got in touch and wanted me to talk about a new rota – they didn’t mean to do anything wrong, but I had to tell them I wasn’t up to it. At one point, a colleague asked if I was planning to come back to work or if I was just going to stay off feeling miserable.’

Fears for the future

‘Quite honestly, I’m scared about the future’

Claire sought help from the BMA when her employer tried to cut her pay against the trust’s own policies. Although the money side of things has been sorted out for now, she still feels isolated – and has continuing symptoms.

‘I don’t think doctors are always very good at supporting each other,’ she says. ‘I’d much rather be at work – and I know it’s harder for my colleagues because I’m not at work – but I didn’t choose this. Quite honestly, I’m scared about the future.’

Some doctors have had a better experience with their employers. Consultant anaesthetist Jennifer Blair was part of the intubation team at Epsom and St Helier University Hospital Trust when she became unwell in early April.

After around two weeks she tried to return to work but still had debilitating symptoms and had to go off as well. ‘It’s a mix of physical and cognitive symptoms which is obviously a concern when you’re doing a high level job,’ she says. ‘It’s not just a matter of being able to stand up and work – you’ve got to be able to think clearly as well.’

Her employers have been ‘very understanding’. ‘I have a clinical lead, who is a friend as well, who has been keeping in touch, which has been very nice on a human level. We’ve had good chats every month or so. The management side initially we weren’t sure how my leave fitted into things, but once NHS Employers made COVID leave a bit more specific, that was a big relief knowing that sick pay was going to be continued. It means I don’t have to worry about the money side of things for a time and can focus on getting better.’

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Need for support She is uncertain what will happen when she feels ready to return to work as under the usual ‘phased return’ rules she would be paid only for the proportion of time she was working, or would have to use holiday entitlement to cover the time off.

‘I think what would be helpful would be something explicit from NHS Employers to say that a much more gradual return was possible – that you could retain your rights to your full pay, but try to work for the time you feel able, even if that’s an hour a week of administrative tasks. I can’t imagine even thinking about doing a phased return because I can’t imagine being able to do full time within the short number of time it would take to use up any annual leave that I had to fill in the gaps.’

As the mother of two boys with all the responsibilities that involves, she needs to

‘You’ve got to be able to think clearly’

get to work for financial reasons – but that’s not the only driver. ‘Getting back to work is important for all sorts of reasons, in terms of your identity, in terms of the fact that it’s so much a part of you – it’s a massive thing.

Increased flexibility around a return to work would be very welcome. I do worry that some people might give up their jobs because they can’t see a way back.’

Ellie returns to GP training in December and hopes that by that time she will be able to work. She believes doctors – including locums – deserve greater financial protection. ‘Organising people to clap for us once a week is great, but when you can’t pay your own mortgage – and you can’t pay your mortgage because there wasn’t enough PPE to start with – it feels very shallow. Like the money for people on furlough, there should be further financial government help for healthcare workers.’

Thrown out of her practice A GP with long COVID who lost her partnership because of a ‘poorly worded’ contract is urging others to check the paperwork carefully When Gillian joined a five-partner GP practice around a decade ago, the wording of the partnership agreement wasn’t her priority. Eager to get stuck in, she didn’t run the document by a lawyer.

But the implications of one clause proved serious.

This stated that any partner had who not been ‘fulfilling their partnership duties’ over a six-month period could be ‘expulsed’ from the partnership; in other words, they could lose their job.

This happened to Gillian last month. After years of training then working as a GP, she has developed ‘long COVID’ and doesn’t know when she will be able to work again. Now she doesn’t have a job.

‘My partners couldn’t cope with the uncertainty,’ says Gillian. ‘They wanted me to say when I’d be well enough to come back to work as normal, and I simply couldn’t give them that certainty. I think they couldn’t cope with the idea of having a partner who was disabled.’

Gillian believes she contracted COVID-19 in April from a colleague who had tested positive and been sent home from work the day before she (Gillian) felt unwell.

She then passed the infection on to her husband, who is also still off work six months later. Both had thought they would be ill for a short while and then bounce back,

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but this wasn’t the case. She tried to go back to work in June, but just one session left her unable to leave her bed for 10 days. Now, having been expulsed from her partnership last month, she doesn’t know what she will do.

‘The partnership agreement at our practice was poorly worded and out-dated. I would encourage all GPs to get any partnership agreement independently reviewed by a lawyer before signing. It’s worth the initial outlay to save a lot of trouble further down the line.’

Gillian had taken out income-protection insurance but it won’t kick in until she has been off work for 12 months – leaving her without any income for six months. If she takes up any paid work in the meantime, for example, a locum session to see if she is able to return to work in any capacity, the ‘clock’ goes back to zero and she would have to wait a further 12 months for income protection.

‘I’m stuck between a rock and a hard place. It seems very hard that I contracted COVID-19 at work, but now I’m left with no job and no income and no idea about what will happen in the future for me and my family.’

Visit bma.org.uk/partnershipagreement for guidance on employment contracts

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FR NGE BENEFITS

TRIM TRIO: (from left) Dr Weidi, Dr Scott and Dr Cullen

Pictures were taken at the start of April, before the introduction of new rules about social distancing and mask wearing for staff

Three junior doctors, having watched a few online videos, offered to cut their colleagues’ hair during lockdown... what could possibly go wrong? And yet the hair-raising initiative not only spared sartorial blushes, but raised thousands for charity and helped staff talk to each other at the most stressful of times.

Seren Boyd reports

I

n uncertain times, the a nurse whose girlfriend seemingly trivial can take had taken one of those big on deep significance. bands you exercise with, So it was that a small back wrapped it around his head room in emergency care was then shaved up to that line,’ literally buzzing with activity recalls Dr Weidi. ‘Then she had at one city-centre hospital panicked and stopped. He during lockdown. looked like something out of For it was there that “Beavis and Butt-Head”.’ bowl cuts, split ends and bad hair days of every hue Barnett formula were banished, thanks to Dr Weidi’s reparations drew an impromptu hairdressing admiring glances from service set up and run colleagues, quickly followed by colleagues. by enquiries about his Armed only with clippers availability to do other cuts. and nervous enthusiasm, a Faced with rising demand, team of three doctors began Dr Weidi recruited two of his administering social lifehair models, foundation year saving skills to friends’ hair.

2 junior doctors Jack Cullen Of course, during the first and Luca Scott, to extend this few weeks of lockdown, selfwellbeing initiative to other inflicted crewcuts and ’80s members of the department throwbacks were something and hospital. A crash course of a badge of in barbering honour. But it ‘She has incredibly thick, courtesy soon became of YouTube beautiful hair and I was apparent so worried I might ruin it’ videos swiftly to Ehsan followed.

‘We searched online for Weidi, a specialty trainee people who were cutting 5 in emergency medicine, their own hair because their that things were getting techniques were very simple,’ out of hand. says Dr Weidi. ‘I had a pair of ‘A friend of mine was

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hair and I’d shave my brother’s now and again – but the rest we learnt as we went along.’

Lockdown Lids was launched in mid-April, with senior colleagues’ blessing.

The trio did the cuts in their own time, generally at the end of a shift and always with colleagues with whom they were working that day. They observed a strict cleaning, handwashing and sterilising regime, and both ‘clients’ and ‘barbers’ wore masks.

In response to reports of an alarming rise in domestic violence during lockdown, the barbers decided to set up an online fundraising page for Refuge – the domestic violence charity – inviting donations in exchange for haircuts.

Done in a snip Though most of the initial clients were men, women soon started asking for cuts too, prompting yet more searches for online videos about layering, bobs and cutting Afro hair.

Hair styling is a great leveller but Dr Weidi could not help but feel nervous when his first women’s cut turned out to be a consultant.

‘She has incredibly thick, beautiful hair and I was so worried I might ruin it,’ he recalls. ‘And she was my boss!

But actually it went well. What we did was really basic but people were pretty happy.’

By this time, the ongoing pandemic, and the weeks leading up to lockdown especially, had taken their toll.

Sitting in the chair proved to be a safe space for people to open up.

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20200410 thedoctor November Issue 26 – p.18-19.indd 2

what was to come: patient numbers were going up and we were seeing some very young people who were very sick coming into the department.

When lockdown came, patient numbers reduced because we’re a city-centre teaching hospital and suddenly there were no tourists or people going out to bars. But there will be ‘forever etched in the was still concern over things memory’. like PPE [personal protective ‘In a good emergency equipment],’ says Dr Weidi. department, people work quite ‘As I cut their hair, I learnt tightly as a team – and the so much about people, about COVID situation has definitely them as individuals, about strengthened those bonds,’ where people lived, how they he says. ‘With the big pressure were doing in lockdown. A lot comes the real relief of the of people weren’t seeing their support and friendship of those partners, some people were around you. stressed about elderly family ‘I think we are getting better members, or the lack of PPE, at self-care in our profession so it was literally a place to but we’re still not good at just sit and it. What I offload. They loved about ‘I think we are getting were also Lockdown better at self-care but expressing we’re still not good at it’ Lids was how that from stressed they were about quite a small gesture, cutting looking unprofessional or how someone’s hair for maybe half long hair was affecting their an hour, people were feeling a self-esteem. lot more confident and happy.

‘Chat is pretty difficult after It was just something practical a night shift because you’re not we could do to help our as sharp as you’d want to be. colleagues.’

I’d only ever do one cut after a Visit https://soundcloud. night shift because it would be com/thebma to listen to an too risky otherwise.’ interview with Dr Weidi

PERFECT PARTING: Foundation year 2 Harrison Carter

ONE OF THE CREW: Foundation year 2 Jack Kingdon

Salon support By early July, when high-street barbers and salons reopened, Drs Weidi, Cullen and Scott had cut 20 women’s hair and more than 100 men’s.

And Lockdown Lids had raised more than £4,000 for Refuge, as staff’s friends and family began donating too, some from as far afield as Australia.

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09/11/2020 11:34

When GP Louise Tebboth died by suicide, her partners had to keep the practice open, dealing with their own intense grief and an avalanche of questions from patients.

Seren Boyd hears why more support for doctors in these tragic circumstances is urgently needed

Fallen friend T

he call comes and time stops. A colleague has died by suicide.

Inside, the shock, a maelstrom of raw emotion. But out there is a busy surgery, patients with needs, patients with questions.

The practice team is thrust into an emergency without a plan, let alone support, forced to improvise, bury their own grief and carry on regardless.

What happens next is the subject of a new report which offers a framework to guide practices through such a ‘major incident’, and calls for support – and just a little more compassion.

Louise Tebboth had been at her Bermondsey practice for 12 years when she died by suicide in January 2015. She was 40.

Like the rest of her team, GPs Rebecca Torry, Louisa Dove and Jasmine Nagpal were profoundly shocked.

Dr Dove, who had joined as a newly qualified GP three years earlier, had been making arrangements to meet up for a drink with Dr Tebboth the week before she died.

‘She was always the first in, often the last to leave… so accommodating, caring and compassionate…’

Dr Torry had been Dr Tebboth’s programme director when she was a registrar. She had been

‘Walking over that threshold was a really hard thing to do: all her things were still in that room’

at Dr Tebboth’s wedding and had travelled with her to Central Asia to visit a former colleague working in a health clinic near the mountains.

‘We’d taken some cheap reading glasses and I’ll always remember Louise’s pleasure in helping people try them on.’

And Dr Nagpal, who joined the practice in 2012 as a GP registrar, found in Dr Tebboth not only a mentor but also someone who shared her commitment to social justice and the most vulnerable. They’d even been to the same school.

Five years on, they are still processing their grief, their hurt, their anger.

Grief’s different faces Dr Tebboth had been on sick leave for several months and had only recently confided in a few colleagues that she was struggling with depression.

Dr Torry, the senior partner, took the call from Louise’s husband, Gary, early one Saturday morning. Breaking the news to the other four partners, she sensed ‘the almost physical blow they experienced’. Between them, they rang the rest of the practice team and informed the clinical commissioning group; on the Monday, they held meetings with staff.

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SARAH TURTON

DR TORRY and DR DOVE: GPs need support from external sources

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NAGPAL: ‘How did I not know she had this going on?’

‘Louise was so accommodating, caring and compassionate’ But surgeries continued as usual.

Dr Nagpal’s first day back at work was the Tuesday. She held her surgery sitting in Dr Tebboth’s chair.

‘Walking over that threshold was a really hard thing to do: all her things were still in that room and no one at that point felt they had the mental strength to remove them.’

Dr Dove found the first few morning surgeries gruelling. ‘I remember talking to patients, some with really trivial things, which seemed a thousand times more trivial because all I was thinking was, “my friend has just died”.

I kept leaving the room to go and cry. It was just mad.’

The poster by the reception desk announcing Dr Tebboth’s death prompted an avalanche of questions and grief in patients, too, which grew when the cause of death became known. As Dr Dove recalls, it was particularly hard for patients battling their own mental health issues. But it was tough for staff too.

‘We had to talk through somebody talking through the trauma of them losing our colleague,’ says Dr Nagpal. ‘We never got to say, “You know what? This is painful for me too.”’

As after any suicide, grief was streaked with guilt, even self-doubt. ‘A lot of our training is about risk-assessing mental health patients, so how did I not know that she had this going on?’ says Dr Nagpal.

Bureaucracy before humanity One of the hardest things to manage was the day of the funeral.

All three GPs are frustrated with ‘the system’ that the practice had to stay open, albeit with a minimal service, which meant not everyone

could attend the memorial.

Some felt they needed to defer to others’ feelings. As Dr Nagpal puts it: ‘All of us felt like somebody else’s right to grief was greater than our own.’

Dr Dove does not hide her anger. ‘I thought the partners had done their best and any anger I had was towards the system, NHS England, the bureaucracy. How could they let us go to work? The processes and rules come above everything else, compassion and humanity.’

Dr Torry knows people were hurt, acknowledges it was a ‘mess’. ‘People since then have asked us: “What was HR doing and what about your senior line management?”

I don’t think they quite understood.’ She and other partners went back to the practice immediately after the funeral.

Dr Nagpal still works in ‘Louise’s room’. For years, she treasured Dr Tebboth’s oximeter, her books, a poem on the wall about migrants – and has a strong sense of continuing her legacy. ‘We recently refurbished a few rooms and I was asked if I wanted to move and I basically just couldn’t let go.’

Everyone, in fact, is still working through what happened, including Dr Torry. ‘We were quite a strong partnership but I did feel I had a considerable responsibility, to the extent that I probably never grieved for Louise.’

Finding a way through Dr Torry and Professor Gail Kinman of Birkbeck, University of London, are co-authors of a new report, Responding to the death by suicide of a colleague in Primary Care, published by the Society of Occupational Medicine and the Louise Tebboth Foundation.

The report offers ‘a postvention framework’ specific to the particular needs of primary healthcare organisations following a suicide. Its key contribution is a checklist of recommended practical actions at different stages throughout the first year and beyond: from how to break the news, to commemorating the loss, to supporting colleagues through longer-term distress.

Crucially, it also highlights the need for support from external sources for GP practices

‘All I was thinking was “my friend has just died”’

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such as Dr Tebboth’s – small, tight-knit independents. Not knowing who to inform, let alone where to seek support, can be hugely stressful (see Farzana Hussain’s story, overleaf).

This support might include: counselling, an external coordinator or taskforce for guidance and practicalities, mentors and peer support groups, crisis funding for locums.

Dr Torry envisages that the BMA wellbeing support services and the Royal College of GPs’ professional development unit could play roles. BMA council deputy chair David Wrigley and Professor Martin Marshall, RCGP chair, expressed their support at the recent launch event for the report.

The report recognises the service would have to be commissioned – and funded.

But help is urgently needed, says Dr Torry.

The obstinacy of lingering trauma was clear in interviews for the report. ‘It struck me powerfully that they spoke of losing their colleague as if it was yesterday, even if it was several years ago,’ she says.

Battling on Suicide postvention is as much about supporting the bereaved as preventing further tragedies – a key theme at the launch.

Clare Gerada of NHS Practitioner Health acknowledged that bereavement around a doctor’s suicide is a ‘complex space’ as professional roles become entangled with emotions. She runs a support group for those bereaved by the suicide or sudden death of a doctor or medical student, and warned against doctors ‘ignoring their own needs’.

Because tragedies such as Dr Tebboth’s death are uncommon, but not rare.

The suicide rate for doctors has been estimated at between two and five times that of the general population, and evidence suggests GPs are at greater risk of suicide than most other specialties.

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‘You get told from med school that doctors are at higher risk of suicide’

considered to be up to four times as high as the national average for women, historically.

But these statistics are old, and there’s a lack of any consistent collation or reporting of data for doctor suicides that might inform targeted interventions, says Dr Wrigley.

He noted alarmingly high levels of mental health issues reported in recent (anonymous) BMA tracker surveys – and continuing stigma as a barrier to disclosure. ‘Doctors just battle on and that’s just a slippery slope,’ he said.

The BMA wellbeing support services – confidential peer support and counselling available 24/7 to all doctors and medical students, as well as their partners and dependants – saw an average 47.5 per cent increase in take-up from June to September, compared with last year’s figures. Use of the BMA’s psychotherapeutic consultation service, DocHealth, run in partnership with the Royal Medical Benevolent Fund, has also risen.

A consistent, comprehensive, specialistled occupational health service addressing the needs of all doctors, including GPs, is long TEBBOTH: Mentor and committed to social justice

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SARAH TURTON

TORRY: ‘They spoke of losing their colleague as if it was yesterday’

Single-handed after suicide

SARAH TURTON

When Farzana Hussain’s colleague was late for work one Thursday morning in 2013, she went to his flat with police – only to find he had died by suicide.

They were business partners – the only two GPs in their east London surgery – and best friends.

DOVE: ‘I kept leaving the room to go and cry’

overdue and ever more pressing, according to ‘Doctors just battle on and BMA GPs committee that’s a slippery slope’ deputy chair Mark Sanford-Wood.

‘With the pressure on GPs at an all-time high, it is vital that we provide increasing support to care for them effectively,’ says Dr Sanford-Wood. ‘Occupational health providers must be given the resources they need to provide a fully holistic service able to intervene at an early stage.

‘GPs need to know that where they become damaged by the intensity of frontline work, the NHS will look after them and aid their recovery. We must all play our part in tackling the issues that lead to so many tragically avoidable deaths.’

Despite the warnings, Dr Nagpal says, self-care doesn’t come easily. She took the call about Dr Tebboth’s death in the middle of a family meeting to organise a bone marrow transplant drive for a cousin. She was the doctor: she carried on. Three other doctors she has known or worked with have died by suicide since then.

‘You get told from med school that doctors are at higher risk of suicide,’ says Dr Nagpal.

‘We can’t just accept that as a side effect of choosing to be in this job.’

To watch the launch recording, visit https://youtu.be/On0FC5kNCL8 Find out more about the Louise Tebboth Foundation at www.louisetebboth.org.uk

I just sat there and cried for about half an hour, and then I called the practice. Our practice manager was really sweet and took charge. I said, ‘I’d better come and do surgery.’ And she said, ‘No, I am going to cancel all these patients, and anyone who has an emergency today will have to go to hospital.’

The next day my practice manager had managed to get a locum in. But there were all the prescriptions to do. I think it took me an hour to do ten prescriptions in between tears. I had to keep the patients safe.

At least I had the presence of mind to work slowly.

The other thing that I found really hard was that I didn’t know who to tell. The CCG didn’t know, nobody knows these things.

On the Sunday, I rang the medical director of a community trust, more as a friend, and they said, ‘You need to tell your medical director,’ but I didn’t even know who our medical director was. They helped me find out. The medical director dropped everything and came on Monday.

I was referred to the Practitioner Health Programme – the medical director suggested that. I saw a mental health nurse, and he said, ‘I think you are going through a normal bereavement and I think you’re quite resilient. I think you’re OK.’ I didn’t feel I needed any more.

I made an appointment with my own GP because I thought I should. They gave me a medical certificate but, of course, if you’re the single-handed GP, who would you give your certificate to? The work needs to be done. I just tore up my certificate.

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GETTY IMAGES: KOLA SULAIMON/AFP

If we can beat Ebola…

UNDER CONSTRUCTION A man sets up a bed inside an isolation centre for COVID-19 patients in Abuja, Nigeria

Nigeria’s preparations to fight COVID-19 were slow to get off the ground owing, in part, to a sense of over-confidence after defeating Ebola. Keith Cooper reports

myths which emerged about COVID-19: that it was a disease of the poor, of the ‘white man’.

‘There was this disbelief.

It was a major challenge,’ he adds.

W

PPE problems

hen COVID-19 arrived in Nigeria late February, it had just about four public testing labs for 200 million people and even fewer isolation centres.

‘Preparation was a bit poor,’ says Osahon Enabulele (pictured above), a chief consultant family physician at the University of Benin Teaching Hospital, a past president of the NMA (Nigerian Medical Association) and president of the Commonwealth Medical Association.

‘It was close to two months before we started to see the necessary level of political commitment, national and healthcare mobilisation to contain this COVID-19 pandemic,’ he adds.

‘The response by Nigeria, like many countries in Africa, was very slow.’

Dr Enabulele puts it down to its over-confidence after it quelled Ebola with few deaths six years ago, and the multiple

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‘It threw even more people deeper into poverty’

Dr Enabulele called for doctors in all commonwealth countries to inspect their facilities themselves, as he inspected his country’s own.

‘You need evidence, not just from books, but from seeing what is happening on the ground to advise Government,’ he says. ‘I compiled a report for my Government and advised them to build more support facilities. Still they didn’t think it was going to affect them. Our biggest initial challenge was poor political commitment.’

As with many countries, its doctors cared for patients with COVID-19 without adequate PPE (personal protective equipment). It took a strike by junior doctors to be properly paid for putting their lives at risk. Access to PPE was particularly poor in the private sector, often the first point of contact with health services for patients.

The Nigerian Government did finally act. ‘It eventually became very clear that this

disease was a leveller, and blind to age, gender, race, socioeconomic and political status,’ Dr Enabulele adds. ‘Measures were eventually put in place after very serious demands from professional bodies, including the NMA.’ The lockdown brought a spate of intimidation, violence and even imprisonment of doctors and other healthcare workers by officers of Nigeria’s security services.

‘It is starting to get better with a bit of education,’ Dr Enabulele says.

The country’s lockdown also had an obvious effect on the over 80 million impoverished Nigerians. ‘It threw even more people, deeper into poverty,’ he says. ‘People starved because of a loss of household income.’

These socio-cultural and economic effects of lockdown will be the evidence that informs Nigeria’s approach. He hopes too that the pandemic will finally force Africa’s political leaders to address staff shortages across the continent.

‘If you don’t have your “soldiers” (ie, physicians and other healthcare workers) on the front line, you are going to have an exposed citizenry.’ thedoctor | November 2020 25

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ISTOCK: Photograph posed by a model

The restrictive measures imposed on medical students owing to the threat of COVID-19 have robbed many of the joys of university life.

Tim Tonkin reports

No time to be a student

‘Y

‘I personally don’t like it as I’m sat [all day] in the same ou’ve got this image in your head of going to room that I sleep in,’ she says. lectures and that kind of university life and ‘There’s no university societies or anything, so I’m instead we’re all just locked in our rooms.’ not getting out other than when I force myself to go out This is how Exeter first-year medical student for a walk.

Harriet Jenner summarises her experience of the early ‘Because I don’t live with any other medics it can feel weeks of her medical degree following the start of the a little bit isolating as I’m not meeting people from my 2020 autumn term in late September. course as much as I would if I were on campus.

As with thousands of other students across the ‘Learning online is quite intense, especially with country, Ms Jenner has had to begin her academic medicine because there’s year amid the uncertain and so much content you seemingly ever-changing landscape of the COVID-19 ‘There’s no university societies or have to learn in the first few weeks. All our OSCEs pandemic. anything, so I’m not getting out’ [objective structured clinical With social distancing examinations] are online as requirements spelling an end well which will be strange,’ she adds. to the traditional spectacle of packed lecture theatres ‘You’re doing a practical clinical degree and not and fresher social events, Ms Jenner explains how she actually having any of the experience. You could just sit has found herself having to adapt to a challenging and at home and do it and not be at university.’ often isolating form of learning.

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JENNER: ‘I’m sat all day in the same room I sleep in’

Hard to engage

‘There was no suspicion that I had any exposure or particular risk of infection; just because I was a medical student I was kept away from the ward,’ he says.

‘I would love to hear more on what guidance the GMC has given on how medical students should be treated alongside the rest of the NHS workforce.

‘I’ve missed one week of training, and that is while staying well away from any COVID-19 infection myself. I just hope that we can absolutely guarantee patient safety while minimising further disruptions to training in the same way that we’ve seen in these last two weeks.’

It has been a similar experience for fellow Exeter first year Education lost Pavithra Poobalasingam, who has started her course The effects of the having already completed a first degree. pandemic on medical ‘Pretty much everything has been online, I’ve only had students’ academic one clinical skills session that has happened in person,’ careers, specifically she says. missed training ‘My placement got cancelled, my second clinical skills opportunities and session got cancelled as well, after two students tested clinical placements, positive for corona. is a concern that has ‘Right now, we’re having two hours of PVR online, four already been raised by the BMA medical POOBALASINGAM: The lack of social contact with other hours of LSRC [life sciences resource centre] online and academic staff committee. students is challenging five hours of pre-recorded lectures.’

MASC chairs Peter Dangerfield and She says she finds online learning harder to engage David Strain wrote to health secretary with and be motivated by than Matt Hancock face-to-face study, adding that on 13 October warning that ‘We are concerned there is a risk of the lack of social contact with students were likely to have other students is challenging. lost a minimum average of four gaps in knowledge arising’ ‘It’s been really, really hard,’ weeks from their education she says. during the academic year.

‘I think I’ve just been lucky because I studied a Calling for a coordinated approach with regulatory previous degree so I have friends from my old university input and oversight from the GMC and Health Education and I’ve been FaceTiming with them, but if I were not an England they warn that gaps in training and education extrovert I would be in a really bad position right now would be particularly concerning for final-year medical because I would not have any medic friends.’ students.

In addition to the limitations of having to learn almost They write: ‘Undergraduate medical students exclusively online, many students are also seeing their represent an unusual cohort, required to acquire not access to clinical placements cancelled owing to COVID-19. only knowledge-based education but also skills and One third-year student, who did not wish to be named, competencies, and within a specific timescale. They explains how he has been forced to miss his placement at also need a supportive structure as they learn to handle complex emotional needs of patients and their families. a local hospital trust after a number of medical students tested positive for coronavirus.

‘We are concerned that there is an inevitable risk of gaps in knowledge and experience arising, despite the Access denied best efforts to date.’

While sympathising with the need to ensure patient They add: ‘With the advent of a second wave of safety, he says he feels frustrated by what he sees as an COVID-19, if rapid action is not taken, there is a real risk overly heavy-handed and reactive measure to ban all that these students will be unable to complete their medical students from green wards, adding that there core competencies, graduate, and form next year’s needs to be greater access to COVID-19 testing. foundation-year junior doctors.’ bma.org.uk/the doctor

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s d n a h e t a v i r p In D

The response to COVID would be vastly more effective if the billions spent on outsourcing to private sector multinationals were spent on NHS capacity and local expertise instead, a BMA event heard. Peter Blackburn reports

avid Rowland produced a report in 2013 which suggested the UK was unprepared for a pandemic.

The director of the Centre for Health and the Public Interest had identified that the ‘hollowed out’ state would not be fit for purpose should a health crisis arrive – and hypothesised that the Government of the day would likely turn to the private sector to coordinate and deliver its pandemic response.

‘We were worried back then,’ Mr Rowland said, speaking at a BMA webinar looking at the relationship between the COVID-19 pandemic and outsourcing.

‘Since then we have seen a big reduction in the funding

going to the NHS, in capital infrastructure, the resources available for public health and a big increase in the use of the private sector to deliver NHS services.

‘Put together all of those various trends since 2013 onward and it has led to a further hollowing out of the state and a further reliance on private providers operating under various different contracts to provide the pandemic response.’

Corporate preference And the evidence of this reliance is not hard to come by.

Among the deals which have been struck so far: DHL, Unipart and Movianto were contracted to procure,

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PA

ROWLAND: ‘We have seen a big increase in the use of the private sector’

COSTELLO: ‘It’s been a total dog’s breakfast’

manage logistics of and store PPE (personal protective equipment); Deloitte to manage the logistics of national drive-in testing centres and super-labs; Serco to run the contact tracing programme; Palantir and Faculty A.I. to build the COVID-19 datastore and Capita to manage returning health workers in England.

At every juncture, the Government has turned to the charms of the corporate world rather than investing in, and trusting, those working in public health, local authorities or primary care.

‘The scale of contracting out in the name of the pandemic suggests real danger that this becomes endemic in future NHS procurement,’ The Guardian journalist Polly Toynbee told the event.

The former director of maternal, child and adolescent health at the World Health Organization and member of Independent SAGE, Anthony Costello, told the event that this pandemic response could have been very different had the political will been there. bma.org.uk/the doctor

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In-house experience Dr Costello said the Government could have mobilised GPs and local public health outbreak teams, giving them the vast amount of money set aside for pandemic response and allowing them to fight the crisis locally using experience, expertise and an appetite for innovation.

He said COVID-19 testing sites could have been linked to GP courier systems, samples sent to the 44 NHS molecular virology labs with results received in 24 hours, new staff employed in practices to contact trace, follow up and monitor symptoms and public health put in charge of contact tracing with significant funding and liaison with GPs. Dr Costello gave rough estimates of £300,000 for an average GP practice of 8,400 people, pro rata, £10m to each of the 151 top-tier authorities in England to strengthen public health, and £30m to each of the 44 NHS molecular virology labs to cover the costs of expanded testing. The bill would total £5bn, which sounds like a lot of money but represents great savings on the £10bn to £12bn the Government has

spent on outsourcing test and trace – and, crucially, the money would be following the expertise.

Dr Costello said: ‘It’s been a total dog’s breakfast.

‘We could have done this – but it would have required the mindset at the beginning and to give people the money in the first place.’

The BMA has consistently called for a publicly funded, publicly provided and publicly accountable NHS. It has surely now been proven that the best chance of a speedy and comprehensive response to a pandemic is a properly resourced health and care system – and it should not be forgotten that this pandemic is not over. We may only be at the start of the second of who knows how many peaks. In future, the Government should place its faith and investment in those who know their areas, their populations and, frankly, their science, best.

As BMA deputy council chair David Wrigley said, if the Government can learn these lessons quickly then perhaps just perhaps ‘we might be able to turn the clock back and salvage something from the mess we are in’.

‘We have seen a big reduction in the funding going to the NHS’

‘The scale of contracting out suggests a real danger that this becomes endemic’

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

An overseas doctor, badly unsupported in his new job, had to cope with a GMC referral and dismissal. With the BMA’s help, he now has a much brighter future. Tim Tonkin reports Waleed Abdalla* decided to come and work in the UK after hearing positive things about the NHS through doctors’ online forums.

Having obtained his primary medical qualification in his home country in the Middle East, he felt that working abroad would be a good way to further develop his medical knowledge and skills.

Dr Abdalla says: ‘I was keen on diversifying my postgraduate training by going to either the UK or USA and decided on the UK.’ In his applications, Dr Abdalla made clear that he wanted to be placed in a junior role and, after receiving an offer for a job at registrar level, was told that he would be allowed to work initially at senior house officer level with a view to promotion at a later stage.

Upon starting his new job in early 2018, however, he was advised that he would in fact be working as a registrar, but that he would be supported in his new role by colleagues in his team.

‘Where I come from the system is totally different to that of the UK,’ he says. ‘[Where he trained] If I do a surgery, I will have a word with the patient afterwards and if they are happy that is it. You would send the patient home and they would be the ones to arrange physiotherapy and post-operative follow-up.’

After starting in his role, he discovered that he had missed his employer’s induction event for overseas doctors and was told by HR that he would be able to attend another, four months subsequently.

When the time came, however, the demands of Dr Abdalla’s job made attendance impossible.

‘The consultant said I could not go and that I needed to cover their clinics. When I asked why, they said that it was fine, and that the induction would be repeated in another four months.

‘At one point I was told to cover a clinic in a different city – I had not even had an induction to the IT system at that time.

‘I was depressed and anxious all the time and considered returning to my home country.’

Despite the pressures of his work, including covering on-calls as a registrar without support or supervision, Dr Abdalla continued to work hard.

After nearly six months into his post he was called to a meeting where issues were raised regarding the quality of his discharge letters, a concern that he was able to resolve by demonstrating his self-taught improvements.

In early 2019 he received confirmation that his contract with the organisation had been renewed for one year.

Just weeks later, however, he was suddenly

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called to a meeting in which a number of concerns about his clinical and communication skills and probity were raised.

He was further advised of concerns that the standard of care he had provided to a patient who had later died had been deficient, and that he was to be referred to the GMC, a decision that would result in an NHS-wide health professional alert notice being placed against him.

He was also notified that there had been questions raised about the standard of care he provided to a patient prior to their death, a case which was now to be referred to the coroner.

Dr Abdalla was dismissed from his role and suddenly found himself without income and facing the prospect of having to leave the UK unless he could find another job.

His dismissal and GMC referral occurred just two days after Dr Abdalla had lodged a complaint against a colleague regarding bullying.

Fortunately, he was able to contact the BMA who were able to provide him with urgent advice and representation through one of its senior employment advisers.

After liaising with Dr Abdalla’s former employer, the adviser was able to assist him in demonstrating that the concerns raised about his probity and skills were unjustified, leading to them being retracted. bma.org.uk/the doctor

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The trust ultimately accepted the objections raised by the BMA, and Dr Abdalla was reinstated in his role, although was still subjected to an investigation by the trust which ultimately saw no disciplinary action being taken against him.

The association went on to support Dr Abdalla with legal representation from BMA Law during the inquest, after his NHS organisation ruled he could not be represented by their legal team or have a separate legal team funded by them, owing to a perceived conflict of interest.

The outcome of the inquest outcome found that Dr Abdalla’s actions were not related to the patient’s death. Following his experiences, Dr Abdalla left his post and is now training to become a GP. He said that his financial losses resulting from his experience, including changing his career path, updating his visa, courses and exams cancellation and legal support, amounted to more than £22,000.

He says: ‘I am happy with the GP lifestyle, the work/life balance is much, much better.

However, I am still planning to use my skills gained from my previous job and be a GP with specialist interests.’

Dr Abdalla has also worked with the BMA as part of a study into the experiences of IMGs (international medical graduates) and how the BMA can help. In particular, his case has highlighted the need for specific financial advice for IMGs and the BMA is working with Chase de Vere to create opportunities to advise doctors about this as part of their membership services.

Having missed his overseas induction, he was also unaware of the need to have medical defence body cover, which would have been able to provide him with legal representation at the inquest and GMC as part of their membership services. The BMA is keen to address this gap and works with the GMC to provide induction to overseas medical staff due to start working in the UK. Dr Abdalla says he has found his support from the association invaluable.

‘Thanks a lot [to the BMA], for your huge efforts and advice. You did a lot of great work, I really appreciate it. It has been a very rough time but I’m very happy that I stood my ground and survived the unfair treatment with your support and help.’ * Names and some other details have been changed

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ANXIETY | STRESS | BULLYING | BEREAVEMENT | RELATIONSHIP ISSUES | ALCOHOL | SUBSTANCE ABUSE | DEPRESSION | ISOLATION

The resurgence of COVID-19 will put added pressure on doctors and medical students which could cause high levels of stress and anxiety. It’s important to look after each other, as well as your patients.

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