The Doctor, issue 28, 2021

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FRONT LINE

The magazine for BMA members

thedoctor

Issue 28 | February 2021

COVID-19: ONE YEAR ON EXPERIENCES FROM THE FRONT LINE 08/02/2021 11:31

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

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

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

The Doctor is a supplement of The BMJ. Vol: 372 issue no: 8279 ISSN 2631-6412

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In this issue 4-5

Briefing BAME doctors feel less protected against COVID

6-13

At the limit

Welcome Chaand Nagpaul, BMA council chair The first COVID-19 case in the UK was confirmed on 31 January 2020 and the first death on March 2.

Doctors have now toiled against tragedy on the front line of the pandemic for a year – placing themselves at the greatest risk, working unprecedented hours under extraordinary pressure and constantly in fear of taking the disease back to their loved ones.

The effect of 12 months working in these extreme conditions is immeasurable. A study published last month found that nearly half of ICU staff working during the pandemic would be likely to meet the threshold for PTSD, severe anxiety or problem drinking.

These statistics are stark, but not surprising. Across the profession doctors have shouldered enormous burden – from public health specialists organising a pandemic response in a specialty cut to the bone, to hospital doctors facing a seemingly endless influx of patients.

In this issue of The Doctor we highlight the incredible work of doctors on the front line – and the unacceptable conditions in which they are working each and every day. We interviewed a large number of doctors from across the country and from a wide range of areas of practice.

There will, hopefully, soon be a time when the worst of this pandemic is behind us.

When this moment comes it is vital a genuine programme of rest, reflection and recovery is put in place because our profession cannot be asked to simply switch from one crisis to another – from protecting the public in the eye of the pandemic storm to dealing with unparalleled waiting lists and requirements for treatment.

If we do not choose to look after the workforce in this crucial moment there will be no workforce to look after patients.

Also in this issue of The Doctor we look at the progress of the vaccination programme, with GPs speaking about their experiences of the process so far.

The February issue of the magazine contains a look at long COVID alongside ME and chronic fatigue syndrome and the BMA’s new BAME network.

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Doctors’ accounts of the first year of the pandemic

14-17

Long COVID – we’ve been here before The parallel lives of ME and long COVID patients

18-21

Don’t forget us The global push for vaccine equity

22-24

The fight back begins GPs reflect on the response from patients to the unprecedented vaccination programme, and the issues with supply

25 Voice of unity The BMA launches a forum for BAME doctors

26-28 The moral cost The conflict between doctors’ values and the decisions they are forced to make in impossible circumstances

29 On the ground How the BMA staved off a £10,000 pay cut for a junior doctor changing specialty

30 Your BMA Fighting to a restore a junior doctor’s mess

31 It happened to me Returning to a very different general practice

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briefing Current issues facing doctors

BAME doctors feel less protected

The vast majority of doctors who have died after testing positive for COVID-19 are from BAME (black, Asian and minority ethnic) backgrounds. In the population as a whole, the burden of COVID-19 has also fallen unevenly.

To give just one example, a report from the Intensive Care National Audit and Research Centre earlier this month found that 28 per cent of patients admitted to critical care with COVID-19 in England, Wales and Northern Ireland between the start of September and mid-January were from BAME backgrounds. That is double the approximate percentage – 14 per cent – of BAME people in the population.

This makes all the more worrying the findings of research which show BAME doctors have an even greater level of concern about their safety than their white counterparts.

The BMA survey of almost 8,000 doctors in England, Wales and Northern Ireland asked if they felt safely protected from COVID-19 in their places of work. A remarkable 72 per cent of

BAME doctors said they either felt only partly protected, or not protected. For white doctors, the figure was 60 per cent. Carried out in December, the survey asked doctors about their confidence in having sufficient and properly tested and fitted personal protective equipment during the current wave. Among BAME doctors, 16 per cent said they were not at all confident and just under 25 per cent said they were only partly confident.

For white respondents, the figures were just under 10 per cent and 17 per cent respectively.

There were also disparities when it came to risk assessments. Just over 46 per cent of BAME doctors said they had been risk assessed and felt confident that appropriate adjustments had been made, while 14 per cent said they had not been assessed and felt that adjustments were needed. For non-BAME respondents, the corresponding figures were 55 per cent and 7 per cent.

To be clear, the figures for white and BAME doctors show that a great deal needs to be urgently done to increase

the level of protection for all doctors, and there were findings in the survey which were similar for both groups – the level of depression, stress, anxiety and other mental health conditions for example. But, given the evidence on outcomes, there has to be concern if in these areas, BAME doctors are faring even worse than the profession as a whole.

BMA council chair Chaand Nagpaul said: ‘We should not have a situation in this country where health and social care workers – BAME or otherwise – are feeling unsafe or at risk from death or disease in their workplace – especially in the NHS where that work is to save the lives of others. It is untenable that a year into this pandemic we are seeing results like this.

‘These results underpin a horrible truth; we have known from very early on in the pandemic that health and social care workers of BAME background are more likely to become ill and die from this virus. COVID-19 has exacerbated existing racial and cultural inequities within our health service that have contributed to this disparity.

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‘The BMA has lobbied long and hard for greater protection and effective risk assessment for at-risk BAME workers and we now want the Westminster Government to bring in proper solutions to address the known ethnic disparities and inequalities.

We need to see further and better research and investment, focused on where it is most needed to bring an end to this dreadful state of affairs.’

Turn to page 25 to find out more about the BMA’s BAME member forum

Mental healthcare reform long overdue A blueprint to bring mental health law into the 21st century has finally arrived, years after the Government pledge to end the ‘burning injustice’ wrought by the existing Mental Health Act. Reforming the Mental Health Act, a white paper, suggests changes to mental health law and practice, including many recommended two years ago by consultant psychiatrist Sir Simon Wessely in his review of the 1983 act.

Ministers have bold ambitions for reform. They will ‘deliver parity between mental and physical health services’, tackle ‘disproportionate detention’ of people from black, Asian and minority ethnic backgrounds, and stop using prisons as ‘holding pen[s]’ for people whose main struggle in life is mental ill health.

The law change will be guided by four principles: increased patients’ choice and autonomy; the use of its powers in the ‘least restrictive’ way; treating people as individuals; and ensuring the act is used for ‘therapeutic benefit’.

Expected proposals to tackle racial inequality include the recruitment of ‘culturally sensitive independent advocates’, tighter rules for community treatment orders, and the patient and carer racial equality framework, a management tool to help NHS organisations deal with long-standing ‘institutional barriers’ to race equality.

The paper was cautiously welcomed by mental health charities, although a MIND spokesperson said: ‘This is just the beginning of what is now a long overdue process.

Thousands of people are still subject to poor, sometimes appalling treatment.’

The white paper pledges ‘to improve the physical environment of hospitals’ but offers no extra funding to do so.

BMA mental health policy lead Andrew Molodynski says the association will examine the reforms closely.

‘We welcome this move to update the outdated Mental Health Act. Additional services, improvements and changes must, however, be fully thought through and funded or the hoped-for changes will not materialise.’

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

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MOLODYNSKI: Welcome move that must be thought through

Read more online – MIND offers NHS managers mental health guide – Call for social care reform – Government backs delayed retirement decision – Deadly delays: mental health beds supply – Reducing the stress of appraisals for consultants – Rotation pause prompts call for well-being awareness Read all the latest stories at bma.org.uk/news

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twitter.com/TheBMA thedoctor | February 2021

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COVID-19: ONE YEAR ON EXPERIENCES FROM THE EDGE

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ED MOSS

At the limit Exhausted and emotionally drained, doctors from across the NHS tell the story of the first year of COVID-19.

Peter Blackburn reports

T

here are evenings when Justin Varney looks out across the Birmingham skyline, opposite, and sees 1.2 million patients – their lives in his hands; the fates of their communities resting on his shoulders – and the burden of responsibility feels totally overwhelming.

Questions rattle around his mind: ‘Have I run out of ideas to stop the spread?’ ‘What else can I do?’

It hardly feels like the moment of rest or reflection needed after another 13-hour day which has seen 400 emails sent and scores of crucial decisions required – decisions only the director of public health in England’s second-largest city can make.

And it will likely only be a brief moment of peace. The work does not stop. There will be more phone calls and emails from political leaders and members of the community desperate for guidance and answers.

‘Relentless’ barely covers the last 12 months for Dr Varney.

There have been moments of great personal pride: in March as stocks of hand sanitiser ran out across the country Dr Varney brought the city’s universities together to find any stocks of ingredients they had, bought hundreds of plastic bottles from a local homewares shop on his personal credit card, set up a bottling line manned by public health staff in the basement of the City Hall and distributed hand sanitiser to children’s care homes across Birmingham. And Dr Varney’s team has also brought mosques and churches together to help communities and supported the growth of networks of foodbanks.

But, there has also been the abuse from COVID deniers, business owners angry about their fates, a constant feeling of being a local ‘arm of the secretary of state’ and those relentless 13-hour days.

The combined toll was such that in May, Dr Varney thought he had suffered a silent heart attack. In the face of

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| Albert Koomson/junior doctor/Essex

‘It has stretched me like nothing else’

DR TAVABIE

DR KOOMSON

| Simon Tavabie/palliative care registrar/London

DR KAR

his endless workload, he continued working for a week, regardless.

‘Like many doctors I ignored my symptoms for a while,’ Dr Varney tells The Doctor. ‘I was exhausted, I put off doing anything about shortness of breath, extreme fatigue and loss of exercise capacity. I didn’t have time to stop and look after myself, decisions had to be made.’

Ultimately, Dr Varney’s illness turned out to be multiple diffuse bilateral pulmonary emboli across both lungs, probably as a result of asymptomatic COVID-19 infection. ‘I think the radiologist used the phrase “shotgun”,’ he says. Dr Varney’s anticoagulant treatment was planned overnight and began in the cracks in the next day’s work schedule.

‘It has been a rollercoaster,’ Dr Varney says, reflecting on the last 12 months. ‘It alternates between being exhausting, overwhelming, humbling

and challenging. It has stretched me intellectually, physically and emotionally like nothing else. It has been an unrelenting series of demands with very little gratitude or acknowledgement.’

It is in these stark conditions that a whole profession has worked for the last 12 months.

Last moments Palliative care registrar Simon Tavabie was working in a hospice as the first wave of the pandemic hit – and in a busy London hospital during the ‘brutal’ second wave. Dr Tavabie trained in his specialty to give understanding to patients during their final moments – to find out what matters to them and their families.

But there is precious little time for understanding in this tsunami of tragedy.

‘A lot of the nuanced palliative care I am used to providing just isn’t possible,’ Dr Tavabie says. ‘Last week we had as many deaths as we would expect in at least a month if not two normally.’

Seeing patients with oxygen levels of 50 or 60 per cent – ‘not compatible with life’ – and trying to comfort families who cannot understand how their relative, awake and talking is likely to die in the coming hours, is a daily occurrence. Every 12-hour shift will live with these doctors ‘for a long time’, as Dr Tavabie says.

‘I think, when the dust settles, I am going to have a significant amount of emotions to have to deal with.’

Baptism of fire Facing this amount of death is perhaps even more troubling for those at the beginning of their careers.

Albert Koomson was a final year medical student when the pandemic hit. His final exams were cancelled and he and colleagues were asked whether they would volunteer in hospitals already being stretched

by COVID. Dr Koomson moved from his medical school back home to Essex and took up the call to arms. He was placed on a general surgery ward full of elderly COVID patients.

‘It will stick with me,’ says Dr Koomson. ‘It was quite overwhelming. Especially around Christmas time it was very noticeable that we were short on staff and

ED MOSS

Partha Kar Diabetes consultant ‘It’s been a steep learning curve learning about the new drugs, when to intervene, calling for help, when to escalate for ICU and a lot of work has been supporting junior doctors, some of whom have been really scared when dealing with really sick COVID patients.

It’s been fascinating to see the NHS spirit – we have dermatologists and rheumatologists and people who haven’t done general medicine for 20 years and are happy to pitch in and be a foundation year 1 or an F2 on the surgical and orthopaedic wards.’

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| Eleanor Deane/medical student/Sussex

| Christine Watson/critical care consultant/Nottingham

| Sarah Linford/critical care consultant/Nottingham

MS DEANE

DR WATSON

DR LINFORD

we were just getting an influx of patients every day.

‘They were very elderly, had lots of co-morbidities and there was a lot of signing do not attempt CPR forms and a lot of discussions with families, preparing them for what was to come.

I wasn’t really prepared to be that involved at such an early stage of my career, to be honest.’

Eleanor Deane, a final-year medical student in Sussex, who has volunteered for shifts in an intensive care unit, adds: ‘The main thing for me is that it is just one shift a week, whereas these nurses and doctors are doing those 12-hour shifts repeatedly, back-to-back. It must be such an emotional drain over and over again.’

There were 480 COVID-19 patients on the wards at an East Midlands teaching hospital in the final week of last month – higher numbers than at any point previously in the pandemic.

The sombre figures are accompanied by a note sent to staff from the medical director which reads: ‘We have already asked so much of you, but to get through this together, I’m afraid we need to ask more.’

The critical care units have reached 200 per cent of their normal capacity and yet more operations and treatments will need to be cancelled to enable staff to support the doctors and nurses working in intensive care and the other hospital wards now swamped with patients with this new virus.

‘We were getting an influx of patients every day’

Third wave

DR MANISTY

It may be easy for many to forget that behind these figures lie a place of work and care, in which critical care consultants Sarah Linford and Christine Watson, also deputy head of service for critical care, have been fighting to save the lives of deeply unwell patients for a year.

In this part of the country there have been more peaks than troughs. The influx of patients in January

CRITICAL CARE: Drs Watson (left) and Linford (right) outside Queen’s Medical Centre University Hospital, Nottingham

ED MOSS

Charlotte Manisty Academic cardiologist, volunteered in a London ICU and has been running an academic project looking at mild COVID among hospital staff ‘It’s the teamwork that has been particularly impressive – everyone has been trying their hardest and recognising that ITU teams have been doing an incredible job under alarming pressure and we all feel we have to do our bit. The NHS should be held up as an example of flexibility and teamwork and collaboration to try and cope in a pandemic situation but I think the under-resourcing of certain areas of the NHS has been highlighted.’

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DR POONI

| Jagtar Pooni/intensive care consultant/The Midlands

VARNEY: Continued working despite suspecting he had had a heart attack

represents a third wave of this pandemic – following huge admissions in October and November.

Dr Watson and Dr Linford have found great comfort in the resourcefulness and dedication of colleagues and the support from their employer, but the pandemic has been exhausting.

‘The difficulty is the length of time it has gone on for,’ Dr Watson says. ‘We see the sickest 10 to 15 per cent of the COVID workload. It’s a sense of relentlessness. Across the team, in essence, we have been running what amounts to more or less a major incident for almost a year with these numbers of patients. It has a massive knock-on impact for our health, sleep and wellbeing.’

For Dr Linford, one feeling overrides everything else – the sheer ‘relief’ at having, so far, not been forced to make decisions like choosing one patient’s care over another’s, as was a very present fear during the early days of the pandemic.

‘I would dread having to make those decisions,’ she says.

Dr Watson, as clinical lead, was among those in charge of drawing up the worst-case scenario plans in those frightening, uncertain, early days and marshalling resources to build a system which could cope with the coming avalanche.

In March scenes from Italian hospitals filled the news – with doctors speaking out about having to ration care to patients, temporary morgues being built, and hospitals absolutely overrun.

‘We talked about it,’ she says. ‘If we didn’t it would have been irresponsible. But we were very clear at the beginning – and thank god we’ve been able to achieve it – that we would take each case on its merit and offer ICU to every patient that would benefit from it. Having to make those decisions would have been anathema to us.’

Dr Watson and her team turned elective theatres into ICU capacity and worked out how to staff them.

Like everywhere else across the country that, ultimately, means an end to the one-to-one intensive care, one specialist nurse per patient, that is usually seen on these wards.

‘If we didn’t need these ratios, we wouldn’t have them,’ Dr Watson says. ‘The vast majority of intensive care is about that attention to detail. As soon as you start to derogate from that things fall through the cracks.’

The impact of this unprecedented year of pressure has been keenly felt. Dr Linford says: ‘There are always patients that impact you more than others – there have been times when I’ve woken up in the middle of the night thinking about patients before. But the scale of it with COVID has been so much bigger. We’ve never had this number of people in our beds. Inevitably you bring more of that home and it has a knock-on effect on family life.’

‘These are not the sorts of things you normally see in medicine’

‘Exhausted’ The Doctor has spoken to intensive care staff in regions across England and the scale of the effects this pandemic is having on the workforce is marked by how unanimously difficult experiences have been everywhere. Jagtar Pooni, an intensive care consultant in the West Midlands, speaks to The Doctor in short bursts broken by relentless calls from colleagues asking for help and advice.

‘They are exhausted and emotional,’ Dr Pooni says,

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| Richard Schilling/consultant cardiologist/London

| Malcolm Finlay/consultant cardiologist/London

| Abbie Brooks/GP/York

PROFESSOR SCHILLING

DR FINLAY

DR BROOKS

True picture These are experiences that Kevin Fong, a London anaesthetist, who was seconded as national clinical adviser to NHS England’s emergency preparedness resilience and response team for COVID-19, has been trying to feed in to senior leaders to close the gap between ‘data’ and the working lives of doctors facing this disease.

Professor Fong has spent time visting and working in intensive care units during their busiest period and taking part in road and helicopter transfers of COVID-19 patients to understand and feel the fear that the frontline staff feel.

‘You have to, in order to appreciate what it is that frontline people are doing,’ he says. ‘It’s such a big incident and it’s hard to capture in any meaningful way in numbers alone. It’s about making sure the people out there actually doing the job have some sort of representation in the information that is passed on and the decisions that are made.’

While there is little doubt Professor Fong’s work is crucial and has a positive effect for staff on the front line, he cannot help but feel some guilt about having been away from the ‘shop floor’ while friends and colleagues were finding life so tough during the first wave. ‘You can hear the struggle in their voices, and you see it when you go down and see it yourself,’ he says. bma.org.uk/thedoctor

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Julian Bion, freedom to speak up guardian at one of the West Midlands hospital trusts, told The Doctor that staff have faced numerous challenges during the pandemic – from the sheer pressure of demand, to facing difficulties communicating with patients through personal protective equipment, being unable to build supportive relationships with families, fearing taking the disease home to their families, and fears for their own health.

He says: ‘The physical demands are considerable but there are also multiple sources of moral distress made worse by lockdown preventing the usual forms of mutual comfort and support.’

Professor Bion, who has retired from frontline clinical practice, adds: ‘My experience is vicarious – through what I see in my colleagues’ eyes and hear in their voices when I go into the ICU. I see the weariness and the fact that at times people are close to tears.’

DR WONG

when asked about the staff he works alongside. ‘They see this as going on for longer and longer and the light at the end of the tunnel is much further away.’

In recent weeks patients have become younger and more unwell.

Dr Pooni says: ‘The mortality seems to be higher.

And in this surge there is a younger age group affected. Before we were looking at people aged 60-80 but there’s more in their 40s or 50s and some younger.

‘We look at them and think their health is relatively good, they are active individuals, they have families and jobs and fully participate in society. You look at them and think you are much closer to them in terms of age, health and personal circumstances. It does shock you.’

Danny Wong Anaesthetic registrar ‘I think there will be a lot of people who, because of the intensity of this, will have symptoms that could be similar to PTSD. People are being asked to do things that they haven’t had training for – especially some of the more junior doctors redeployed to ICUs who haven’t been on intensive care before let alone having to deal with a COVID ICU which is a completely different beast.

There is disempowerment and a feeling that you are meant to be in training but aren’t receiving that. I do worry it may make people leave.’

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| Farzana Hussein/GP/London

| Kevin Fong/ consultant anaesthetist/London

DR FONG

DR HUSSEIN

GETTY IMAGES

RANKIN

The professor of intensive care medicine at the University of Birmingham, adds: ‘The problem is the health service may very rapidly forget the emotional burdens of the pandemic on staff, and as soon as the numbers go down we will get told to get on with the waiting lists. This is understandable but there has got to be time for staff to decompress.’

In hospital wards across the country – not least intensive care wards – doctors from a wide variety of backgrounds, levels of experience and specialties have volunteered to fill shifts totally alien to their normal roles. For some it has been an eye-opening experience, for others it has been exhilarating, and for many, reflection on these long shifts has been marked by overwhelming sadness.

Filling nursing shifts

positive, energetic atmosphere.

‘But now these guys have been doing this constantly for a year and they are wiped out. I don’t know how they keep trudging to work and doing it.

It’s a real grind. From me personally there’s a feeling of exhaustion and just sadness really.’

Malcolm Finlay is a consultant cardiologist and has filled some of those 766 shifts Professor Schilling and his team organised.

He says: ‘I sat on the Tube coming back one morning – sitting opposite my clinical director who had been doing the same shift.

‘We both said we just really don’t want to go back.

It’s hard work, it’s emotionally draining – you look after a pregnant, 30-year-old who is ventilated and you just think “bloody hell”.

‘These are not the sorts of things you normally see in medicine – you might have one or two cases a year where you think “my god that is awful” but now you are in a ward and you see a chap down the way whose father, mother and brother all died in the same unit in the last four weeks.’

For Dr Finlay, as with many other people The Doctor has spoken to, there have been positives among the challenges, including the sense of ‘unity and purpose’, the sacrifices made by so many doctors to help out, the challenging of ‘snobbery and hierarchies’ and the insight into the work of intensive care nursing staff.

Dr Finlay describes those experiences as ‘humbling’ and ‘quite incredible’.

The impact on wellbeing and family life stretches beyond hospital wards and public health and across the profession. In general practice, doctors have undergone great change and strain – innovating virtual and telemedicine, managing massive cohorts of patients unable to be seen in hospital and continuing to bear the risk of seeing the most needy face-to-face.

York GP Abbie Brooks says: ‘As GPs we are holding more risk because patients aren’t going into hospital, they are being discharged early and these are our risks to carry.

‘At the moment I am really living on adrenaline’

In January, as a relentless storm of COVID infections and hospital admissions strangled London’s hospitals, consultant cardiologist Richard Schilling took on responsibility – along with a team of others – for arranging doctors to fill shifts taking on nursing duties. In the space of just two weeks 766 nursing shifts were filled – including by Professor Schilling himself.

‘I am used to being the top dog and very confident in what I do,’ Professor Schilling says. ‘You walk into an area where you can’t do anything that useful and you have to learn as quickly as you can. You can’t afford to be proud. It is a very humbling experience.’

The pandemic has been a period of great change for Professor Schilling, who was also one of the key figures in the establishment of the London Nightingale hospital.

Taking shifts on ICU has been more ‘exhausting’ than refreshing but equally valuable as London’s hospitals struggle under enormous pressure. ‘Working in this environment is brilliant because it self-selects people who are doers and went into medicine to help people and are willing to make sacrifices.’

He says: ‘The first wave it was all adrenaline and buzz – we all felt we were marching to war and understood what we were doing. It was an amazing, 12 thedoctor | February 2021

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Sacrifice and leadership BMA council chair Chaand Nagpaul says: ‘Doctors and other healthcare staff have made enormous sacrifices since the beginning of this pandemic. These past 12 months have stretched the emotional and physical well-being of my bma.org.uk/thedoctor

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PROFESSOR MCKEE

‘I was feeling like if my kids or husband got unwell, I was the person who brought it home. Even when we’ve been allowed to see people I’ve chosen not to because I don’t want to be that person. ‘ London GP Farzana Hussein agrees. She says: ‘At the moment I am really living on adrenaline. I am trying to look after two teenagers who have had A-levels and GCSEs cancelled. I have to say it feels like 12 years (rather than 12 months) – I have been working in the day and then in the evening.

We have had to learn about this new disease, how to protect staff and as a single-handed GP I’ve had to be on top of so many things. I haven’t stopped since March.’

The question on many lips is what will we be left with after this pandemic is eventually behind us.

It is a question regarding the economy and wider society – but not least the NHS and its exhausted workforce. The experiences of doctors on the front line are a recipe for PTSD and other mental health difficulties, burnout and an exodus to other countries or careers.

Professor Fong co-authored a study published last month which found that nearly half of ICU staff are likely to meet the threshold for PTSD, severe anxiety or problem drinking during the COVID-19 pandemic.

He says: ‘There is definite injury – our staff are definitely injured and injured to a degree which impairs their ability to deliver care. Our duty of care extends to our colleagues not just patients because looking after colleagues is looking after patients.’

Asked what should be done to deal with this injury, Professor Fong is unequivocal. The end of the pandemic must not mark an immediate move to tackling waiting lists and diverting staff from one crisis to another. ‘We need a huge programme of rest and recovery – if not reward too,’ he says.

‘I think the stress that the frontline workforce has been under is unlike anything – possibly unlike anything outside of war. We need to do some deep thinking because to get this wrong will be to risk further injury and to risk retention of staff. This has been horrific.

‘It is really important to understand this is not a question of looking after staff or looking after patients.

It is looking after staff so they can look after patients.’

Martin McKee Member of the Independent Sage group which aims to influence public discourse around the pandemic.

‘I don’t think I’d appreciated the volume of work that goes into it. We’re trying to inform public policy – I don’t think we should be so presumptuous to think we could influence it. Public policy in this country is particularly impermeable for the academic community. There is a very clear view in the Government that scientists advise and policy makers decide. There are a lot of things wrong in the academics/politics interface in the UK and that has been a problem for years – that doesn’t make our life easy. The UK is one of the most difficult to work in, in terms of getting evidence in policy.’ colleagues beyond comprehension.

‘Many of us will need time and space to reflect and recover when the worst of COVID-19 is behind us and it will be vital Government and NHS leaders show the leadership required to ensure this is possible. It will also be crucial that the sacrifices of staff are recognised with fair pay, better working conditions, more supportive, safer environments and, ultimately, that they return to normal work in an NHS which is properly funded and resourced.

‘The Government can no longer try to run our NHS on the goodwill of staff who have been asked to go above and beyond for far too long’.

Like many others, Dr Varney has been through so much over the last 12 months. The personal triumphs against adversity, the great challenge and the endless days, the abuse and the health scares.

The unrelenting nature of this ruthless pandemic has been met and matched only by the unrelenting dedication, care and compassion of doctors and other healthcare staff who have put themselves at the greatest risk while protecting the public and saving lives. bma.org.uk/covid-19 thedoctor | February 2021 13

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Long COVID – we’ve b Long COVID is a new condition, but those who have endured years of ME/CFS can share their common experience – and a long history of being misunderstood. Jennifer Trueland reports

W

MUIRHEAD: ‘I just kept thinking I had another virus, a flu or infection’

hen it was becoming clear that COVID-19 was a serious issue early last year, Nina Muirhead had a strong suspicion about what would happen next.

As a doctor who had developed ME/CFS following an attack of glandular fever four years ago, and in common with others in the scientific and ME patient community, she predicted that there would be a sub-set of people who, like her, would still be suffering months or even years after contracting the virus.

‘I wrote to Professor Whitty [England’s chief medical officer] and Sir Patrick Vallance [chief scientific officer] back in March saying there’s going to be a long COVID, and maybe there should be a health warning put out about this – maybe people should be advised of the long-term consequences, maybe we could do a study.

‘But they were so overwhelmed with fighting the big fire [acute COVID], and because ME is so misunderstood by the medical profession, they didn’t have the same end of the binoculars as I do. They didn’t see it coming in the same way.’

Nearly a year on, it’s becoming accepted that long COVID is a serious problem. The Office for National Statistics said in December that an estimated one in five people testing positive

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e been here before Charles Shepherd is a case in point. Now the medical adviser to the ME Association, he became ill while working as a junior doctor in Gloucestershire around five decades ago.

‘Like most people with ME or long COVID, I was a young adult in my early 30s never having had any medical problems at all. I got a very nasty dose of chickenpox from one of my patients who had shingles, and it had an encephalitic component to it.

Slow lane ‘Like many people with ME This almost flurry of research ‘Patients are looking at the research and long COVID, including into long COVID contrasts health professionals, I that’s going on in long COVID and with the experience of many went back to work far asking if this is a hope for them’ with ME/CFS, who often too early, didn’t have any have felt ignored or misunderstood by the medical convalescence or sensible recovery stage – I just profession. But for some, the interest in long COVID is kept going back to work, going off sick, going back to an opportunity to learn more about the longer-term work and so on. It took me two years before I got any consequences of viral infections – which could, in time, diagnosis or form of management.’ also benefit people with ME/CFS. David Strain, who is playing a leading role in the BMA’s COVID response, and who is researching long COVID as part of his job as a senior clinical lecturer at the University of Exeter Medical School, has witnessed this at first hand.

‘Prior to COVID, I was already working on chronic fatigue syndrome, and pre-COVID it was very, very STRAIN: Research into difficult to get anyone to take an interest in either CFS is now research, or data evaluation or to do studies into attracting more chronic fatigue syndrome, in the UK at least. I put grant attention applications in to do work into the underlying causes of CFS, pre-COVID, and they were commonly side-lined as low priority; now exactly the same grant applications are being funded.

‘Most of the patients in our CFS network are looking at the research that’s going on in long COVID and asking if this is a hope for them, because of the amount of political drive that’s going into it. Because [long COVID] has become a mainstream disease, does it mean that there is hope for them, assuming that their CFS or ME are similar, post-viral, debilitating illnesses?’

Certainly, there are strong similarities between the experiences of people with CFS/ME and long COVID. This includes doctors who have developed the conditions following work-related exposure. for COVID-19 exhibit symptoms for five weeks or longer, with one in 10 exhibiting symptoms for 12 weeks or longer.

Back in October, the NIHR published a dynamic themed review of evidence, which concluded that ‘ongoing COVID’ may be up to four syndromes, and that it can affect everyone, not just those who are hospitalised with the virus.

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\1 2\ 3\ 4\ 5

WEEKS

1 in 5 people

testing positive for COVID-19 exhibit symptoms for 5 weeks or longer

\1 2\ 3\ 4\ 5\ 6\ \7 8\ 9\ 10 \ 11 \12

WEEKS

1 in 10 people

testing positive for COVID-19 exhibit symptoms for 12 weeks or longer

SOURCE: Office for National Statistics

Physical v psychiatric

that was the solution.

ME was renamed and redefined as chronic fatigue ‘But now I think the clock has turned completely syndrome in the 1980s, says Dr Shepherd, and there the other way and we have now, I think, got general acceptance that we are dealing with a was an ‘intense’ medical debate about whether it was physical or psychiatric. medical problem.’

‘I suppose in simple terms that psychiatry won The ME Association has developed guidance and the day at that point, and convinced an awful lot of information resources for people with long COVID, and people that CBT [cognitive behavioural therapy] and has also been the port of call for people who simply graded exercise was the answer, because all that was don’t know where else to turn.

Dr Shepherd believes happening was that patients ‘I just kept going back to work, that the ME/CFS community were getting a viral infection, has a great deal to offer in they were getting abnormal going off sick, going back to work terms of how to manage long beliefs and behaviours and and so on’ COVID, partly because of its becoming deconditioned and long history of battling and campaigning, which has had some success. Graded exercise therapy is one example: the latest NICE guideline on ME/CFS has SHEPHERD: ‘I went back to work ‘finally got the message’ that this isn’t the answer, says far too early, didn’t have any convalescence’ Dr Shepherd.

‘People need a different approach to activity and energy management along the lines of what we’ve been promoting for years, which is basically pacing and just trying to live within your energy envelope.’

Amy Small, a GP in Lothian who has campaigned on long COVID after becoming ill herself, acknowledges that she has learned a lot about management of the condition from the experience of people with ME/CFS. ‘One of the first things I did when I realised that I wasn’t getting better was that I phoned a friend who has had severe ME for several years.

‘I asked her what would you want to know if you were me now, and you could see this coming – what would you do? She suggested pacing first and foremost – learn to pace properly. I had never really understood what pacing was – I thought it was to do what you’re doing, but do it more slowly.

‘But someone on Twitter recommended a book to me called Classic Pacing for a Better Life with ME and that was a real turning point for me.’

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SMALL: COVID has given her greater insight into treating ME/CFS

Brain fog

Unable to work, and unable even to fold a pair of Keeping a symptom diary and consulting a nutritionist socks before becoming exhausted, she eventually went have also been helpful – although Dr Small admits to her parents’ house for a few days to recuperate. that some of the advice would previously have been ‘I ended up staying there for five months, pretty much anathema to her as an evidence-focused medic. bedbound, being helped in and out of the bath, being ‘I think a lot of people with long COVID had found given tiny meals and being helped to eat; I could barely giving up sugar very helpful, and she’s got me on lift my fork at times. But I was really convalescing, a load of supplements. I said to my husband years sleeping 16 hours a day, so that turned things around ago that if he ever caught me taking turmeric for for me in terms of starting to enable my body to start medicinal purposes, then shoot me,’ she laughs. rebuilding itself.’

‘Boy did I live to regret that. I think my attitude Ms Muirhead’s symptoms included post-exertional has changed.’ malaise, extremely debilitating fatigue, total body pain, Almost a year into the pandemic, Ms Muirhead, cognitive dysfunction, headaches, nerve pain and a specialty doctor in dermatology surgery in tingling, and generalised weakness. She could barely Buckinghamshire, sees many parallels between walk and had to use a wheelchair. In other words, long COVID and her own symptoms that are being experience with ME. ‘Helped in and out of the bath, reported by those who have After contracting glandular what has come to be known being given tiny meals and being fever, she kept going back as long COVID. helped to eat’ to work despite remaining ill, Her employers have while also caring for her two young children, now aged been hugely supportive, she says, and have adapted her five and eight. work schedule to accommodate her needs – she ‘I just kept thinking I had another virus, a flu or has now built up to doing two days’ work per week, infection. I was really quite ill – coughing up blood clots although she actually does it over four days. at one point for 10 days – but I carried on working for But although her condition has improved, she is still months and months while really being debilitated.’ far from well, which only underlines calls for proper She first had glandular fever in September 2016, recognition and management of serious post-viral and by the following March, she was so weak that conditions. ‘So basically I’m long COVID four years on she could barely get to the car park after finishing an – this is what it looks like,’ she says. ‘I do feel for the operating list. people with long COVID. Brain fog meant that the simplest admin tasks ‘It’s horrible, and there are no easy answers. But we became an overwhelming challenge. Realising she was need to take this seriously because we’re only seeing unsafe to practise, she took time off work, then tried to the tip of the iceberg at the moment, and it’s going to return – and ended up taking time off again. get worse.’ bma.org.uk/thedoctor

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CHRIS ALLAN

Don’t forget us

FRONT LINE: Dr Helene Muller and nurse Buhle Nkomonde of MSF at a COVID testing and screening tent in South Africa

Wealthy countries have reserved billions of doses of COVID vaccines while the majority of patients in poorer nations have little chance of being protected this year. Seren Boyd reports on the worldwide push for vaccine fairness

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or hard-pressed governments running low on public confidence and good will, the urge to buy up vast stocks of COVID vaccines for their populations is understandable.

Mass vaccination offers a much-needed boost to national morale, especially as more infectious variants of the virus emerge.

Protecting one’s own is a clear political obligation – and being seen to do so is an easy way to score points in an increasingly politicised pandemic.

But wealthy countries hoarding vaccine doses is an ugly counter to appeals for

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international solidarity in a global health emergency.

International bodies such as the WHO (World Health Organization) have appealed to the ethical principle of health as a universal human right and called for equitable access to vaccines.

The WMA (World Medical Association) says it is vital that ‘no country should be left behind’. Its president, David Barbe, insists: ‘We’re not just a global economy: it’s a world society now.’

This is not just a lofty moral ideal, says Julian Sheather, BMA specialist adviser in ethics and human rights.

‘If you have several billion highly impoverished people with no access to a vaccine, you have an enormous reservoir of COVID doing its Darwinian thing and it may well come back in a form that sidesteps the vaccines,’ says Dr Sheather.

Or, as the BMA puts it in a recent submission to Parliament’s foreign affairs committee, ‘pathogens do not respect borders’. Vaccine access is important to global health security.

Moral failure It’s clear that ethicists’ ideals and market forces alone will not be enough to ensure COVID vaccines reach remote corners of war-torn Yemen or Syrian refugees.

The People’s Vaccine Alliance, a coalition of international charities, has predicted that at least 90 per cent of people in 67 low-income countries stand little chance of a COVID vaccine this year.

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reserved more than half (51 per cent) of the 5.96 billion vaccine courses which manufacturers of the 13 leading COVID vaccines are projected to produce this year, according to The BMJ. And they have the option to buy more. These nations represent just 14 per cent of the global population.

Such deals prompted WHO director general Tedros Adhanom Ghebreyesus to issue a stark warning at the WHO executive board meeting in January. The world, he said, was ‘on the brink of a catastrophic moral failure – and the price of this failure will be paid with lives and livelihoods in the world’s poorest countries’.

At that point in midJanuary, 39 million doses of COVID vaccine had been given across about 49 higher-income countries.

By contrast, only one lower-income nation had administered any vaccines at all. That was Guinea – where just 25 jabs had been given.

Osahon Enabulele, president of the Commonwealth Medical Association, argues that countries with underresourced healthcare

systems should have equitable access to vaccines, even if COVID case numbers are lower in such countries.

At the start of the pandemic, the Central African Republic had just three ventilators to serve the entire country, according to the International Rescue Committee; South Sudan had four. In Nigeria, where Dr Enabulele is based, healthcare workers only started receiving significant supplies of PPE (personal protective equipment) after a strike by resident junior doctors in June.

At the time of writing, COVID cases were rising again in Nigeria, the most populous African nation. ‘Public health information dissemination and risk communication mechanisms remain poor,’ says Dr Enabulele. ‘Few people are wearing masks and a lot more seem to doubt the reality of COVID-19.

‘Access to COVID-19 vaccines has nothing to do with the case numbers: it has everything to do with providing equitable access to vaccines and delivering quality care to every citizen of the world,’ Dr Enabulele says. ‘And, of course, with

ENABULELE: Pressing for equitable access to vaccines

‘The price of this failure will be paid with lives and livelihoods in the world’s poorest countries’

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MACK ALIX MUSHITSI/MEDECINS SANS FRONTIERES

globalisation, even small numbers can infect the entire global community.’

Urged to share One expression of a more equitable, internationalist approach to vaccine allocation is the COVAX Facility.

Co-led by Gavi (the Vaccine Alliance), CEPI (the Coalition for Epidemic Preparedness Innovations) and WHO, it enables countries to pool their buying power and negotiate prices collectively.

Crucially, rich countries involved agree to help finance access for the 92 lowerincome countries who have signed up, through a so-called AMC (advanced market commitment).

At the time of writing, COVAX had signed deals to secure 1.3 billion doses (or 650 million vaccine courses) for these 92 nations. Its aim is to immunise one billion people with two billion doses – achieving ‘up to 20 per cent population coverage by the end of the year’ across all 190 countries taking part in COVAX. Here, the UK has shown global leadership. It has helped to raise US$1bn for the COVAX AMC, through match-funding other donors, in addition to pledging £548m in UK aid. ‘More high-income countries must be encouraged to do the same,’ says Arthy Hartwell, BMA head of international and immigration.

But even generous contributors to COVAX, including the UK, have signed ‘side deals’ with pharmaceutical firms, raising concerns about reduced availability of

vaccine for the shared pot.

Last month, WHO director general Dr Tedros urged them to share their own doses with COVAX to ensure that health workers and older people in lower-income countries took precedence in the vaccine queue over younger people in higher-income nations.

People not profit Likewise, countries have also been urged to surrender vaccine stockpiles for COVAX’s ‘humanitarian buffer’, a reservoir of vaccine doses set aside for communities such as refugees. Canada has secured more than four doses per head of population.

Ms Hartwell says: ‘At the World Health Assembly last May, we applauded the commitment of global leaders to recognise COVID products, including vaccines, as global public goods, but since then we’ve witnessed an insidious rise in vaccine nationalism and selfinterest. We must remember we are only as strong as

our weakest.’

Extraordinary times demand extraordinary measures. Many believe that more should be done to ensure that vaccines should be for ‘people not profit’.

Big pharma too should play its part in ensuring global access, instead of prioritising deals and regulatory approval in countries which can afford to pay.

The BMA is concerned about pharmaceuticals retaining exclusive intellectual property rights over scientific breakthroughs funded by public money. By December, AstraZeneca-Oxford, Moderna and Pfizer-BioNTech alone had received more than £3.79bn of public funding to develop their vaccines, according to People’s Vaccine Alliance estimates.

Some vaccine developers have moved to assuage concerns with the potential for profiteering.

AstraZeneca’s partnership with the Serum Institute of India to manufacture vaccine doses is a promising

SPOT ON: MSF staff check temperatures in Zinder, Niger

‘We’ve witnessed an insidious rise in vaccine nationalism and self-interest’

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debated include whether a vaccine’s approval by the regulatory authority in one nation could suffice for countries with similar standards. Russia and China’s vaccine rollout last year under ‘emergency use authorisation’ – without data from phase 3 clinical trials – caused widespread criticism.

WMA

example of collaboration.

Likewise, AstraZeneca/ Oxford University has pledged to distribute 64 per cent of their vaccine in developing nations and has committed to providing vaccines to them at cost ‘in perpetuity’.

However, its ‘no-profit’ pledge does not extend beyond the pandemic for higher-income countries.

Civil society organisations have called for greater transparency over the terms of the supplyand-manufacture deals pharmaceutical firms are making, and over vaccine development and clinical trial costs.

Such information is vital if purchasers are to be able to demand fair prices in the longer term, says MSF (Médecins sans Frontières).

Current vaccine prices vary wildly, from £4.40 to £54.50 per course.

Dr Sheather of the BMA argues for a less squeamish approach to pharmaceutical firms’ profits. Investing even billions of pounds of public funding in vaccine development to end a pandemic which cost the global economy an estimated £5tn last year makes good financial sense, he argues.

‘In my view, we need to look at ways in which we can accept that big pharma will get a reasonable return on its investment but, if they’re taking public funds, they must make commitments to enabling access to much less expensive vaccines in the global south as a consequence of their freedom to sell it in highly resourced markets.’

Other issues being hotly

Distribution issues Securing vaccines on home soil is far from the end of the story.

In Nigeria, Dr Enabulele says, areas beset by militant and extremist violence are virtually ‘cut off from public health interventions’: healthcare workers have been attacked, even killed, during the pandemic.

A lack of power infrastructure and appropriate cold-chain storage facilities makes distribution of mRNA vaccines such as the Pfizer/ BioNTech one hugely problematic. Vaccine hesitancy, a global health threat, is a significant issue in Nigeria too.

Yet, Dr Enabulele is determinedly optimistic.

COVID, he says, presents an opportunity that his country must seize.

‘Before COVID-19, people in political office would travel abroad for their care needs,’ he says. ‘But when international borders got closed as a result of the pandemic, they had no choice but to use local health facilities.

‘So, COVID-19 has engendered some greater political commitment to health. If we can maintain this momentum and disposition,

I’m optimistic we can overcome COVID-19 and other healthcare challenges.’

Dr Barbe of the WMA predicts that some lowerincome nations may require support from NGOs such as national Red Cross and Red Crescent societies. Countries at the vanguard of vaccine roll-out must share their learning on how models and strategies are having to be adapted on the ground, says Ms Hartwell.

Above all, Dr Barbe insists, a truly global response requires that every nation on the planet has a plan for effective vaccine distribution – and for the future.

‘Some countries have had sort of a national plan on paper, that just sits on the shelf gathering dust,’ says Dr Barbe.

‘That is not a plan. It has to be living and breathing, updated, rehearsed and adequately funded with the necessary infrastructure in place: that’s how we stay ready.

‘We cannot be caught flat-footed again. This is not the first pandemic; it won’t be the last.ming together is the only way we can address this effectively and rebuild global health security.’

BARBE: ‘We are not just a global economy: it’s a world society now’

‘This is not the first pandemic; it won’t be the last’

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GETTY IMAGES

The fight back begins As millions receive their COVID vaccines, GPs tell Tim Tonkin about patients’ sense of joy and relief, and how maintaining a good supply will now be vital

‘That warm glow of feeling like you are contributing to moving towards an end point in this pandemic’

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t is roughly one year since the COVID-19 pandemic upended everyday life and began exacting its terrible toll on lives and communities throughout the UK. For the majority of 2020, doctors and other healthcare staff battled valiantly to check the spread of a contagious and poorly understood virus, one for which there was no standardised or proven treatment.

The sense of relief and hope that greeted the arrival of the first vaccine, approved and licensed for use in the UK in the autumn of 2020, was perhaps even greater for the exhausted ranks of the medical profession than for the rest of the country.

Beginning in earnest in December, the roll out of the Pfizer BioNTech and Oxford/ AstraZeneca vaccines has finally provided the health service with the means of preventing infection and ultimately bringing an end to the pandemic.

With more than 3.5 million people reported to have received their first vaccine doses by 16 January, there is growing confidence among

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HODES: ‘Patients haven’t been out of their houses for months on end’

A partner at the city’s Park View Surgery, she and her colleagues have since 21 December been administering doses of vaccine at a central hub and through visits to care homes, an effort organised by the Nimbus PCN. ‘Outside of the hub there is sometimes frustration from relatives or patients that they have not yet been invited for vaccination, but you don’t feel any of that on the ground,’ Dr Brooks says.

‘You just feel that warm glow of feeling like you are contributing to moving towards an end point in this pandemic.’

many doctors that the tide can be turned Supply problems against COVID-19, provided this rate continues Many aspects of the response to the to grow. pandemic have been administered by the ‘It’s been incredibly emotional and very private sector, with the likes of Deloitte motivating,’ says Watford GP Simon Hodes. entrusted with managing drive-in COVID ‘The patients are unbelievably grateful and testing centres and Serco being involved in the atmosphere in the clinic is almost like a the contact-tracing programme. carnival. A lot of these patients haven’t been out By contrast, the COVID-19 vaccination of their houses for months on end, they’re frail programme was in large part entrusted to and elderly and have not seen general practice as part of an ‘The patients are unbelievably grateful enhanced service agreement their children or grandchildren for long periods of time.’ between NHS England and and the atmosphere in the clinic is Improvement and GPs. almost like a carnival’ Service as usual While the roll out has so Dr Hodes is a partner at the Bridgewater far seen a slow but steady rate of progress practice, whose premises are being used for in increasing the numbers of those being the vaccinations, the process for which is being vaccinated against the virus, challenges and overseen and implemented by the Grand Union difficulties remain.

PCN (Primary Care Network) of which the There is still contention with the practice is part.

He says his practice made a concerted effort to continue to provide normal services while conducting the vaccination programme by working overtime and bringing in volunteers.

‘We did not want to jeopardise normal services,’ he says.

‘All the problems we had seen earlier on in the pandemic of people complaining about not being able to access their GP ... in our minds to cancel any other services, routine or acute, to prioritise the programme didn’t feel right.

‘I think when you’re a GP for a long period of time, a lot of these patients become friends.

It’s more than just a transactional medical relationship, you become part of patients’ lives and vice versa.’

This mutual sense of joy and relief with the BROOKS: arrival of a vaccine is something York GP Abbie Vaccinating as Brooks understands too. safely as possible bma.org.uk/thedoctor

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JABS: Drs Hodes (left) and Brooks (below) administer COVID-19 vaccines

following vaccination.

‘It’s been an incredible amount of work just organising the logistics around the Pfizer vaccine because it’s so time-pressured when it arrives at the practice,’ says Dr Hodes.

‘It’s a new process for us. Normally, the vaccines we get are just ready-made in a syringe with a needle on the end, you get them out of the fridge, pop them in someone’s arm and off they go.’

Safety first By contrast, while supply of the vaccines has become more consistent from Dr Brooks’s point of view, providing the vaccine to so many patients while accommodating other health needs and meeting the Government’s decision to increase the wait safety requirements, remains a challenge. time between initial and booster doses of the ‘The challenge there is just doing it as vaccine from three to 12 weeks, while issues safely as possible,’ she says. around ensuring consistent supply of the ‘In the first round we would go in to do a vaccines to practices and hubs also remain. whole home, but if there are new residents Dr Hodes says ordering vaccines took place joining then you keep having to go in to through an online portal and it was often “mop up” as it were which is a challenge. something of a lottery as to whether you ‘Every time you go into a home you have to would receive the vaccines, which type they have a negative lateral flow result, take your would be and when they would arrive. own PPE [personal protective equipment] and ‘Deliveries are extremely consent forms. sporadic and unreliable,’ says ‘While care homes are the right thing to ‘While care homes are Dr Hodes. prioritise, it is a lot of work to continue absolutely the right thing to ‘We went to get a delivery prioritise, it is a lot of work to keep them vaccinated’ of the Pfizer vaccine last to continue to keep those Wednesday [13 January], only to receive an homes vaccinated.’ email at 4.30pm on the Tuesday to tell us it At the time of interview, Dr Brooks’ wasn’t coming, meaning we had to frantically practice had already vaccinated the majority phone around to cancel with patients. of over 80s.

‘It’s not unique to our practice and has She says of this group: ‘It’s a huge number happened a lot around the country.’ of patients and frailty and mobility issues Dr Hodes also expresses frustration with mean that you have to ensure there are the decision to open mass vaccination wheelchairs and people to assist at the centres, something he said has resulted [vaccination] hub. These patients have in some patients receiving conflicting multiple co-morbidities, so observation is key. notifications as to where they should attend ‘When we start to move down the age to receive the vaccine, with this confusion groups, I think things will start to move a creating extra administrative burdens for GPs. bit faster.’

Added to this, and problems with supplies, The Government’s Joint Committee are the challenges presented by storing and on Vaccination and Immunisation has administering the Pfizer vaccine which has to stated it aims to ensure every adult in the be reconstituted before use, has a relatively UK aged over 18 has received at least a first short shelf-life and requires patients who dose of a COVID vaccine before the end of receive it to be observed for 15 minutes this year.

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Voice of unity In response to racial inequalities highlighted further by COVID-19, the BMA has established a forum for BAME medics to come together and be heard. Seren Boyd reports

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fitness to practise proceedings, for example. Care Quality Commission inspections are more likely to rate as ‘inadequate’ GP practices with BAME partners.

The BAME forum, Dr Nagpaul said, was a response to ‘calls from the grassroots’ – and should remain a ‘forum for the grassroots’. Its success would be judged on whether it made a ‘palpable difference’ to members’ experiences in the workplace.

Structural racism

LAWRENCE: Disease highlighted structural racism

Making BAME voices heard has been a strong motivation for Baroness Doreen Lawrence.

Speaking at its launch, she applauded this ambition for the forum.

Her report into COVID’s effect on the BAME community, An Avoidable Crisis, was highly critical of the Government including for the lack of proper personal protective equipment for frontline workers. Her recommendations remain unanswered.

More than 90 per cent of doctors who died in the pandemic’s first wave were from a BAME background.

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tructural inequalities and racial discrimination have persisted for generations as BAME (black, Asian and minority ethnic) doctors know full well.

But COVID’s disproportionate toll on the BAME community has proved a powerful catalyst for change – including at the BMA. It has just launched a national BAME member forum, supported by regional networks. The aim is to ‘unify and amplify the voices’ of BAME medics, who represent about 40 per cent of NHS doctors, so the BMA can better advocate for their interests.

Speaking at the recent BAME forum launch, BMA council chair Chaand Nagpaul described it as ‘a defining moment’.

The organisation has a long history of campaigning for race equality and has worked hard to protect and support BAME doctors during COVID. ‘But there’s so much more to do,’ said Dr Nagpaul.

Inequalities persist in treatment, experiences, and opportunities for development for BAME doctors. The harmful effects of this are made clear by the evidence showing differential attainment in everything from exams to career progression and pay.

BAME doctors are two-anda-half times more likely to be referred by employers for

ATEWOLOGUN: Solidarity and support key to ending isolation

‘Most of the challenges and distress that people were experiencing were not just from the pandemic but because of the structural racism that had existed for generations, which the disease has highlighted,’ said Baroness Lawrence.

Other speakers at the launch included Doyin Atewologun and Roger Kline, authors of Fair to Refer?, a GMC review of disproportionate referrals for disciplinary processes.

Their recommendations – including support for doctors in more solitary roles – would be a good starting point for regional network discussions and advocacy, Dr Atewologun suggested.

Latifa Patel, deputy chair of the BMA representative body, said the forum was proof the BMA was ‘proactively changing’ on issues such as BAME representation. ‘“No decision about us without us”, that remains our mantra,’ said Dr Patel.

A film about the BMA’s work on racial equality and details of how to get involved in the BAME forum can be found at bma.org.uk. For non-BAME members, the BMA offers allyship training, which builds understanding of the situation of those facing discrimination thedoctor | February 2021 25

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UNDER PRESSURE: The Royal Alexandra Hospital in Paisley, to which the Press Association was recently given access. Some staff spoke of their exhaustion and the intensely demanding work

The moral cost There is a profound disconnect between doctors’ values and the decisions they are forced to make in a health service wracked by unsustainable pressures.

Seren Boyd examines the effects

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t’s that uneasy sense of compromise, all the rationing and painful prioritising, the gnawing guilt that you’re not doing a ‘proper job’ despite your best efforts and long hours.

It’s being assigned three patients when you should have one, making urgent referrals that leave patients suspended in limbo, facing impossible ethical choices alone at 3am.

Increasingly, it’s being given a name: moral distress.

This disconnect between doctors’ core moral and professional values and the decisions and actions they are forced to take is nothing new.

For more than 10 years now, the lack of time, resources and support has been taking its toll. But COVID has exacerbated systemic pressures and weaknesses, says Helen Fidler, deputy chair of the BMA

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consultants committee.

‘What drives us to carry on working is the reward of getting the best outcome for a patient,’ says Dr Fidler. ‘The stress of the job, the onerous responsibility, is offset by this feeling that you’re helping. But if the feeling that you’re helping is taken away, you’re destroying the very kernel of why people go into medicine. Instead, we have a continual feeling that we’re letting our patients down.’

work all those unpaid hours. When you can’t meet that responsibility, it’s upsetting – and really damaging.’

These are problems that Southampton GP Alex Freeman feels acutely too. ‘We are having to manage so much more in the community so we’re seeing people that we know we can’t help,’ says Dr Freeman, a BMA council member.

‘We refer when we’re running out of options ... and then there’s this long wait. A lot of the time all you can do is listen.’

That sense of powerlessness is compounded by many other factors.

Sense of failure What moral distress looks like is different for everyone, and different every day.

For a consultant gastroenterologist such as Dr Fidler, having to assess people on the phone owing to COVID restrictions can be deeply frustrating. Hearing the distress of someone who doesn’t speak English and who is trying to explain symptoms in their own language is painful enough.

Suspecting a patient may have cancer and making a referral that you know may condemn them to an indefinite wait is ‘almost torturous’.

‘At the end of the conversation, you just feel a sense of failure, and the patients are often distressed and crying on the phone,’ says Dr Fidler.

‘And what can you say? It’s just awful for them, and you can’t even be a safe haven for them. You’re apologising for something that’s outside your control and that’s demoralising.

‘From the moment you see a patient and make a plan, you have an inbuilt instinctive responsibility for them and for getting the best possible outcome for them, almost like a contract. There’s an emotional bond too because we’re human. That’s what drives us to

FREEMAN: ‘You feel like you’re not good enough’

MATT SAYWELL

FIDLER: ‘You’re apologising for something that’s outside of your control’

Dr Freeman mentions patients’ distress, unfair criticism of GPs in the media, the guilt felt by doctors having to shield because of their own medical conditions, even the moral outrage provoked by seeing people in public choosing not to wear a mask.

COVID itself has put additional strains on the doctor-patient relationship, particularly in the absence of proper personal protective equipment.

‘It’s a horrible dilemma: am I putting myself at risk by bringing a patient in or am I putting that patient at risk by not seeing them in person?’ says Dr Freeman.

‘All doctors have this huge moral imperative to do their best for their patients and if that care is in any way compromised, either because of the system or the risks, you feel like you’re not good enough.’

Struggling alone Not long before the pandemic’s second wave engulfed ICUs (intensive care units), Southampton consultant in intensive care bma.org.uk/thedoctor

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‘There’s been times when my entire focus medicine Chris Danbury gave a vivid analysis has been: Can I get through today? People’s of the ethical dilemmas regularly facing first priority has to be themselves, even critical care consultants such as him. He though that cuts across everything that they was speaking at the BMA online conference, stand for.’

‘Justice, fairness and medical ethics seen through the lens of COVID-19’.

He described in detail the complex Sharing, not shaming considerations involved in deciding which Addressing systemic failures is a longer work patients to admit to ICUs operating at full that must extend far beyond the pandemic. capacity – and the loneliness of that process.

Dr Fidler’s wish-list is extensive: an end ‘At 3 o’clock in the morning, who do I to the culture of blame, the threat of legal have to help me make my decision?’ asked action, honesty on the part of politicians Dr Danbury. ‘I will have a site manager and I and the Department of Health about the real will have probably a member of the executive pressures upon the NHS, to manage patients’ board who is on call and unused to being expectations. woken at 3am to help with decisions. I don’t Then there’s proper funding for an NHS have an ethics committee.’

Long-Term Plan ‘backing the workforce’, Recognising the pressure on doctors money directed into public health not privateshouldering the ‘moral burden’ of such highsector providers, health policy informed by stakes decisions, the BMA frontline workers…

‘Over the years I’ve seen so many devised an ‘Ethics guidance But there are simpler, note’ on prioritisation smaller, older ideas too: people impacted by the system that in response to COVID. sharing forums such as lacks basic humanity’ Government attempts last Schwartz Rounds (and year to provide national guidance or a ‘triage ringfenced, prioritised time to ensure doctors tool’ to ensure consistent decision-making can attend) or communal spaces where they ended in failure. can rest, offload and share.

Isolation, whether perceived or actual, Naming the problem is an important place to start, says Dr Fidler. is dangerous, says Dr Freeman. The risk is ‘When I’ve spoken of moral injury recently, that doctors internalise these pressures I’ve seen people start to cry. That disconnect and become mired in self-criticism. That’s we’re all feeling, the responsibility you put when moral distress can harden into moral on yourself but can’t meet, it’s not talked injury, which can lead to burnout and about. Nobody dare say anything about it. psychological trauma.

It’s really important to name this awful sense Losing talent of crippling guilt, and recognise that other Mounting anecdotal evidence, including BMA people feel the same way.’

COVID tracker surveys, links these factors to high rates of early retirement, the crisis of The BMA is surveying doctors on moral staff retention – and worse. injury. The data gathered will be used Dr Freeman chairs the Louise Tebboth to inform its next submission to the Foundation, a charity supporting doctors’ Review Body on Doctors’ and Dentists’ wellbeing and the families of doctors who Remuneration and its work on issues have died by suicide. such as NHS funding, workforce retention It’s important to be clear on causality, she and regulations says: the system is at fault, not the individual.

‘Over the years I’ve seen so many people Confidential 24/7 counselling and peer impacted by a system that lacks basic support services open to all doctors and humanity,’ says Dr Freeman. medical students (regardless of BMA ‘But somehow, things tend to be turned membership), plus their partners and around to imply there’s something wrong dependents, is available on 0330 123 1245 with them, that they somehow lack resilience.

The only thing wrong with them is that they Visit bma.org.uk/advice-and-support/ happened to be human. your-wellbeing 28 thedoctor | February 2021

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

A doctor stood to lose thousands of pounds owing to the interpretation of a few words in her terms and conditions

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single word or phrase can sometimes be at the centre of a legal or contractual dispute. For one doctor, a £10,000 pay cut was at stake.

The doctor was switching from her previous specialty to general practice, and because the latter is officially ‘hard to fill’, she qualified for pay protection, but there was an important condition.

The 2016 junior doctor contract states: ‘Where a doctor opts to switch into a hard-to-fill specialty having achieved an Outcome 1, Outcome 2, or Outcome 6, in their most recent ARCP, and would have otherwise progressed to the next grade had they not switched specialty, their pay-protected amount will be based on the basic salary for the grade they would otherwise be at had they not switched.’

To explain to anyone who isn’t or hasn’t recently been a junior doctor, the ARCP is the annual review of competence progression undertaken by trainees.

At the time of applying for GP training, the doctor’s most recent ARCP, for the specialty trainee 2 year in her previous specialty, was an outcome 1, which signifies satisfactory progress, with the development of competences at the expected rate.

But then a problem arose. Having accepted a GP training post, she handed in her notice, and it was during this period that she received another ARCP outcome, for her ST3, and this time it was a 3 – defined as ‘inadequate progress by the trainee – additional training time required’.

Her new employer said this meant she did not qualify for pay protection.

This would have been a severe blow – a pay cut of more than £10,000, down to ST1 level, and a huge disincentive to fill a specialty that needs all the doctors it can get.

However, let’s go back to that wording. It refers to ‘where a doctor opts to switch…’. At the time of ‘opting to switch’ – making her application, it being accepted, her giving in her notice – the most recent outcome had been 1.

It was surely that ARCP, rather than the more recent one, which applied.

The doctor was not succeeding with her arguments, so she asked the BMA for help. An employment adviser had a number of emails and phone calls with the trust. The trust was turning to NHS Employers for advice, but the employment adviser could refer back to the BMA’s policy directorate, which has detailed knowledge of NHS contracts.

The adviser says: ‘In the end, they accepted our position on this and offered the pay protection. It was a case of being persistent with our position and trying to persuade the employer that our interpretation of the provision was correct.’

The member said she was relieved, and the BMA employment adviser was supportive, helpful, and professional.

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Your BMA BMA representative body chair Helena McKeown and her deputy Latifa Patel set out how they take action for members – and the success following their debut column

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fter our first column was published last month a junior doctor working in a hospital contacted us to ask for help.

His trust has shut down the juniors’ mess – leaving junior doctors with nowhere to go apart from busy hospital wards, feeling like they are being punished despite working beyond the call of duty during the pandemic and increasingly worried about their wellbeing.

We contacted his regional junior doctors committee chair who has spoken to the junior doctor local negotiating committee rep at the trust and the BMA’s industrial relations officer, and negotiations on reopening the mess are now taking place.

Last month, we asked you to tell us about the issues that matter to you so we could look to represent you to the very best of our abilities – and this sort of case is exactly why we need to hear from you. Please come to us – we will listen and we will either help you ourselves or find the right people to assist you if we can’t.

The BMA has around 160,000 members and more than 535 permanent staff. Wherever you are, from a large teaching hospital to a small, rural GP surgery, we will have someone who knows the issues in your area, who understands the needs of doctors working in your specialty and who can help.

And we aren’t just here to listen, we are here to take action. We have the expertise and the influence to force change. We have heard stories across the country about similar issues. Doctors are reporting the closure of their messes and the removal of much-needed and deserved benefits given during the first wave of the pandemic such as free parking, refreshments and additional wellbeing and rest facilities.

This is not acceptable.

In 2018 the BMA published the fatigue and facilities charter. It was adopted by trusts and came with £10m of funds shared out between hospitals to provide proper rest facilities. The charter places a responsibility on hospital trusts to provide appropriate rest areas 24 hours a day and seven days a week allowing staff to nap during breaks. We are deeply concerned – and will take action – where trusts have adopted this charter and received these

funds but closed their hospital’s doctors’ mess.

The reality is that these issues are even more important now than ever before – with the COVID-19 pandemic stretching staff and services across the country. Doctors across the profession are working under unprecedented pressure and putting themselves at the greatest risk to protect the public.

The BMA’s most recent tracker survey – contributed to by thousands of doctors – highlights the effects these working conditions are having. It reveals that 88 per cent of doctors feel uneasy about not being able to provide the standard of care they would like during the pandemic and more than half feel anxious about being unable to see and treat patients in appropriate times.

The survey also shows that 46 per cent of respondents are suffering from depression, anxiety, stress, burnout, emotional distress or another mental health condition relating to work or study made worse by the pandemic.

It also found that 32 per cent of doctors’ health and wellbeing was even worse than during the first wave of the pandemic and that 62 per cent are living with a level of fatigue or exhaustion higher than before the pandemic.

These are stark statistics but they’re also daily realities for doctors working on the front line of this pandemic. Our colleagues are more at risk of burnout than ever before and the harsh truth is that these working conditions make caring for patients much harder and mistakes more likely. These working conditions leave doctors at risk of burning out and unable to work. These conditions represent a real risk of a worsened future crisis in retention of staff.

It is even more important now than ever that employers and trusts provide the facilities they are obliged to and, beyond that, treat staff with the support, care and compassion they expect to be given to patients.

As we said in our first column, last month, we want to know the issues that matter to you – whether that means worries about rest facilities and the working environment or anything else – so we can represent you to the very best of our abilities. Please get in touch.

Contact us at rbchair@bma.org.uk

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it happened to me

SARAH TURTON

Returning to a very different general practice

Doctors’ experiences in their working lives

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t was with some trepidation that I returned to general practice after a year’s maternity leave, especially as I was re-entering the workforce during a pandemic. It was immediately obvious that everything had changed during my absence: a paradigm shift to remote consulting, all non-urgent referrals stalled, and most patients reluctant to leave the house.

Before restarting my own clinics, I watched other doctors, who had worked through the pandemic, negotiating clinical risks and patient expectations, almost exclusively remotely. When it came to my first surgery, it felt completely foreign to be working solely on the telephone. I brought far more patients in for review than my colleagues; I wanted to be able to lay a hand on an abdomen and see a crying child in the flesh.

While telephone consultations add more flexibility for patients and clinicians, the pandemic has taken away the precious human foundations of the doctor-patient relationship. Through sharpened yet tired eyes, the doctors who have worked relentlessly during the pandemic have grown accustomed to the new normal and new risks, whereas I found the balance of individual risk versus the wider risk of coronavirus hard to reconcile. Many decisions on a government and public health level during this pandemic have been based on the risk to the population, but when talking to a patient this can be hard to translate.

Starting at a new surgery has been challenging; the lack of pre-established relationships with patients, combined with remote consultations, makes developing the doctor-patient relationship difficult. Patients are just a name on a screen, and I cannot get an idea of what really might be going on behind the scenes, or observe them struggle to walk down the corridor, or bring their shopping bags, friends or family with them. No consultation is untouched by the pandemic and the collective toll on the nation’s mental health is yet to be seen; I have lost count of the number of ‘not fit for work’ notes I have completed.

Trying to get to know a new workplace and team, while everyone is wearing a mask and maintaining social distance, made me realise how much I took for granted team meetings around a table, the chat over making a cup of tea, and popping into each other’s rooms to discuss patients. A fluctuating workforce, owing to members of the team self-isolating, makes it even harder to get familiarised.

With rising vaccine numbers, and falling cases, there is a glimmer of hope on the horizon.

It is important to try to remember the things which keep us positive; hopefully it won’t be too long until we see more of each other face to face.

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A L FA S A A D U AMGED EL-HAWRANI A D I L E L TAYA R HABIB ZAIDI J I T E N D R A R AT H O D MOHAMED SAMI MAHMOOD SHOUSHA E R W I N S PA N N A G L ANTON SEBASTIANPILLAI ABDUL CHOWDHURY FAYA Z AYA C H E SYED ZISHAN HAIDER PETER KHIN TUN EDMOND ADEDEJI KAMLESH KUMAR MASSON K R I S H A N G O PA L A R O R A M A N J E E T S I N G H R I YAT SADEQ ELHOWSH M E D H AT S O B H Y ATA L L A SHREE VISHNA RASIAH Y U S U F PAT E L NASIR KHAN FURQAN ALI SIDDIQUI CRAIG WAKEHAM TA R I Q S H A F I K A R A M AT U L L A H M I R Z A SAAD AL-DUBBAISI POORNIMA NAIR T H A U N G H TA I K ABDEL WAHAB BABIKER ABDORREZA SEDGHI M O H I N D E R S I N G H D H AT T MAMOONA RANA A U S T I N FA I S O N G U N D A R U D R E S H K U M A R D I N A N AT H PAT H A K D AV I D G E O R G E E D W I N W O O D HABIBHAI BABU PA U L K A B A S E L E KRISHNAN SUBRAMANIAN MARTIN MANSELL THOMAS OELMANN DONAL O’DONOGHUE ANTHONY GERSCHLICK AUGUSTINE OBARO ABDUL-RAZAQ ABDULLAH M A L I N D A D I S S A N AYA K E

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