The Doctor, April 2021, issue 30

The magazine for BMA members

thedoctor

Issue 30 | April 2021

Sharing the joys Parenting, pay, and the need for equality Test and Trace

What went wrong, and how it could be better

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SAS doctors

New contracts promise better recognition

Vaccinations GPs reassure reluctant patients

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thedoctor

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

Email thedoctor@bma.org.uk

Editor Neil Hallows (020) 7383 6321

Call a BMA adviser

Chief sub-editor Chris Patterson (020) 7383 6978

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 £170 (UK) or £240 (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.

The Doctor is a supplement of BMJ vol: 373 issue 8287

Senior staff writer Peter Blackburn (020) 7874 7398 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 Cover Ed Moss Read more from The Doctor online at bma.org.uk/thedoctor

ISSN 2631-6412

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In this issue 4-5

Briefing

A new campaign for fairness, after years of shrinking pay

Welcome Chaand Nagpaul, BMA council chair Doctors have done remarkable work during this pandemic.

In this issue of The Doctor alone, we tell the stories of public health leaders taking test, trace and isolate schemes into their own hands to protect their communities and GPs phoning vulnerable patients to encourage them to take the COVID-19 vaccination.

These are not isolated cases. Across health systems doctors and other healthcare staff have changed working patterns and roles, broken down organisational and hierarchical boundaries and upheld remarkable levels of patient care in trying circumstances.

It is crucial, now more than ever, that the dedication, compassion and goodwill shown by staff in responding to this pandemic – having already spent their careers in an under-resourced and creaking NHS – is not taken for granted. There could be no more vital moment, after the unimaginable stress and strain of these last 13 months, for the terms and conditions of doctors to be improved – and the BMA is taking action.

We speak to doctors about the rest and restoration they need after more than a year on the front line. We discuss the BMA’s report Rest, restore, recover: Getting UK health services back on track, which explores how pushing the NHS to return to business as usual in an unrealistic timeframe will put further pressure on exhausted staff.

Inside is a feature which considers shared parental leave and the potential effect it could have on the medical gender pay gap. In this article, Lynn Hryhorskyj and Mike Kemp speak of the ‘blessing’ of shared parental leave and my colleague Helen Fidler points out that it could right some of the wrongs of female consultants being disadvantaged in career terms by having children.

This issue celebrates the introduction of new specialist and specialty doctor contracts for staff, associate specialist and specialty doctors in England and Wales. The contracts, which were endorsed in referendums last month, will ensure that highly experienced and skilled SAS doctors will be able to benefit from enhanced pay, greater workplace recognition and simpler career progression.

There is also a feature on the evolution of COVID-19 and Stephen Glascoe, a retired GP from Cardiff, remembers the despair and bigoted attitudes faced by AIDS patients in the 1980s following the airing of TV show It’s a Sin. Read the latest news and features online at bma.org.uk/thedoctor

6-9

Share and share alike

Shared parental leave helps individual doctors and reduces the gender pay gap. Its full benefits should be available to all

10-13

Without a trace

What went wrong with NHS Test and Trace and what are the alternatives?

14-17

Pause to proceed

Rushing back to business as usual after the pandemic will pile undue pressure on exhausted staff

18-19

The mission

A British doctor explores the origins of COVID-19

20-23

A fairer future

Better recognition and career prospects for SAS doctors

24-27

Patient by patient

How GPs persuaded vulnerable but reluctant patients to get their jab

28-29

When AIDS arrived

The bigotry faced by AIDS patients in the 1980s

30-31

Life experience

Have you ever been told you didn’t look like a doctor? It’s not you who has to change.

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briefing Current issues facing doctors

HARWOOD: Staff must be rewarded with ‘fair pay’

FAIRNESS FOR THE FRONTLINE

A campaign for fairness If only the health service could run on warm words alone.

To give one of many examples from senior politicians since the pandemic began, this was health secretary Matt Hancock addressing NHS staff last November: ‘When people look back on this tough time in our history, they will be awed by the outstanding contribution that has been made by so many people. You have been there for us, just as you always were.’

It was a very different communication from the Government when the Department of Health gave its recommendation last month for NHS staff pay in England to the Review Body on Doctors’ and Dentists’ Remuneration last month. A 1 per cent rise was all it could afford, it said.

Mr Hancock spoke of the financial ‘challenges’ the country faced – although these challenges were no doubt made much worse by the £37bn spent on a test and trace programme which MPs said failed to make a significant difference in reduce the spread of COVID-19.

The response to that pay recommendation was immediate and angry from doctors – a ‘kick in the teeth’ was how BMA council chair Chaand Nagpaul put it – and now the BMA has launched a campaign to demand fair pay.

The campaign, Fairness for the Frontline

(pictured above), focuses on consultants, who have seen a severe drop in pay. Since 2008-9, estimated real-terms take-home pay for the average consultant in England has fallen by more than a quarter.

BMA consultants committee chair Rob Harwood said: ‘With the NHS facing the largest backlog of care in its history, and the demands of COVID still very much a daily reality, the pressures on consultants have not gone away and are not going to go away for the foreseeable future – it is only right that NHS staff, including highly experienced doctors, are rewarded for their efforts with fair pay.’

The aims of the campaign have public backing. Research by the polling company BritainThinks found that 62 per cent of the public think doctors should get a pay rise.

Consultants are calling for an increase of 5 per cent. In an email to consultants, Dr Harwood cited a recent BMA tracker survey where more than 40 per cent of consultants in England report suffering from depression, anxiety or burnout resulting from the experience of treating COVID, while more than a third said they or their colleagues had had to take time off work because of the pandemic.

He said the repeated failures from the Government, such as the inadequate supply of personal protective equipment, had left consultants feeling unprotected and let down.

He urged doctors to contact their MPs to call for fairness in their pay.

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COVER UP: Many staff could not access PPE

Rarely, if ever, has so much been asked of consultants and yet they have been left feeling unsupported. It is only a few weeks since the Government announced its decision to freeze the lifetime allowance on pensions until 2026, which will have punitive implications for consultants who take on extra work or extra responsibilities at a time when the service requires them to do just that. The campaign also demands a reversal of that decision.

A 5 per cent rise this year would not undo the effects of more than a decade of shrinking pay for consultants. That’s why, as Dr Harwood says, it’s just the beginning of a campaign to restore proper recognition for the work consultants do.

How members’ voices help the fight for change GETTY

One reason why the BMA knows what it knows about the effects of COVID-19 on the profession has been because of its series of tracker surveys.

Their aim – targeted at doctors from all branches of practice and from all parts of the UK – is to ensure the voices and experiences of UK doctors did not go unheard by the public or the Government.

Between April 2020 and last month, a total of 12 surveys were conducted equating to tens of thousands of doctors sharing their views.

While the numbers of those taking part in the survey varied, the average response rate came to 7,860, with the highest number peaking at 16,306 towards the end of April last year, with an overall total of 94,320 responses across all 12 surveys.

Early questions focused on issues such as PPE (personal protective equipment) – whether or not staff had adequate access to it, what kinds of PPE they were receiving and if they ever felt pressured into attending to a patient in an aerosolgenerating procedures environment without protection.

Keep in touch with the BMA online at

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These first waves of the survey in early April 2020 laid bare the grim and disturbing reality of working conditions and the shortages and shocking lack of access to PPE many staff experienced during the early weeks of the pandemic.

As the virus’s disproportionate effect in infection, severity of illness and mortality on patients and healthcare staff from ethnic minority groups became more apparent, the BMA began to probe staff from such backgrounds or with specific individual needs as to what particular challenges they were facing with regard to accessing and fit testing PPE. Issues of poorly fitted PPE were reported by female doctors.

It was in April that the surveys also began to ask doctors about their mental wellbeing in an effort to establish what effect COVID-19 was having on rates of depression, anxiety, stress and burnout among members of the medical profession.

Armed with such knowledge, the BMA is better equipped to represent doctors – and everyone who has taken part so far has helped in this vital role.

Read more online – Value NHS staff, demands BMA – A genuine opportunity for career progression – Vaccination success is about collaboration not capitalism – COVID-19: my year on the front line Read all the latest stories at bma.org.uk/news

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ED MOSS

VITAL SUPPORT: Shared leave has enabled Mike Kemp and Lynn Hryhorskyj to tackle parenthood together

Share and share alike Shared parental leave can help narrow the gender pay gap, but only some doctors receive the enhanced pay that makes it a viable option. The BMA is demanding change. Jennifer Trueland reports

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hen Lynn Hryhorskyj and Mike Kemp found out they were going to have a baby, they were clear they wanted to split childcare as much as possible.

As junior doctors they were among the first to apply for enhanced shared parental leave after it was negotiated in 2018. In the event, when baby Edith was born prematurely, they were incredibly glad that they had.

‘I had originally planned to take around 10 months off, and Mike was going to take a month near the start. But we hadn’t planned to have our daughter at 28 weeks, so when that happened in the August, we had to think again,’ says Dr Hryhorskyj, a GP trainee in Manchester.

‘Being able to take shared parental leave made all the difference. It meant, especially at the beginning, that I was able to get lots of support from Mike, which would have been irrespective of when she’d been born, but especially so because of our circumstances.

I wasn’t very well myself – I’d had pre-eclampsia – and I’d had a section, so I couldn’t even drive to the hospital to see Edith. But it also gave Mike extra time so that we could bond as a family unit, which was really important.’

Dr Kemp, a neurology registrar, was keen to be as involved in the upbringing of his baby as much as possible, so was very enthusiastic about applying for shared parental leave. He found the whole experience so valuable that he made the decision to reduce his hours even when the parental leave was over, allowing him to spend more time with his daughter.

‘We wanted to have children, but we always intended for me to have a significant role in childcare,’ says Dr Kemp. ‘Having a child should be an equal partnership – it shouldn’t be the case that it’s the mother’s role to bring up the kids.

‘Also, it’s about work-life balance. One of the things we’d always talked about was that rather than one of us dropping down to working 50 or 60 per cent, perhaps we’d both work at, say, 80 per cent, so we’d both have that role in our child’s upbringing.’

Quality time When Edith was born prematurely, the shared parental leave was a ‘blessing in disguise’, he says. ‘It allowed me to be far more involved than some of the other dads on the neonatal thedoctor | April 2021 07

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BLESSING: ‘Edith is definitely a daddy’s girl’

‘Being able to take shared parental leave made all the difference’

‘Some warned me that it would slow my training down, but it’s not a race’

unit, who had less support from their employer, or who couldn’t afford to be there as much because they had to be at work or they wouldn’t be earning.

‘But it started the process where I was at home more often, and it got me involved in the childcare early – it normalised it, and made me part of the routine care of our daughter.’

He took around three months of leave in the first half year of Edith’s life, in a mix of parental and annual leave, and then in February he dropped to 80 per cent. Most of his colleagues reacted very positively.

‘Within the other trainees, nobody questioned it. At the time, one or two of the consultants in the department were a little more conservative. Some warned me that it would slow my training down, but it’s not a race. If I don’t finish my training until I’m 36, then so what? I’ll not be retiring until I’m 68.

What does it matter in the grand scheme of things – you don’t get that time with your children again.’

Later, both dropped further hours and do all the childcare between them – something they probably wouldn’t have done if shared care hadn’t been ‘normalised’ in those first few weeks and months.

‘Shared parental leave is perhaps a gateway drug to increased paternal childcare, and that’s really important for helping to shift the gender pay gap,’ adds Dr Kemp.

It has also helped family relationships.

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‘Edith is definitely a daddy’s girl – he even did the first nappy change, while she was in an incubator and with my mum watching,’ laughs Dr Hryhorskyj.

‘I know we’re incredibly privileged to be able to do this, not just because of our terms and conditions [of service] but also because we earn enough to be able to make it work financially. But the irony is that when we complete training, we may potentially not have access to it [enhanced shared parental leave] – and that irony isn’t lost on us.’

When the UK Government’s long-awaited report into the gender pay gap, Mend the Gap, was published late last year, one of its clear recommendations was to ‘extend enhanced pay for shared parental leave to all doctors to overcome a cultural barrier to men playing more of a role in caring and to challenge stereotypical assumptions of gender roles’.

In its response to the report, the BMA said this should be implemented without delay.

Left out Helen Fidler, deputy chair of the BMA’s UK consultants committee, says it’s an important issue for ensuring equity, changing cultures, and narrowing the medical gender pay gap.

‘It’s something that really raises my hackles,’ says Dr Fidler. ‘In England, all NHS staff working under the Agenda for Change contract, junior doctors and SAS doctors on the newly accepted contract have access to enhanced

GENDER DISPARITY: The Government’s report recommends enhanced pay be extended

‘Shared parental leave is perhaps a gateway drug to increased paternal childcare’

‘I was completely drained, didn’t know what to expect’

FIDLER: Told going part time would destroy her career

shared parental leave. In general practice they are in discussion on how GP practices can offer enhanced shared parental leave to employed GPs. So, while we watch this equalityenhancing right being offered to the vast majority of the NHS, this is not being extended to consultants, unless we agree to make other changes to our contract. This is a benefit that offers a chance to improve equality in the profession and I don’t think it is remotely acceptable to use this as a manipulative lever to force unrelated changes that can be to the detriment to some of our members.’

She believes many female consultants have been disadvantaged in career terms by having children, but that making enhanced shared parental leave available would help to change that. ‘I’ve got five children, and financially it wasn’t viable for us to split parental leave, so my husband – who may or may not have wanted to take time off – didn’t have a choice, basically. I took time off, and we know that the gender pay gap starts around the age of 30, which is the time many start to have children, and so essentially it’s a maternity penalty.’

Burst into tears Dr Fidler was a junior doctor when she had her first child, aged 32, and – like most new mothers – found it tougher than she had anticipated to combine work with being a parent, particularly as her child had special needs.

‘I was completely drained, didn’t know what bma.org.uk/thedoctor

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to expect and thought I’d be able to control the situation. I think a lot of women who are successful in their careers think it will be different for them, but of course it’s exactly the same as it is for everyone else.’

At the time she was doing a demanding job in a transplantation unit and, she says, had to leave ward rounds to burst into tears.

‘A very understanding GP signed me off for two weeks and I was able to sleep; I felt like a different person and realised I needed to go lessthan-full-time. When I mentioned this at work, a female consultant told me it would be the death of my career if I went part time. But I felt I had no choice, so I pushed and pushed to do it.’

She was made to feel she was ‘work-shy’, she says, when she had to leave on time to pick up her child. ‘It was very hard, and created a bad work environment.’

Her husband was also a senior registrar and was working very long hours so was unable to pick up any of the slack, she says. ‘It did cause friction at home. Having shared parental leave would have made a difference because I would have had someone at home, available to help, rather than someone working 14-hour days, who was also tired when he got home. And it would have helped with the culture, because if there were male colleagues doing the same as me and taking time off to look after children, they would have understood. It would have been more acceptable – it wouldn’t be such a gendered issue.’ thedoctor | April 2021 09

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GETTY

VAST SUMS: MPs said NHS Test and Trace had a ‘persistent reliance’ on the private sector, which had to stop

Without a trace Despite being handed £37bn, MPs found NHS Test and Trace had failed to reduce the spread of coronavirus significantly.

Peter Blackburn asks what went wrong, and looks at more successful alternatives

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hirty-six alerts arrived on the computer screens of staff at Norfolk County Council during the late afternoon of Friday, 19 March – each alert representing a new COVID-19 case in the area.

The council’s team of data crunchers, contact tracers and outbreak management staff leapt into action in response to this series of messages from the national database. By 6.30pm, 70 per cent of the people who had tested positive had been contacted – with contacts identified and isolation advice and support offered. A third of the cases were linked to outbreaks in schools and before the weekend even head teachers had been contacted, risk assessments undertaken and action plans put in place.

It was a far cry from how the system had worked previously. Prior to that week those alerts would have represented positive

results from 48 hours prior – a lag between national and local systems taking away the opportunity to take immediate action and leaving experts with little ability to stop the rampant spread of this disease.

‘The team are really excited and positive,’ the council’s director of public health, Louise Smith, tells The Doctor. ‘They are describing it as a complete game-changer.’

Dr Smith adds: ‘Six months ago, we found out about outbreaks in schools from social media or reading it in the local newspaper. By then the whole community were worried and we were three days late. It makes a big difference.’

It is just one small moment, in one part of the country, in the midst of a gargantuan pandemic response – but it could hardly be more prescient when it comes to an insight into the factors which can break a country’s test and

SARAH BROWN

SMITH: Welcomes move towards localism

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NHS test and trace COVID-19 lateral flow device kit

trace programme. Swift action is undoubtedly important. The value of localism – and particularly local knowledge, expertise and relationships – seems hard to argue against now.

The time and understanding to look at outbreaks and put appropriate actions or plans in place is crucial. And the importance of packages to support those who you ask to isolate is increasingly obvious.

Limited effects These are qualities that have often been lacking in England’s response to the COVID-19 pandemic. A report published last month did not manage to find any clear evidence that NHS Test and Trace has made a significant difference in reducing the spread of coronavirus.

NHS Test and Trace was originally given a budget of £22bn but has since been handed a further £15bn with the £37bn total covering the first two years of the scheme.

The Parliamentary public accounts committee report said NHS Test and Trace had been set up and staffed at incredible speed but that vast sums had been spent

on private consultants – it described this as a ‘persistent reliance’ and urged bosses to ‘wean itself off’ that reliance.

It was a brutal assessment.

In mitigation, many doctors and public health experts will explain that the national test and trace has not been a total failure. It is true that Government has achieved significant amounts of capacity and trained a large workforce.

And many directors of public health will testify to the importance of having national involvement in the whole test and trace programme – particularly where the efficiencies of scale are useful. However, the sums are vast – and it is clear that the project has had vast failings. Perhaps the most damning thing of all, though, is that none of the problems are luxuries of hindsight.

In a feature in the July issue of The Doctor, doctors highlighted the same issues – localism, private sector reliance, the need for public health investment – as are being raised now.

BMA public health committee co-chair Penelope Toff says: ‘One of the problems is the scale of the

money that has gone into this and how it has been spent.

This money really should have gone into increasing public health capacity, enabling this work to be done locally where it is done most effectively and in supporting people to self-isolate.’

These issues remain of the utmost importance. While the vaccination programme has progressed with good speed and the worst of the first and second waves of the pandemic are becoming memory rather than daily reality, the success of test and trace programmes in England will be crucial to managing this pandemic from now.

The concept of test, trace – and isolate – is, in fact, likely to be more important than ever as society is opened up in the coming weeks and months and with the constant threat of variants mutating to evade the virus looming large.

So, what is the blueprint for a more successful test and trace programme?

The Doctor spoke to public health leaders in parts of the UK which have learned lessons and filled the gaps where the national system thedoctor | April 2021 11

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OUT OF FOCUS: NHS Test and Trace has suffered from a lack of clarity in its aims

‘Six months ago, we found out about outbreaks in schools from social media’

‘There is still a great focus on how many tests we are doing which totally misses the point’

fails, to find out.

Public health consultant Jackie Hyland helped to set up the alternative systems to NHS Test and Trace in Northern Ireland and Scotland – having initially begun to work on the COVID pandemic in January 2020 when the situation in China was becoming clearer.

In the very early days of the pandemic Dr Hyland had great clarity about what would be needed – using the health protection outbreak model to create a shadow health protection team, bringing in staff and training them to be able to interview cases, find out who they contacted and look to stop the spread.

It was a difficult situation in which to create the team with many existing professionals struggling to deal with other issues such as outbreaks in care homes, so staff from other backgrounds were brought in to help.

While the English system follows a basic call centre model, Dr Hyland felt that in Northern Ireland it would be important to have as many professionals together in one room – in a bid to ensure the situations of those testing

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positive are fully investigated and cases could be mapped to places of outbreak.

Complex cases are passed to more expert staff.

‘National contact tracing services tend to be less effective – simply calling people and telling them to isolate means you’re not likely to get more information.’

It was a slower process in Scotland but Dr Hyland eventually set up a similar system.

‘Understanding what people are doing is what impacts the spread of infection,’ Dr Hyland says.

‘That helps us to understand.

We can then tailor what we do to individuals and groups at local levels – engaging with hard-to-reach communities. This can’t be done at a national level. At the national level it has been all high profile chasing of big numbers and statistics, but it should be about asking what the problem is, what skills have we got and how do we develop systems to respond.’

The experience in Northern Ireland suggests a heavy focus on the terms ‘test’ and ‘trace’ is a big part of the problem – with opportunities for information, understanding and changing behaviour all lost while numbers of tests and contacts traced leads the agenda. A significant degree of localism appears to be a crucial part of a successful plan – and allows directors of public health to feel in better control of the spread of the disease in their areas. In Wales there is a partnership between local and national, which according to those involved, has hit

the right sort of balance.

The national leaders set policy – for example strategy around symptomatic and asymptomatic cases. But then regional leaders take that strategy and respond however best locally.

Mobile resources For Kelechi Nnoaham, director of public health in Cwm Taf Morgannwg, it means being able to utilise funding where required – moving testing units to the communities where they are most needed or controlling access to laboratories how he sees fit.

‘That flexibility is absolutely crucial,’ Dr Nnoaham says. ‘The system here means consistency nationally but local expertise and delivery. That is the key strength.’

The East London borough of Newham is one of the parts of the UK which has been hit the hardest by the COVID-19 pandemic. It is a borough with high levels of deprivation, has a very diverse population and a high proportion of people living in crowded housing.

Here, the greatest challenge, perhaps, is that many people simply cannot isolate – even if called by the national system.

Here, council leaders have diverted huge numbers of staff and recruited vast swathes of volunteers to help people in that position.

Staff are able to organise food shopping, sometimes even paid for by the council, voluntary services and charities befriend people who are lonely – and the council even has the capacity to pay for people to stay away from

‘Every part of the country has people who face barriers to isolation’

A COVID-19 testing centre

GETTY

bma.org.uk/thedoctor

SARAH TURTON

‘One in four or five people are asking us if we would walk their dogs’

their families while isolating.

Newham’s director of public health, Jason Strelitz, says: ‘We should have this in place everywhere. Every part of the country has people who face barriers to isolation.’

These are projects which cost money – but the sums are nothing compared to those being spent nationally.

He says £1.5m has been found for the next 12 months for this part of his council’s work. But in Newham they would like to do more – more to help the homeless, those with no recourse to public funds, to make sure food poverty isn’t a barrier to isolation and to provide support to immigrants.

There are so many infection risks which could be managed. One can’t help but hear the lengths local staff have gone to in Newham and wonder what more they could do if only they were the beneficiaries of the vast sums of money now in the bank accounts of firms like Deloitte and Serco.

Back in Norfolk, Dr Smith explains the importance of a local role in this process with one reflection. ‘Rather sweetly, something like one in four or five people

STRELITZ: Isolation an issue across the UK

are asking us if we would walk their dog. Something as simple as that can make the difference between someone participating [in isolation] and avoiding further transmission.’

It might sound like a minor issue but the pandemic response in this country has to be founded on positive cases being found – and supported to isolate.

The Government may be able to point to massive amounts of testing capacity and increasingly high numbers of contacts reached, but the reality is that it rarely knows whether people who might be infectious are infecting others or not and that is a monumental flaw in the system. And beyond £500 support payments – which directors of public health told The Doctor are often incredibly hard to access – little has been done to change this.

It has been a long time coming but there is a positive trend toward localism in pockets around the country.

In Norfolk Dr Smith’s team is taking increasing control of the meat and drink of test, trace and isolation objectives and funding is coming from

national emergency pots to pay for that.

The same applies to the team in Newham. And there are other areas too – just last month the London borough of Lambeth took test and trace in-house. There will always be a need for national structures – whether it is for support and flex when local authorities cannot do all the work they need to do, in the running of a national app or for policy and guidance, but it is abundantly clear that the most effective work – away from the misjudged national targets and statistics – is done in local areas by those who know their communities.

Just as the pandemic has shone a light on the dramatic – and tragic – health inequalities in our society it has also shone a light on the importance of well-resourced public health structures, with genuine devolved responsibility.

The trend toward localism is positive, but directors of public health could do even better with more resource – and that means a permanent return of the investment drained out of the system during a decade of austerity. thedoctor | April 2021 13

SIMON GRANT

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Pause to proceed The pressures COVID-19 has placed on doctors are unprecedented, and without a carefully thought out plan to return to business as usual, many will not be able to cope. Tim Tonkin reports

‘I ‘The focus is on COVID but the backlog of elective care is on the radar’

t’s only since I went on maternity leave that I quite realised how tired I was,’ explains London GP Rammya Mathew.

‘Whilst you’re in it [work] you’re not even getting a chance to stop and think about how the situation is affecting you.

‘Once you step out of that environment you have a chance to look back, reflect and digest a bit of what has happened,’ says the GP. ‘It’s been a year like no other and not everyone has had the chance to even recognise or realise that.’

COVID-19 has tested the resolve and endurance of the health service, and its staff, like no other public health challenge in NHS history.

Fighting the pandemic has at times felt like total war, necessitating that access to many non-COVID and elective services be limited across primary and secondary care, to free up capacity.

Meanwhile doctors, as with all healthcare staff, have been required to go above and beyond in their duty of care to patients on a daily basis and for more than a year.

While the growing number of vaccinations and falling rates of infection attest that

these sacrifices have not been in vain, they do not change the fact that doctors, incredible as they are, are still human beings with physical and mental breaking points.

While efforts against the pandemic continue, attention is already starting to shift towards the vast backlog of unmet elective care that continued to stack up during the course of last year, and is now casting a vast shadow over the heads of an already exhausted workforce.

The extent of Dr Mathew’s mental and physical fatigue is one that many doctors can relate to, and an issue that the BMA has become increasingly concerned about over the past 12 months, particularly in light of what is anticipated as the next huge challenge facing the NHS: tackling the non-COVID backlog.

Recovery vision To highlight the need for doctors and other healthcare staff to be given an opportunity to pause, rest and reflect on everything they have endured over the past year, the association launched a report Rest, restore, recover: Getting UK health services back on track.

At its core, the paper

emphasises how pushing the NHS to return to business as usual in an unrealistic timeframe will put further pressure on exhausted staff and ultimately ‘make it harder for the NHS to recover and provide timely and safe care to patients who need it’.

In doing so, the BMA says the Government and employers must put staff’s safety and mental wellbeing at the centre of their plans for rebuilding the health service by implementing measures to expand system capacity and workforce.

The report also calls for ministers to be frank and honest with the public on what can realistically be achieved by staff tasked with tackling the NHS backlog during the immediate post-COVID era.

Failure to do so, it warns, will likely result in worsening morale, burnout and sickness absence among doctors, ultimately making the job of tackling postponed procedures and unmet care needs that much harder.

‘I think we’re in an inbetween moment. Largely the focus is still on COVID but definitely the backlog of elective care is on the radar and we all know that it is coming,’ explains Dr Mathew. thedoctor | April 2021 15

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ELTUHAMY: ‘Damage to resilience persists’

‘No time to acknowledge what people have gone through’

MATHEW: No chance to pause and reflect

‘Patients have been incredibly patient and understanding during COVID. Lots of people have had their care set back multiple times and have been left struggling for a very long time. Expectations are now increasing and we’re still quite powerless in terms of being able to action that.

‘I worry that, given the pressures that there are from all ends, we [doctors] could well just fall into the trap of just being asked to get on with the work and there’s no kind of time to pause or reflect and acknowledge what people have gone through during the pandemic.’

Fatigue compounded Consultant in paediatric sleep medicine Mike Farquhar has written extensively on the issue of how tiredness in the workplace affects doctors and has previously worked with the association in developing its fatigue and facilities charter.

He says that fatigue and burnout were already huge issues in the NHS even before the pandemic struck and acknowledges that unless steps are taken now to address this, the potential consequences for the health service could be dire.

‘For the last year, the vast majority of NHS staff have been working above and beyond and a lot of people have been burning up their reserves in order to keep doing that,’ Dr Farquhar says.

‘If we keep pushing people, who are already exhausted, into more all that will happen is that they will work less efficiently, get more stressed, burn out and [potentially] leave the NHS, which means the

problem of addressing unmet need becomes even greater.’

While acknowledging that there is no single solution to the issue of staff fatigue, Dr Farquhar points to actions already being taken in his workplace that chime with the BMA’s calls for staff risk assessments to incorporate discussions about mental health, and for employers to ensure timely access to occupational health and psychological support.

‘I’m lucky enough to work for a trust that I think has really put looking after staff at the forefront of everything we’ve done in response to the pandemic,’ he says. ‘[For example] We’ve employed additional psychologists whose role is 100 per cent to support staff.

Lots of people have been through very stressful and traumatic experiences over the last year … so putting in the support to staff to make sure that we’re identifying that and we’re giving people the space and time to reflect and address the consequences I think is really important.’

Drop targets In addition to increased support in the workplace, the BMA’s report urges the Government to not only support the development of COVID recovery plans at local levels, but for an end to crude practices such as threatening trusts with financial penalties if they fail to meet elective care targets.

‘I think there is an argument for saying that we appreciate the waiting lists are severe ,we appreciate people suffer the longer they’re on the waiting lists and the longer care is

delayed, but actually maybe it’s better that we aim to get to 75 or 80 per cent of our prepandemic levels of activity and then use that time to make sure that staff rotate around and get decent periods of time to rest and recuperate,’ says Dr Farquhar.

‘This is [already] being done locally and some trusts are already looking at things like this, but at the end of the day it comes down to somebody having to justify waiting lists so it’s always a very difficult thing to do given that many trusts’ income is relative to how well they perform on some of these metrics.’

As funding and resources have been central to the NHS’ ability to respond to COVID, so will they be to measures designed to increase system capacity in any post-COVID recovery plan.

The BMA’s report calls for the Government to commit to fund a ‘rapid expansion’ of diagnostic services across all of the health service and to allow employers to bring in additional or locum staff to help maintain capacity while existing staff are on leave or sick.

Flexible working Dr Mathew says that the post-pandemic era will be a time to consider how care is reorganised and delivered in the future. This will include taking more flexible approaches to work.

‘One of the worries is that there’s been lots of help and resources given to fight the immediate crisis of the pandemic but is that going to continue long enough for us to recover and address all this backlog?’ she asks.

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‘If we keep pushing people all that will happen is that they will work less efficiently’

‘Asking too much of doctors could potentially increase already lengthy waiting times’

‘Care is going to look very different and we need, as much as we can, to allow ourselves the time and space to deliver care in the way we want to and meet people’s needs. We need some freedom in the way we operate in order to do that.’

London-based foundation year 2 Yousef Eltuhamy is one of thousands of young doctors who have faced a baptism of fire owing to COVID-19.

He says, during last year, he felt his mental health being undermined by the changing dynamic at his workplace, which left him constantly adapting to meet the day-today requirements of his job, and leaving him never sure of what he was doing.

‘When the first wave of the pandemic hit, I was eight months into my career as a doctor. Overall it has been a very difficult time,’ he says.

‘The rotas were changed, were more intensive and less respectful of weekends.

It meant that getting that recuperation time was very difficult. The work itself was at times exceptionally difficult.

‘Thankfully, that has improved as the cases [of COVID] have gone down but that sort of damage to resilience and reserve persists. While the edge has been taken off as cases have gone down, there is still a long-term impact of having worked through the pandemic so far.’’

He says that failing to give doctors time to take stock and recover will further reinforce the notion their efforts are not recognised or appreciated, something that could ultimately undermine an already ailing NHS workforce.

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‘I don’t feel particularly valued as an individual in the NHS,’ he says.

‘It feels like I am just a number on a rota a lot of the time. Even though I’ve had a supportive experience in my foundation programme so far, there have been moments where it is clear I am actually just filling a rota gap.

‘When you compare this to places like Australia or New Zealand it becomes very obvious that the balance of quality of life and actually feeling valued and useful is more on the side of potentially leaving the NHS either temporarily or permanently.’

Highlighting the BMA’s report, however, Dr Eltuhamy believes there are many things that can be achieved by the Government and employers that would allow staff opportunities to recover while also improving morale and ultimately the care available to patients.

‘I think employers can do a lot more to help make their staff feel more valued and help retain those staff, whether it’s doctors, nurses or anyone in the workforce,’ he says.

‘I’d like to see employers moving away from online yoga webinars to things that can make a genuine difference such as ensuring adequate staffing, having more flexible working and evidence-based workforce planning, having clean and comfortable rest spaces for people during their shifts. Most importantly making people feel valued and changing the culture in the hospital to make every member of staff in that hospital feel valued, their work recognised and appropriately compensated.’

FARQUHAR: ‘People have been through traumatic experiences’

Speaking about the report, BMA council chair Chaand Nagpaul says that while doctors understand the importance of addressing the NHS clinical backlog, but any approach to such a huge undertaking has to be taken appropriately.

If left unchecked, he warns that the levels of exhaustion and burnout among ‘talented and committed healthcare professionals’ could undermine the health service’s ability to deliver care.

‘As our report lays out, this realistic approach must be complemented with a dedicated effort to attract more staff into the NHS, not only to help bring down the numbers of patients on the waiting list, but to fill gaps for existing staff taking time to recuperate. The wellbeing of our healthcare workforce must be viewed as a priority for the effectiveness of the NHS. This report gives a stark warning to Government: to ignore the threat posed by burnout is to put future services and patient care at risk.’ thedoctor | April 2021 17

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The mission A British epidemiologist and two other researchers who went on the World Health Organization mission to investigate the origins of COVID-19 describe their experiences. Tim Tonkin reports

I

n December 2019, the city of Wuhan in Hubei province, China, saw the first recorded hospitalisations and deaths resulting from a hitherto unencountered coronavirus.

Within a few months, the virus would become known globally as COVID-19 with Wuhan becoming renowned as being ground zero for the disease.

It was not until just over a year later that the World Health Organization commissioned an international team to visit Wuhan and work with their Chinese counterparts, in an effort to start the process of investigating the origins of a still-ongoing pandemic that, by this stage, had resulted in around two million deaths worldwide.

Following the conclusion of the one-month investigation, the mission was subsequently met with controversy, following claims that the 18

Chinese authorities had not shared data with members of the international team.

The fall out saw US national security adviser Jake Sullivan express his and the White House’s ‘deep concerns’ about how the early findings of the mission were reported and reached, with Mr Sullivan adding that it was ‘imperative’ that the mission’s findings be ‘free from intervention or alteration by the Chinese government’.

The report, published last month, did not draw firm conclusions, and said further investigation was needed. It said bats appeared to be the reservoir of the virus, but the intermediate host(s) had not yet been identified.

Following the report, 14 countries including the UK released a statement saying: ‘Scientific missions like these should be able to do their work under conditions that

produce independent and objective recommendations and findings.’

In light of the controversy and ahead of the publication of their full report, three members of the WHO mission, virologist Marion Koopmans, zoologist Peter Daszak and consultant clinical epidemiologist and senior medical adviser at Public Health England, John Watson, spoke about their experiences as part of an event hosted by international affairs think tank Chatham House.

During the event Professor Watson and his colleagues sought to address some of the claims levelled at their mission as well as expand on what has so far been learnt.

IN THE SPOTLIGHT: Great attention has been paid to the role of Chinese wet markets in the early spread of the virus

‘The independent element is an important part of the way in which the mission was set up’

No smoking gun Professor Watson acknowledged that while he had previously participated in many international missions,

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CROWN COPYRIGHT

none had ever been faced with as much ‘external interest and pressure’ as this one. He added that the investigations that took place in Wuhan represented a promising start to understanding the origins of COVID-19, but he felt that the remit and purpose of the WHO’s mission had frequently been misconstrued.

‘This was set up as a joint mission. What this was not set up as was as an external group coming in to investigate and point fingers with the hope of identifying a smoking gun.

‘The WHO team was made up at its core of 10 independent experts drawn from around the world – people who were neither beholden to the WHO or indeed to their own countries of origin. That independent element is an important part of the way in which the mission was set up and the weight that’s placed on what we conclude from it.’

Like the rest of his colleagues on the WHO team, Prof Watson was required to quarantine for two weeks following his arrival in China, before he and the team could properly begin their investigations.

He insists that the team was rather given good access to data, locations and people, even if the overall speed of the investigation was slowed by health requirements and cultural factors.

‘We were shown a lot, but the process was slow because of quarantine and because of the issues of language and translation,’ he says.

‘In that respect [the investigation] was slow, but despite that we were shown a very great deal, we recognise bma.org.uk/thedoctor

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and will be asking for the opportunity to take that further, but we learnt a great deal.

‘This kind of investigation is not just about illness in humans or indeed just about an interface between humans and animals, but feeds into an altogether wider discussion about the way in which we [as societies] use the world, resources and how we interact with the animal environment.’

Limited opportunities Professor Watson’s overview of the mission was shared by Professor Koopmans, who told of how she had been ‘pleasantly surprised’ by the amount of work that the team carried out and the amount of data she and her colleagues were presented with.

She accepted, however, that work had had to be carried out under challenging circumstances, adding that social distancing requirements had hindered interactions between team members in social settings, such as discussing the investigation during mealtimes, something that she felt had reduced opportunities for the sharing of ideas.

‘What was very disappointing for us was that while we were there [in Wuhan], there was a resurgence of cases which changed the quarantine rules so that meant that the second phase of our trip, after the hotel quarantine, we still could not freely go about.

That was a disappointment for all of us.

‘We had the handicap of being in full-blown quarantine for the first 14 days, and then restrictions in the second half

of our visit. None of that is really conducive to the type of discussion you would want to have when you sit around the table to look at and scrutinise data.’

Rebutting claims that the WHO mission had had access requests turned down by the Chinese state, Dr Daszak insisted that a list of sites and people of interest was submitted by the team while in quarantine, and that none of these had been refused.

Shedding light Dr Daszak added that while he had seen no evidence to support speculations that COVID-19 was the result of a lab leak at the Wuhan Institute of Virology, examinations of the city’s markets during the visit, coupled with data shared by the team’s Chinese counterparts, had helped shed further light on the virus’s potential origins.

‘What we did see data on, from the China side, were the animals that we know are able to either be infected by SARS coronavirus or SARS COVID-2 were present in the market,’ he says.

‘We also found that there was a conduit from Wuhan to the provinces in South China where the closest relative virus to SARS COVID-2 are found in bats.

‘That’s quite important because it provides a link and a pathway by which a virus could convincingly spill over from wildlife into either people or animals farmed in the region and then shipped into a market.

‘Those beginnings of an understanding of a pathway need to be followed up pretty rapidly.’

WATSON: Unprecedented ‘external interest and pressure’

‘We had the handicap of being in fullblown quarantine for the first 14 days’

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A NEW DEAL: New roles will offer higher salaries and safeguards to protect work/life balance

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A fairer future Following years of BMA lobbying and negotiations, SAS doctors are being offered new roles which give better recognition and career prospects. Tim Tonkin reports

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he year of 2008 will be remembered by most clear career framework for personal development and people when a global financial crisis changed the opportunity to hold senior roles in workplaces millions of lives, and the world. that had not been accessible to SAS doctors since the For staff, associate specialist and specialty doctors, closure of the AS grade. however, it represents another bitter and lamented The contract package was subsequently put to a landmark, namely the closure, at a national level, of referendum in England and Wales, with SAS doctors the associate specialist grade to new entrants. in both countries ultimately backing the deals in This soon came to be widely regarded as a grave overwhelming margins. inequity that served to place limitations on the recognition and career prospects of SAS doctors.

A national contract In the years that followed, the BMA lobbied hard for Dorset-based specialty doctor in emergency medicine a reopening of the AS grade, a position that had enabled Cathy Wield was among those who voted for the new experienced, senior doctors who were neither in contracts. training nor consultants, to take on senior clinical roles Dr Wield, who had previously been negotiating with in hospital settings. her employer about becoming an AS (the only way since The breakthrough finally came last year when the 2008 that it has been possible to join the AS grade), says association’s SAS committee began the contracts overall represent a huge 12 months of negotiations with NHS opportunity for SAS doctors.

England and NHS Improvement, ‘For me this is an opportunity to NHS employer organisations and the progress to the new specialist doctor ‘This is an Department of Health. contract which I really feel I deserve,’ opportunity to The result was an agreement she says. progress’ to introduce a new contractual ‘I have been working as a senior settlement for SAS doctors in England specialty doctor for some time; I’m and Wales involving a revised specialty actually termed a senior specialty doctor contract and a wholly new doctor in my department, and yet the specialist grade contract. ability to re-grade seems to be fraught with problems.

Under the terms of the deal, applicants to the new ‘There are [also] a lot of discrepancies between trusts specialist and specialty doctor roles will benefit from in the way that they apply various rules and whether they comply to the SAS charters [and] I think that to higher starting salaries and flatter pay scales, in-work have a national contract will get rid of such disparities safeguards designed to protect work/life balance and and make it fairer.’ on-call supplements in line with those received by Under the terms of the deal, the Government has consultants. committed to a multiple-year pay deal of 3 per cent The new specialist grade, meanwhile, promises a thedoctor | April 2021 21

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ELBANA: ’A step forward for SAS doctors in having their contributions to the NHS recognised’

WIELD: New contracts may encourage other branches of practice to see SAS doctors differently

per year over three years to those enrolled on the new ‘I find it really annoying when, for example, I have to contracts. This is in addition to flatter pay scales which phone 4ways, the radiology OOH provider, and am asked the BMA hopes will help to reduce the gender pay gap whether I am “a consultant or a registrar?” I tell them among male and female members of the grade.

I’m an SAS doctor and they have no idea what I mean These improvements have, however, so I end up saying registrar because I come at the expense of an extension to cannot say that I’m a consultant and it’s plain time pay from the arrangement no use trying to explain – they do not ‘The contract is a of 7am to 7pm to 7am to 9pm on understand. recognition that we weekdays, a shift that Dr Wield admits ‘The contract is a recognition in the SAS grades she had not particularly welcomed. that we in the SAS grades are senior She acknowledges, however, that doctors and I really think it’s time the are senior doctors’ the overall pay enhancements negate language changed about who we are this downside. and what we contribute to the system.’

‘Prior to becoming a specialty doctor Historic misunderstandings at my previous trust, I was paid as a trust registrar. When Dr Wield’s sense of cautious optimism about the new I became a specialty doctor, I faced a cut in pay owing to contracts is shared by Cumbria specialty doctor in the fact that I was being paid a basic salary and OOH (out trauma and orthopaedic surgery Husam Elbana. of hours) with only the basic salary contributing to my new salary. The new trust was very reluctant to rectify He says the historic misunderstandings of the SAS this and the BMA conceded that contractually, I could do role and the discrimination members of the grade nothing about it – so I ended up working more antisocial often face cannot simply be erased overnight via the hours at lower pay,’ she explains. introduction of the new contracts in England and Wales.

‘Now, when I consider the new contract as a whole, He adds, however, that they offer ambitious I think of those colleagues coming in and hardworking SAS doctors an and starting afresh and how they’re opportunity to develop their skills going to be on a higher starting salary further while receiving greater ‘Changing a recognition of their abilities and and there will be a faster and easier culture is a very experience in the workplace, and that progression up the pay scale.’ slow and daunting over time this would lead to a shift in Dr Wield says that, while the SAS how the grade is perceived. grades are a potentially great career process’ ‘There is still a lot to be done pathway for those in medicine, many because changing a culture is a very members of the grade have for too slow and daunting process which we long faced discrimination and not will have to continue to work on [but] I feel that this received proper recognition, something she now contract is a step forward for SAS doctors in having their hopes will start to change. contributions to the NHS recognised.’

‘I hope that these new contracts will actually Having qualified in Egypt, Mr Elbana worked in a encourage some of the other branches of practice number of health services across the Middle East and to see us in a different light,’ she says.

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KUMAR (left) and KOCHHAR: ‘This contract is indicative of a general shift in opinion among the medical establishment towards us’

Dr Kumar’s election to chair of SASC UK providing Asia before coming to the UK in 2013. continuity in the negotiations. They say the contracts After working several years as a specialty doctor, he are a ‘giant step’ forward for SAS doctors. ultimately took the decision last year to embark upon ‘These contracts, which met with overwhelming the certificate of eligibility for specialist registration approval from SAS doctors during the referendums, in order to join the specialist register and become a is the first giant step towards making the SAS grade a consultant. positive career choice.

He says that while the new contracts will not make ‘The closure of the AS grade in 2008 resulted in a a difference to his own career and salary, he is acutely diminishing and detrimental impact upon the career aware of how the new terms would hugely benefit development prospects of our grade. other doctors in the SAS grades, particular those at an ‘Our committee, and indeed the BMA as a whole, has earlier stage in their careers.

‘Some people don’t want to be consultants,’ he says. spent years calling for the AS grade – which provides SAS doctors greater opportunities for promotion, ‘They are highly experienced, but they have reasons recognition and independent working such as family commitments, and – to be reopened. decide that they don’t wish to pursue ‘Last autumn, our demands were consultancy but want to continue ‘Our demands finally heeded by the secretary of practising at a senior level. were finally heeded state and NHS Employers, both of ‘This new grade not only recognises by the secretary whom committed to meeting us at their competencies but benefits the the negotiating table with a view to reNHS by utilising these doctors’ skills to of state’ establishing the role of AS in England. the best of their experience.’

‘These new specialty and specialist contracts have the potential to make Huge potential for improvement huge improvements to our grade and to our individual Further benefits of the contracts include access to working lives, and we should feel enormously proud of trust-level, ringfenced funding to support SAS doctor what we have accomplished. development during the first and third year of the ‘This contract is also indicative of a general shift in contracts in England, with one-off development opinion among the medical establishment towards us, funding provided by the Welsh Assembly to be made finally giving SAS doctors more of the recognition they available to doctors in Wales. have for so long deserved.’

The contracts will also see guidelines developed for From 1 April doctors in England and Wales will the introduction of an SAS advocate role, the purpose have a six-month period in which to express interest of which will be to improve support for SAS doctors’ in transitioning to the new contracts, while doctors health and wellbeing in the workplace. wishing to remain on their existing terms and The new SAS contract negotiations were initiated conditions will be able to do so. in 2019 as an effort to reopen the historic AS grade by The terms of the contract package for SAS doctors the then co-chairs of the BMA SAS committee, Rajesh in Northern Ireland is awaiting financial sign-off from Kumar and Amit Kochhar. Despite the pandemic, the Stormont and is yet to be put to a referendum. negotiations carried on throughout last year, with bma.org.uk/thedoctor

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ED MOSS

FAROOQI: Uptake is ‘really poor’ in some areas

Patient by patient Having seen his city suffer from COVID, Azhar Farooqi was determined his most vulnerable patients were not going to miss out on vaccination. So he and his colleagues rang the reluctant ones – with stunning results.

Peter Blackburn reports

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THE LONGEST LOCK DOWN: Leicester has suffered more restrictions than most other cities

‘With the best will in the world there is only so much people can take’

‘T

he vaccine is the only route out of this for us,’ Leicester GP Azhar Farooqi says, when asked what life has been like for patients and doctors in a city which has been locked down for the vast majority of the last 12 months.

While much of the country moved out of lockdown last year – able to travel, meet friends and family and visit hospitality venues – the city of Leicester was placed in local lockdown last July and restrictions have hardly loosened at any point since then.

It has taken its toll on the community – and doctors in the city are concerned rules may be broken by frustrated locals if a path out of restrictions isn’t found soon.

‘It has been a really tough year and with the best will in the world there is only so much people can take,’

Professor Farooqi says.

However, despite all this pain and there being one obvious route back to being able to reconnect communities, soon after the vaccination programme got up and running Professor Farooqi found hundreds of patients in the top four at-risk groups had not taken up the opportunity to receive their jabs.

‘Nationally the vaccination programme has clearly been pretty successful – and most of that has been done by GPs, but what we’ve noticed in our areas is that although uptake has generally been good there are some areas where it is really poor. And the real worry is that it has been really poor in those areas which are socially and economically deprived, or areas with high black, Asian and minority ethnic populations.

‘It could be anything up to

50 per cent lower than average in those areas and it’s a real concern because these are the communities most affected by hospitalisations and deaths.’

Overcrowding In Professor Farooqi’s communities, patients are more likely to live with large numbers of other people, there are a higher proportion of people from ethnic minorities and many patients are employed in jobs which cannot be done through remote working and often involve much greater social contact and, sometimes, poor protections.

‘We were really worried the people who really needed that vaccine just wouldn’t get it,’ he says.

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Leicester’s railway station has reflected the slow-down in commercial life

‘Uptake has generally been good, there are some areas where it is really poor’

‘Some people need individual, one-to-one attention and assurance’

plan. It could hardly sound more simple but it could hardly have been more effective. On one Saturday Professor Farooqi, his GP colleague and other practice staff called those patients.

They managed to make contact with around 300 of those patients. Around 70 per cent of those contacted took up the offer of a vaccination after a conversation – and 95 per cent of those subsequently followed through and turned up for their jabs.

The results are amazing but there should be no great surprise. After all, isn’t this what general practice does at its best? Relationships with patients, understanding of local communities and a calm and trusted voice among the madness of modern social media, mistruth and fear.

With so much at stake, and the potential for vaccine hesitancy to undermine the vaccination programme, how did Professor Farooqi and his colleagues go

about those conversations, The Doctor asks.

‘You can’t be too dogmatic, this isn’t about lecturing them. You are there to listen to their concerns but then to explain why what they have been thinking isn’t quite right, why they might not have the right information, or to explain why it is actually really important.’

There isn’t as clear a narrative to describe these patients as some who like truth to be binary might hope.

Some patients had fallen victim to mistruths peddled in the media or through whispers in communities. But others felt they were safest staying at home shielding as they had been for so long and many were concerned about how the vaccine might react with the medicine they were taking for other conditions.

‘It has been amazing. As GPs we know that if we ring people up, they will often do things because we have those relationships and those conversations are important but I don’t think we expected

this level of success.

‘That’s why you go into medicine. To have an impact on individuals and their lives.’

Scheme expanding NHS managers in Leicester have now been convinced, with the evidence speaking for itself, that the scheme should be rolled out across many more areas in the city.

Twelve PCNs (primary care networks) are likely to be involved, with 50 or 60 GP practices covering the more deprived or diverse parts of the community set to take the scheme up. It is thought this could mean seven to 10 thousand more patients being vaccinated, potentially taking total takeup in the area to above 90 per cent.

For many GPs around the country the thought of taking on a scheme like this which adds to the workload will seem impossible, particularly after such a challenging and exhausting year. Professor Farooqi says the efforts were ‘time consuming’ but feels

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LOWER UPTAKE: Patients from some ethnic minorities have taken up the COVID vaccine in lower numbers

VAUTREY: ‘Reach out and give them more time to discuss their questions’

‘Local practices that have a good relationship with their patients and understand their local community can make a big difference to vaccine uptake’

they were very much worth it, and funding has now been found at sustainability and transformation partnerships level to resource and compensate those practices taking part. Professor Farooqi estimates the staff costs at £1,000 to £2,000 in his practice and says health leaders have found up to £100,000 to cover the wider efforts.

Professor Farooqi, who has been a GP in this community for more than 30 years, says: ‘This is impacting the areas that need it most, highly deprived communities with high proportions of people from BAME backgrounds where the prevalence is greater. These are the areas we need to try our hardest in – and this works. The broad approach of inviting people through the media works for the majority, but the trouble is that is the same whether you live in Westminster or South Shields, whether you are from a poor background or are a millionaire. Some people in these groups need

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this individual, one-to-one attention and assurance. This bespoke approach is best.’

BMA GPs committee chair Richard Vautrey adds: ‘This is a good example of how local practices that have a good relationship with their patients and understand their local community can make a big difference to vaccine uptake.

It’s why the vaccination rates have been so high across the country and the programme has been so successful.

‘Where there is a need to reach out to particular individuals and groups and give them more time to discuss their questions or anxiety related to the vaccine this would be helped by additional support to cover the time involved.’

Community leadership The scheme in Leicester is just one example of initiatives having success around the country. Earlier this year the pastor of the UK’s biggest black majority church set about urging members of his congregation to take

up offers of the COVID-19 vaccination, in a bid to help dispel hesitancy and concerns among people from ethnic minority backgrounds.

Agu Irukwu of the Redeemed Christian Church of God, which has around 800 places of worship across the country, told The Observer newspaper that he was hoping to encourage congregations to take their jabs and to ‘dispel vaccination concerns’.

The Volunteering Interfaith Programme, an initiative in Bradford which joins the city’s Christian, Hindu, Muslim and Sikh leaders and which has supported the community during COVID-19, has been supporting vaccine take-up.

Dr Vautrey adds: ‘We are also seeing examples of pop-up vaccination clinics in places of worship and other local community settings, again done through practices working with others in the area. GPs want to protect their patients from COVID-19 as quickly as they can, and they will do all they can to enable this.’ thedoctor | April 2021 27

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HEALTH CAMPAIGN: An HIV awareness campaign in London in 1987 (left) and a contemporary poster

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When AIDS arrived A TV drama inspired Stephen Glascoe to remember the despair and bigoted attitudes faced by AIDS patients in the 1980s

Credit: The Board of Trustees of the Science Museum

A

s with much of the nation, I am reeling from the effects of a TV drama series.

In It’s a Sin, writer Russell T Davies draws on his own experience to tell the story of five gay friends living in London through the AIDS pandemic of the 1980s. And the atmosphere he creates is so powerful that I find myself transported back nearly 40 years to my own experience of AIDS, not as a gay man but as a GP who bore witness to countless stories of suffering and death, some eerily similar to the ones which were playing out on my TV. Reports began to emerge, in 1979, of increasing numbers of young, gay men in the San Francisco area falling prey to illnesses normally associated with a defective immune system. At first, it was called the ‘gay plague’. It was not

long before we would hear US evangelical pastors, politicians, and even senior medical figures tell us these men were ‘architects of their own destruction’.

The medical response to it was at first deplorable.

We had, after all, plenty of experience of dealing with blood-borne infections, in particular hepatitis B, which spreads in exactly the same way as AIDS, but when it came to AIDS I noticed some doctors deploying bigoted and judgmental attitudes. One of my AIDS patients had been due to have a routine hernia repair, and had been booked into his hospital bed in the usual way.

But when a senior registrar arrived on the ward and glanced at his medical notes he exploded.

‘What’s HE doing here?’ he demanded of his accompanying nurse. Without

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waiting for a reply and refusing even to look in his direction he shouted for all the ward to hear: ‘Get him out of here now, sister. I will not have patients like him on my ward!’

Offering comfort Another man, new to my practice, told me what happened when he had entered his previous doctor’s surgery.

‘Oh my God it’s the man with AIDS!’ yelled one of the receptionists the moment she saw him. I told him he was welcome at my practice and I and my team would treat him no differently than any of my other patients. And I asked him to spread the word among his gay friends I would also welcome any other gay man or AIDS patient who had experienced similar discrimination from the medical profession.

One by one they came with their horror stories, not unlike the one inflicted on one of the characters in It’s a Sin, who, no sooner is he diagnosed than he is whisked away and locked up in an isolation hospital, under archaic legislation designed to stem the spread of cholera.

Apart from being furious with my colleagues who had behaved so despicably, my predominant emotion at the time was that of utter helplessness. Beyond bearing witness to their plight, I could do very little for these people, and at the time, neither could anyone else.

But there was something I could do. A friend once defined the role of a doctor in these terms: ‘To cure sometimes, relieve often, and comfort always.’ In those early days the first option was out of the question. As for the bma.org.uk/thedoctor

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second, even treatments to alleviate suffering were limited; even considering the recent advances in palliative medicine, people often died in terrible pain. But comfort: here at least I could do something, even if it meant only putting an arm round a shoulder, or simply giving a good old-fashioned hug. This meant a great deal to these people who were far more used to being shunned.

And perhaps it meant even more coming from a doctor.

It showed them I wasn’t afraid to touch them. You don’t get AIDS by touching an infected person, or even kissing them, although many people didn’t know that at the time.

In 1982 one of my haemophiliac patients, Huw, came in to ask what a series of purple-ish blotches which had appeared on his skin might mean. He said he thought he might need an HIV test.

It turned out Huw was the first patient in my practice, and one of the first in the UK, to have contracted AIDS from a blood transfusion. For some time the UK had been buying in Factor VIII concentrate from the USA, much of which had been derived from the prison population. Later this plasma was screened and the problem was avoided, but in the interim thousands of haemophiliacs all over the world died of AIDS. My patient was one of the early ones. Huw was dead within 18 months of that first fateful encounter in my surgery.

Mother and child Around the same time I had a young woman patient some to see me. Heather was what doctors call a poly-drug abuser, although she had resisted injecting them until she formed

an unfortunate liaison with a hardened IV drug user who introduced her to its delights.

And naturally enough, as lovers do, they shared everything.

She too came in and showed me the tell-tale signs of Kaposi’s sarcoma which had appeared on various locations on her body. My heart sank as I realised what I was looking at and advised her to have the test. It was positive of course; worse still, if such a thing is possible, her pregnancy test proved positive as well.

Heather’s progress was entirely predictable. Her baby was born with AIDS, and died within a few months. She followed her baby less than a year later.

I did my best to shut myself off emotionally from the tragedy, as doctors are tacitly encouraged to do, but this proved impossible.

Yet there were survivors too. Of the people who tested positive in those killing days, a few, amazingly, are still alive today. I think particularly of a man called Iorwerth. Softly spoken and self-effacing, he radiated a quiet charm. He first tested positive in 1983, but his t-cell count remained consistently high. And when anti-retroviral treatment finally became available, he responded well and his viral load fell away almost to zero. Nature rarely obliges us in that way.

I am grateful to It’s a Sin for stirring my memories and, more importantly, for educating a huge cohort of people too young to remember what happened 40 years ago, in the time of another great pandemic. Their stories must be told, lest we forget.

GLASCOE: Pictured in the 1980s

‘I told him he was welcome at my practice’

‘At least I could do something, even if it meant only putting an arm round a shoulder’

Stephen Glascoe is a retired GP from Cardiff thedoctor | April 2021 29

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viewpoint Have you ever been told you don’t look like a doctor? The answer is not to change how you look, but for society’s outdated attitudes to catch up with a diverse profession. By BMA representative body deputy chair Latifa Patel Comportment. It is not a word one hears often. But when I opened Twitter recently, it was trending – and I had no idea why.

As an intermittent tweeter, I sometimes find myself in the dark about the most recent #MedTwitter discussions. Most of the time this doesn’t phase me.

However, when an issue completely takes over my timeline and my personal dictionary is presented with an unfamiliar term I feel forced to do some digging.

For those not on Twitter, to summarise in a few words, it was suggested that a female doctor may have been mistaken as a nurse owing to her ‘comportment’, or her behaviour. Well, that was news to me – and it was news to almost all of #Medtwitter, thankfully.

I reflected back to one of the many times I had been mistaken for something other than a doctor. The number of times I would introduce myself to a family as the doctor looking after the child only to hear them tell their friend on the phone that the nurse was in their room.

Or, there were the occasions when the nurse asked me if I could action all the TTOs thinking I was the ward pharmacist. And then there was the time one of the senior doctors thought I was part of the domestic team because I regularly emptied the mess bin on nights.

If doctors were expected to display a specific ‘comportment’, what would it even look like? Would it be taught? Examined on? Who decides what ‘comportment’ would be apt for a doctor?

Thankfully, this isn’t the case.

I don’t mind being mistaken for another profession but I do mind not being recognised as a doctor. And I know it happens more to women than men. Doctors aren’t superhuman or different from the general population – our ‘comportment’ varies as much as the rest of society’s. It isn’t our ‘comportment’ driving these discussions – it is the observer’s bias.

The comportment discussion reminded me of many of the reasons I first became involved in the BMA – and the values that drive me in my position as deputy chair of the representative body.

One of the BMA’s aims is to make the medical profession reflective of the society we live in – and the patients we look after. We should never forget that medicine is best when it is a partnership. We know simply telling patients and families what they should be doing is less effective than working with them – when care is bespoke and personalised. If we are to truly understand our patients’ needs we should reflect them far better.

In this issue of The Doctor we spoke to a GP in Leicester running a scheme where doctors call patients who have not taken up their offers of jabs.

The difference this trusting relationship makes – a relationship where doctors do not feel external to the communities in which they work – is vital.

As a foundation year 1, I was fortunate to be able to join the BMAs equality and diversity committee, now called the equality, diversity and inclusion advisory group, which aims to celebrate and support diversity in medicine.

The group will be open to new members in July this year and doctors are able to nominate themselves to take part. If you feel passionate about these issues get in touch with the group, speak to myself and Helena or even run for a position later this year.

One other area where we need to take action – and where the ‘comportment’ debate is particularly apt – is around sexism. The 2019 NHS staff survey reported the highest levels of sexism to date and we are keen to find out about doctors’ experiences and how we can look to address these problems.

Dr Patel can be contacted directly through Twitter at @drlatifapatel

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

An abrupt termination of an overseas doctor’s contract left him in difficulty with his visa, but a BMA adviser’s efforts bought him the time and space he needed to keep his career on track An overseas doctor faced having to leave the UK because an employer misled him about the length of a fixed-term contract.

The doctor had been offered a number of short-term posts, including one local to his home address, but when he was offered a 12-month appointment some miles away he took it because it meant he would reach his qualifying period for applying for ILR (indefinite leave to remain) during the yearlong post fulfilling one of the criteria. He duly moved house, taking out a 12-month lease on a new property.

Part of the way through his contract, and just a few months before he was able to apply for ILR, his department dropped a bombshell.

It gave him three months’ notice to end his job – not because he was under-performing, but in the words of a rather curt email, there had been an ‘error on the contracts’. Another doctor was coming to take up the post and the overseas doctor was not needed once that doctor arrived.

The doctor thought there had been no error at all. He believed the hospital had deliberately planned it that way, getting him for exactly the time it wanted without any thought as to the consequences to his future. It had advertised for a 12-month post, knowing it would get more applicants that way, rather than a shorter-term post.

The notice period could not have fallen more badly. It meant he was due to leave his post weeks before he could have applied for ILR. Worse than that, the employer insisted he kept to his notice period, meaning that he could not easily apply for other posts to help him make his ILR application and stay in the country. He was offered a post in another part of the country but was unable to give

his potential new employer a start date, and it seemed in jeopardy. At the same time, he was trying to apply for training posts, but this too was affected by the uncertainty with his immigration status. He faced the prospect of his visa running out and having no choice but to leave the UK. The BMA adviser contacted HR, calling for the decision to be reversed given that the hospital was under-staffed. It seemed that his employer had to lose a doctor and had picked him without any consideration for his circumstances. If he could not be kept on, the adviser argued, he should at least be released early so he could look for other jobs and find an employer prepared to sponsor his visa.

This was a great example of persistence by the adviser. The department – the same department which had given him notice – was then worried about being short-staffed and wanted to keep him on for the full notice period to fill rota gaps. But the adviser worked on the HR department and encouraged it to see the situation from the doctor’s point of view. The department shifted a little, saying he could go early if another doctor could be found, but the adviser persisted, saying those gaps could be covered by locums – it wasn’t fair that the doctor was viewed as the cheaper option when he had not chosen to leave.

Eventually the employer relented and allowed the doctor to leave early so he could give a start date to the new employer so they could arrange the correct visa. It had been a stressful time for him. He had wanted to return to his home country to visit a sick relative but had felt unable in the circumstances. Now he was able to apply to stay permanently in the UK. He said he had received ‘exceptional support’. thedoctor | April 2021 31

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