The Doctor – October 2021 by The BMA

The magazine for BMA members

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Issue 36 | October 2021

Besieged Standing up for scapegoated GPs A lesson in hope

The doctor who grew up with war, disease and malnutrition

‘Do I belong?’

The question that prompted a push to boost diversity

Side effects

COVID – technology’s friend, bureaucracy’s foe?

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In this issue 3 At a glance General practice sees a two million increase in patient consultations

4-7 Cornered GPs are facing abuse and violence. The Government needs to stop fuelling unrealistic patient expectations, and invest in primary care

8-11 Never give up Waheed Arian survived war, disease, and malnutrition. Arriving in the UK as a refugee, he became a doctor and now provides vital support to colleagues overseas

12-15 ‘It’s not fair and I can help’ The doctors who took the initiative to provide immediate medical care to Afghans arriving in the UK

16-17 A shared struggle Increasing African and Caribbean representation in the profession

18-21 The future barges in How the pandemic forced rapid technological change and some welcome cuts in bureaucracy

22 Your BMA Protecting ourselves, and supporting others to take proper breaks

23 On the ground A doctor is oﬀered very poor sick pay after covering a COVID ward and catching the virus

Welcome Chaand Nagpaul, BMA council chair No doctor should ever have to face abuse or fear for their safety when in their workplace. Unfortunately, many of us will have seen the rising tide of hostility that is threatening to engulf general practice. Numerous accounts of doctors and their primary care colleagues enduring verbal abuse, intimidation and sometimes even violence in their workplaces is unacceptable and an area of concern receiving focus from the BMA. This month’s edition seeks to give a voice to those working in primary care, some of whom are facing abuse on a daily basis, and to set out the extensive work being undertaken by the association to address this situation. The fall of Afghanistan to the Taliban, and the subsequent humanitarian crisis provoked by this event, has been one of this year’s most shocking tragedies. While the future of the country remains grave and uncertain, there are at least many individual stories of courage and determination that can hopefully inspire hope. One such story featured in this month’s edition is that of the personal journey of Waheed Arian. Born in Afghanistan during the conﬂict with Soviet forces, Dr Arian faced disease and destruction throughout early childhood before eventually coming to the UK as a teenager where he was able to realise his dream of becoming a doctor. In another piece we hear more about what actions are being taken in the UK to support the health needs of Afghan refugees arriving in this country. As October sees the BMA join celebrations to mark Black History Month we hear from recently qualiﬁed Olamide Dada who, as a medical student, set up Melanin Medics – a charity advocating for greater representation of black people in medicine. Drawing on her own experiences, Dr Dada expands on the barriers faced by many people of African and Caribbean heritage who wish to enter the medical profession, and what can be done to improve diversity in the NHS workforce. Lastly, we explore the many ways in which the pandemic has changed day-to-day practice from the introduction of new technologies to reduced bureaucracy and new ways of working. We hear from doctors working in primary and secondary care as to what advances and challenges these changes have presented, and which innovations they believe could be here to stay. Read the latest news and features online at bma.org.uk/thedoctor

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

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AT A GLANCE GPs face unfair criticism, and even abuse, for not being sufficiently available to patients. However, new data from NHS England shows they are offering more appointments than before the pandemic, while face-to-face consultations are increasing – and all from a workforce which has fallen sharply in the last five years despite Government promises to increase it. BMA GPs committee deputy chair Mark Sanford-Wood said the figures prove that primary care is working harder than ever. He said: ‘Every part of the NHS is under an immense burden like never before. Waiting lists, a huge backlog and many people needing their GPs who have been waiting so as not to overload general practice – all these factors layered together give us a crisis in healthcare. COVID is still impacting GPs and their teams with staff absences, having to cope with small waiting rooms and now an earlier than normal increase in respiratory viruses piling on even more pressure. Despite this, these Government figures show GPs are working harder than ever and dealing with even more patients than before the pandemic.’

The total number of GP appointments was 25.5 million in August 2021 whereas it was 23.3 million in August 2019

GP SURGERY

Source: NHS Digital

The percentage of appointments delivered face to face was almost 58 per cent for August 2021, the highest of any point this year

58%

There are 1,904 fewer whole-time equivalent GPs in England than there were five years ago Source: NHS Digital

1,904

20,000

Almost have signed the petition in support of general practice

bma.org.uk/thedoctor

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Source: BMA

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SIMON BOLTON

JANJUA: ‘The Government needs to change its stance and actually protect NHS staff’

CORNERE GPs and their practice colleagues are facing abuse, threats and violence. They tell Tim Tonkin why the Government, rather than fuelling unrealistic patient expecations about a desperately under-funded system, needs to invest in primary care and be honest with the public

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RED

he NHS’s response and role in fighting COVID-19 has, at times, seen many sections of the health service and its staff lionised by Government ministers, the public and the press. While the merit of simply ‘clapping for carers’ could be, and has been, questioned by many in the ranks of an understaffed and under-invested-in NHS, the sentiment behind this outpouring of gratitude has not. Yet there is another side to the national narrative on COVID and the health service, one which not only appears to be an attempt to scapegoat one part of the medical profession, but which is fuelling a disturbing rise in abuse, harassment and even violence against frontline doctors and their colleagues. General practice, and the doctors, nurses and administrative staff who operate it, are on the receiving end of a growing tide of verbal and sometimes physical abuse from patients, apparently angered by their opposition to the vaccination roll-out, delays in accessing care owing to systemic pressures from the pandemic and claims in certain parts of the media that GPs are ‘refusing to see patients’. An example of abuse and intimidation, submitted to the London-wide local medical committees by a GP surgery in the capital, highlighted one of several unpleasant confrontations encountered by staff in recent weeks. ‘A patient came into reception a few weeks ago (maskless) at my practice, found no one at the front desk so barged round into the back office where staff were, shouting and pushing his phone and a letter we had sent into the face of a receptionist and repeatedly demanding she read it aloud,’ the anonymised staff member reported. ‘He was upset that we had sent him another invite for vaccination after he had specifically asked us not to. I came out to reception on hearing the commotion, along with another clinical colleague. The man was aggressive enough that we called 999 – shouting, swearing, getting very close and “squaring up” to us, despite my attempts to acknowledge our error and apologise, and offer to discuss. ‘Distressing for all concerned, as you will imagine, and this is just the worst of a number of incidents. We have had reception staff in tears several times in the last few weeks because patients or relatives have been so unpleasant.’

Primary care targeted Another anonymous account told of how they and their colleagues had received numerous ‘abusive responses on text, via email, by phone and in person’ from patients during the pandemic. They went on to explain that the most upsetting thedoctor | October 2021 05

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going to take you to the court of human rights”. We’re and unnerving instance of this abuse came when an getting e-consultations which are littered with abuse and anonymous letter warning that ‘all medical practitioners, foul language. It’s coming at us from all angles.’ doctors and nurses’ would be ‘on trial and held accountable for war crimes’ for their role in delivering the vaccination programme. Police called ‘This was photocopied numerous times and put in Most frightening are the occasions when patients and envelopes and individually addressed to each of our other members of the public attend the practice and clinicians and posted through the door after dark,’ abuse and threaten staff in person. the staff member noted. ‘I reported this to the police Ms Fielding tells of two occasions, one where she and our CCG but [got] no response from the police.’ and her colleagues were confronted by a well-built, 6ft Disturbing anecdotal accounts are unfortunately all 5in tall, male patient who became aggressive and threw too frequently buttressed by the data something at staff over the reception drawn from multiple surveys of doctors desk, and one where someone locked ‘The man was working in primary care. themselves into and then destroyed the aggressive enough A BMA Viewpoint member survey practice’s toilet. of more than 2,400 doctors in On both occasions, Ms Fielding that we called 999 – England, Wales and Northern Ireland contacted the police, but no officers shouting, swearing, carried out in July, found that 46 per attended. ‘I called the police and asked getting very close and them to come out and told them that cent of GPs had experienced one to “squaring up” to us’ five incidents of verbal abuse, while the only people in the building were roughly one-in-five (19 per cent) had four female members of staff,’ she says. received threats, in the previous ‘They [the police] said they didn’t have month. the resources to send anybody out while all we could Within the same survey, 67 per cent of GPs said that hear was stuff [inside the toilet] being smashed.’ they had witnessed violence or abuse directed at other Misleading media staff in their workplace in the past year, while 37 per As unacceptable and unfair as the rise in hostility cent said that the instances of threatening behaviour, violence or verbal abuse they experienced had increased towards general practice is, the phenomenon does not appear to have begun within a vacuum, with significantly on the same period 12 months ago. sections of the national press having since last year Meanwhile, a study from May this year conducted by set critical and accusatory tones with regard to GPs’ the Institute of General Practice Management found role within the pandemic. that 75 per cent of GP staff surveyed claimed to have A notable recent example of this has been in a experienced abuse from patients on a daily basis. tabloid newspaper, with a campaign ostensibly to ‘I think every member of staff has been subject to increase the number of face-to-face abuse in one way or another,’ says appointments offered in practices. practice manager Theresa Fielding*. ‘We have patients phoning up and But in doing so, it has come up with ‘We’re getting headlines such as ‘the great GP shouting and swearing at them and e-consultations surrender’ and called for practices abusing them on a daily basis. Every which are littered which do not offer in-person single member of staff has pretty consultations to be penalised. much been in tears by the behaviour of with abuse and Contrary to the narrative circulating patients.’ foul language’ in sections of the national media, In charge of a practice in central Ms Fielding says that many GPs are London, Ms Fielding says that while actually seeing more patients than ever abusive behaviour from patients was before, in part because of the rise in telemedicine and not unheard of prior to COVID, the frequency and level of abuse has definitely increased during the e-consultations, leading to unrealistic expectations. course of the pandemic. This was supported by recent NHS Digital figures for England, which showed there were 25.5 million GP She tells of how aggressive and rude behaviour is experienced across every platform the practice has for appointments in August 2021, compared with 23.3 million in August 2019. communicating with patients, from phone calls and ‘We have been seeing patients face-to-face but that’s emails, to responses to automated texts. not the narrative they’re getting because of what’s out ‘Some of the [text] responses we got back were things in the press,’ says Ms Fielding. ‘Everybody is bashing like “I’m going to come down there and kill you”, “I’m 06 thedoctor | October 2021

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VAUTREY: Abuse is unacceptable

general practice, everywhere you turn there are conversations about not being able to see a GP, or that GPs aren’t seeing patients. ‘The fact that there is this national narrative about us “not doing the job” [when] we’ve got a national shortage of GPs, we’ve got GPs off sick, we’ve got GPs with COVID who are isolating, there is no account made for that whatsoever.’ Ultimately, the effect of this climate of abuse is taking a toll on practice staff already exhausted and stretched to breaking point from COVID. ‘All of my doctors are constantly saying that they’re barely managing,’ says Ms Fielding. ‘We’ve been going into work every day to provide a service right the way through the pandemic, and yet people think it’s acceptable to swear and abuse us. ‘I know that there are staff who have had to seek support from the mental health services that are available because we can’t cope.’ Lancashire-based GP Adam Janjua’s experience of aggressive and abusive behaviour from patients led him to make a public plea on Facebook live for general practice staff to be shown more respect. While the video was well received by those working in healthcare, its message has not made a noticeable impact on the day-to-day realities being faced by Dr Janjua and his colleagues. ‘Barbed comments and passive aggressiveness has been on the rise ever since [the video streamed], we’re getting it daily now to be honest,’ he says. ‘GPs are fed up. They are working flat-out, 12-hour days or longer and, on top of that, having to face abuse. The least we would like is a little bit of appreciation if not from patients then at least from NHS England or the Government to say that we’re doing a good job and have carried the country through the pandemic. ‘Morale is at an all-time low and people are looking to leave [general practice] whether that means emigrating abroad or retiring early, but we are looking at a huge shortfall of staff in the next couple of years.’ Dr Janjua says he feels misinformation put out by NHS England concerning the type of services being offered by GPs, coupled with statements by the Government, had fomented an environment of suspicion and resentment towards GPs among sections of the public. ‘The trigger here I think were the NHS England press releases saying that GPs needed to start seeing patients face-to-face,’ he says. ‘That triggered a lot of anger from patients and then other people just jump on the bandwagon.’ Dr Janjua says he would like to see laws introduced that would see those guilty of physical abuse or even threats of physical abuse to NHS staff facing tougher sentences, something that the BMA has also advocated for. He also felt that practices needed to be given powers bma.org.uk/thedoctor

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allowing them to remove a patient from their lists if that individual had been abusive towards their staff. ‘The Government needs to change its stance and actually protect NHS staff,’ he says. ‘If you’re going to stand up and tell people or release press statements that GPs aren’t seeing patients, the retraction needs to be just as good. People will hear the scandalous stuff but if you don’t shout out that you were wrong and that general practice has always been open and is in fact operating at greater efficiency than before the pandemic, then you haven’t done enough to support general practice.’

Demand to act Following an attack on a GP practice in Manchester on 17 September, in which four members of staff were left injured, BMA GPs committee chair Richard Vautrey held an emergency meeting with health and social care secretary Sajid Javid to urgently discuss the ‘terrible trend’ of abuse, harassment and physical attacks being levelled at general practice. During the first of a series of planned meetings on 23 September, Dr Vautrey said the association had called on the Government to back GPs, invest in primary care and be honest with the public over pressures in the NHS. ‘This emergency meeting with the health secretary allowed us to make it crystal clear how unacceptable the increasing abuse against hardworking and dedicated GPs and the general practice workforce is. ‘We made it very clear that the Government has to explain to the public why healthcare workers are still working within the constraints of infection, protection and control measures. ‘The health secretary must confront the reality of unsustainable workload pressures, poor premises, the impact of the care backlog and secondary care work transfer to general practice. ‘Words are not enough, we now need urgent action.’ Theresa Fielding is a pseudonym

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WAHEED ARIAN

EARLY AMBITION: A young Waheed Arian who chose to pursue medicine from the age of ﬁve

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Waheed Arian has lived in a refugee camp, sheltered in cellars from a civil war, and endured malaria, TB and malnutrition. Now a doctor in the UK, who supports colleagues in his Afghan homeland and other countries, he makes a passionate case for solidarity and kindness. Seren Boyd reports

UK, Dr Arian uses telemedicine to support his counterparts in his homeland. ‘We need to tell them that we haven’t abandoned them. It feels like everyone has left, and we’re telling them we’re still here, supporting them. We shouldn’t underestimate how important that is.’

The fight for survival Dr Arian’s own extraordinary story illustrates vividly how decades of conflict and political turmoil have robbed Afghanistan of a

Pakistan in 1998. His father was a conscientious objector, and evaded conscription by hiding in Logar province. The rest of the family had stayed in Kabul, Dr Arian’s mother depending on rental income and friends to feed her children. ‘Military service meant being sent to the front line and that was usually a death sentence,’ says Dr Arian. ‘There were Afghans on both sides of the conflict, and my father didn’t want to fight Afghans.’ Pakistan was a chance for

‘It feels like everyone has left, and we’re telling them we’re still here, supporting them’

WAHEED ARIAN

ope is a powerful thing. For now, it’s sustaining the doctors working in Kabul’s hospitals – even despite running short of bandages, blood products, antibiotics… everything. The supply of COVID vaccines has dried up and they are reusing disposable personal protective equipment again and again. Most of the doctors in Afghanistan whom Waheed Arian supports have resisted the temptation to join the exodus after the Taliban takeover in August. These doctors want to believe things can improve. But hope can’t run on empty. ‘The border is closed, food and medicine are running out, prices have sky-rocketed,’ says Dr Arian, a former Afghan refugee now living in Cheshire. ‘They are still working – the female doctors too – but they are all terrified. ‘Doctors haven’t been paid for months. One texted me and said: “I don’t want to leave the country but I need to find another job.” And that breaks my heart.’ One of the biggest risks to the healthcare system in Afghanistan – and the morale of its workers – is international isolation. Doctors fear they might lose not just humanitarian support but also the window on to another world, the prospect that things might improve in Afghanistan too. So, alongside his work in emergency medicine in the

functioning health system and human capital. Dr Arian had wanted to become a doctor since he was five. After years of ‘hiding in cellars from the daily rockets, bombs, shelling and jets in the sky’ during the Afghan-Soviet conflict, the family fled to

the family to be together – but it was treacherous too. To reach Peshawar, they travelled at night through the mountains in a caravan of horses and donkeys, along the weapons-supply route for the Mujahideen. Dr Arian only survived a Soviet helicopter

LIFELINE: Dr Arian advises a doctor in Afghanistan

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GETTY

‘My parents sold everything to get me out’

gunship attack because his father hid him in a bread oven. Within days of arriving at the Babu refugee camp, they caught malaria. Soon, Dr Arian fell ill with tuberculosis. ‘The conditions in the camp were absolutely inhumane. There were big families living in tents, in 45-degree heat, with hardly any food, clean water or sanitation. Many people died of malnutrition and malaria.’ The camp doctor gave Dr Arian odds of 50:50 that he would survive because he was so malnourished. But, noticing the boy’s fascination with his X-rays, and the absence of any toys, he also gave him a stethoscope and an old medical textbook.

A sustaining ambition

‘There’s no capacity to train specialists, and doctors don’t have the opportunity to train abroad’

In 1991, they returned to Kabul, because Dr Arian’s father was beyond the age of conscription. For a year, things were calm. ‘For the first time ever, I had a ball to play with and started going to school, so I was very happy.’ But within a year, the civil war had entered a new phase as the Mujahideen ousted the Soviet-backed president, Mohammad Najibullah. ‘It was a street-by-street fight so we were hiding in cellars again, fleeing from one part of the city to another, stepping over dead bodies and dodging bullets.’ His education faltered again, fuelled only by the few books his father could find, and classes in the refugee camp in Pakistan where they fled again as the fighting in Kabul intensified. When depression descended on Dr Arian at the age of about 10, what

sustained him was ambition, and snatches of ‘an alternative reality’ glimpsed through the BBC World Service and the occasional Hollywood film – not the sedatives his doctor prescribed. ‘Sedatives made me sleepy and in wartime you have to be on your toes. So, I’d hang on to the hope that one day I would go to school, have friends and become a doctor – even though I didn’t know how.’ Unwittingly it was the Taliban who propelled Dr Arian into fulfilling his dream. By his early teens, he was helping his dad run a taxi service and the Taliban often took rides. ‘I remember them saying: “Would you like to fight with us? You could be a good soldier.”’ Then a rocket attack on their neighbours’ house wiped out that entire family. Dr Arian’s parents decided it was time: they sold the house and possessions to raise £7,000 to buy their son what they thought was legitimate passage to London, where they had a friend. ‘The dream was to become a doctor in Afghanistan but all those doors were shutting on me. The country was isolated. I couldn’t get into medical school: we were not privileged enough. So, my parents sold everything to get me out.’ When he arrived in London, just 15 and with £70 in his pocket, he was sent straight to the Feltham Young Offender Institution. His papers were false.

Three jobs and study For the next three years, Dr Arian held down three jobs – as kitchen porter, cleaner and shop worker in London – and studied for A-levels in the

evenings, as his autobiography In The Wars recounts. It was years later that Dr Arian diagnosed his hyper vigilance back then, his sensitivity to the sound of the Tube, his visions of tanks in the street. This most recent Afghan crisis has triggered his PTSD (post-traumatic stress disorder) and cost him sleepless nights. He read voraciously in the house he shared with other refugees, then started taking evening classes and exams. He did well and decided to aim high: Cambridge. ‘My colleges discouraged me from applying and, though I was pretty humiliated by that, it just made me more determined to prove them wrong.’ He won a place to study medicine at Cambridge, did his clinical training at Imperial College London and won a scholarship to do an elective at Harvard. It was when he was a junior doctor in London and Essex that he started to combine trips to his family in Kabul with visits to five local hospitals. He was shocked to realise how basic the health service was. ‘Afghanistan’s education system is very outdated, there’s no capacity to train specialists, and doctors don’t have the opportunities to train abroad. The brain drain means many have left the country.’ Dr Arian noticed that colleagues in the UK were fascinated by his stories from Kabul and wanted to help. But it was too dangerous for them to visit. He had also started to realise the potential of telemedicine, noticing the ease with which scans and

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WAR-TORN: Abandoned Soviet tanks litter Panjshir province, Afghanistan WAHEED ARIAN

reports were transferred between hospitals, even internationally, during his radiology training in Liverpool. Even if Afghan hospitals did not have presentation technology, doctors had smartphones with Skype or Viber. Collaborating closely with the Afghan Ministry of Public Health to establish a strong clinical governance framework, he set up Arian TeleHEAL in 2015. Six years on, the charity is supporting emergency departments in 14 hospitals across Afghanistan, with casebased discussion, guidance and training seminars provided by an international network of 150 volunteer specialists. ‘Doctors send us scans and medical details of the cases they’re dealing with, whether it’s a bomb blast or serious illness, and I allocate them to one of the specialist groups of volunteers we have according to their specialty,’ he says. Arian TeleHEAL has since partnered with other governments and charitable bma.org.uk/thedoctor

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organisations to set up telemedicine initiatives in several nations including India, Syria, South Africa and Uganda. It has won Dr Arian many awards, from the UN Global Hero Award in 2017 to The Sun’s Who Cares Wins ‘Best Doctor’ award last month

Kindness and solidarity For now, Afghanistan is in purdah politically, its future veiled, its economy in crisis. At the time of writing, hospitals had a week’s worth of supplies left, with strict rationing in place. Some 3.5 million displaced people face a fierce winter without shelter or warm clothes. Dr Arian is adamant the UK Government needs to engage with the Taliban to ensure safe passage for continued humanitarian support. ‘You have to differentiate humanitarian engagement from political engagement. You can’t punish the Afghan people, with 15 million of them living in poverty.’ Since the Taliban takeover, Arian TeleHEAL has stepped

up its support in Afghanistan and Dr Arian has campaigned for proper support for Afghan refugees arriving in the UK, as the BMA has also done. His charity is appealing for mental health professionals to volunteer to support doctors in Afghanistan and new arrivals to the UK, many of whom are suffering from PTSD as he does. What will make the difference for Afghan refugees – and doctors in Afghanistan – is kindness and solidarity, he believes. Dr Arian knows that the compassion of others sustained him – from strangers in Kabul who sheltered his family during bombing raids, to the barrister who fought to free him from Feltham. ‘Our doctor colleagues in Afghanistan are not requesting a better life or better things. But they know their country will be extremely isolated. More than ever, they need moral support. It means the world to them that the international community is still in touch with them.’ bma.org.uk/afghanistan

HELPING HAND: Dr Arian with Afghan children

‘You can’t punish the Afghan people, with 15 million of them living in poverty’

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EMMA BROWN

KARIM: ‘I’ve never seen such a huge crisis’

When hundreds of Afghan refugees arrived in Britain, GPs took the initiative, visiting them, reassuring them and providing immediate medical care. Now the government needs to step up too. Peter Blackburn reports

‘It’s not fair and I can help’

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ohra Karim packed her doctor’s bag and prescription pad and drove the one hour and 10 minutes from her house to Heathrow. It meant leaving her family on her husband’s birthday, but she needed no convincing that it was the right thing to do. The north London GP had heard that between 600 and 800 Afghan refugees – people who had been plucked from their lives, shepherded on to overcrowded aircraft and transported some 3,500 miles to the UK – were being housed in airport hotels southwest of London. Dr Karim had phoned one of the hotels, informed them she was a GP working in the UK, originally from Afghanistan – and that she spoke Pashto and Farsi, two of the common languages in the country. Within 10 minutes she had received ‘so many’ calls from the paramedic staff working at the hotel asking for help that she left straight away, telling her family: ‘It’s not fair and I can help.’ ‘I’ve never seen such a huge crisis,’ Dr Karim says. ‘You are talking about up to 800 people per hotel. There was one woman with nine children there.’ Dr Karim, who was at the hotel until midnight and went straight back the next day, moved from room to room – assessing and prescribing as she went along. Some of the experiences were moving, and tragic: seeing a 12-year-old boy who was so malnourished he looked six, and speaking to one woman who had seen several deaths during a violent attack. ‘She saw the bodies of lots of children. She said that was something she can’t get out of her head,’ says Dr Karim. There were pregnant people and others who needed assessing for aches and pains. But many of those who found themselves in this strange and foreign country just wanted to talk. ‘It wasn’t just about the medical assistance, it was about reassuring them and telling them it will be fine,’ Dr Karim says. ‘There were a few young girls. I told them I came here like you, I have a job and a nice life. This is an opportunity if you work hard. You will get there, I told them that.’

Gratitude and relief Roghieh Dehghan is a GP in London with expertise in care for refugees and asylum seekers, and went to the Heathrow hotel with Dr Karim. Dr Dehghan had heard lots of stories

about ‘the horrors’ people had seen but didn’t find patients in desperate distress on the whole. ‘I found a relatively healthy population,’ she says. ‘And I thought I would see people bereft but that wasn’t my experience. If anything, what surprised me was most of them were grateful for being here and there was this sense of relief. ‘What was most important was that people wanted to share their story – they wanted to tell you their experience.’ Dr Dehghan, who is originally from Iran and heard grateful stories about help received from UK newspaper editors and army personnel, says, however, that those providing care in the coming weeks and months may have to be wary – as there is often a ‘honeymoon phase’ when it comes to these experiences. ‘When they arrive, that is usually the happiest period,’ she says. ‘That PTSD may come later.’ At the Heathrow hotels Dr Karim and Dr Dehghan’s efforts had been part of no organisation or structure. The care these Afghan evacuees received was entirely thanks to the compassion of their doctors, who worked without the backing of a CCG (clinical commissioning group) and with no confidence over their medical indemnity. The powers that be had simply arranged security guards and private paramedics, with no particular links to Afghanistan, who ‘didn’t have basic assessment equipment’ to hand. The London GPs had been in touch with health leaders urging them to put support systems in place and to empower them to help and gather others to help. The

DEHGHAN: Refugees can have a ‘honeymoon phase’ on arrival, but PTSD may follow

‘It wasn’t just about the medical assistance, it was about reassuring them and telling them it will be fine’

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responses – responses like ‘this isn’t your job’ – arguably paint Government and NHS leaders in a particularly unflattering light.

‘A mass of humanity’ The phrase ‘postcode lottery’ is often heard when it comes to the health service and patchy provision in many areas of care. For the Afghan evacuees arriving in the UK it was to be a swift introduction to the notion. While in many areas, such as Heathrow, care came largely from solo volunteers breaking down barriers to help, in others The Doctor has found coordinated and significant efforts to respond to the health and social care needs of these newest members of their communities. The decisions were made in Luton and Milton Keynes on the Thursday before the August bank holiday, with 800 Afghan evacuees due to arrive in three hotels in a matter of hours. A meeting was held with NHS England and their regional team, the local authorities and the providers of healthcare in the area. A critical incident was declared and GP, and CCG chair, Sarah Whiteman sprang into action alongside her dedicated colleagues. ‘We realised the people arriving were likely to have significant health and social care needs which were, we felt, clearly not going to be met by an onsite ambulance technician or healthcare assistant,’ Dr Whiteman tells The Doctor. Dr Whiteman posted about the situation on a Whatsapp group – ‘called something slightly embarrassing like “medics who mocha” – and the response was overwhelming. ‘It seemed to unite something and all of a sudden people from all over the country were volunteering to help us over the bank holiday weekend in whatever way they could,’ she says. The scenes at three of Luton and Milton Keynes’ most unremarkable hotels that weekend were far from unremarkable. Piled high in the areas where guests would usually have read the morning papers, had breakfast, or attended conferences were the sprawling signs of human need: supermarket shopping bags full of donated clothes, colouring books and toy diggers in hastily organised piles and boxes stuffed full of basic medicines and equipment like asthma spacers. The scenes hinted at the scale of the volunteer effort from the local community and

across the country and the pace at which local health leaders mobilised whatever response they could muster. For Dr Whiteman, who visited all three hotels in her area during a 24-hour period, the experience was overwhelming. There were experiences which were heartbreaking and others which were life-affirming. From the rooms which were a ‘mass of humanity – with children playing and colouring’ – and the pregnant women whose newborns would have a new life, to the couple in their 20s who were looking after three young boys who were the sons of the brother and sister who had been shot in front of them. Through compassionate tears Dr Whiteman says: ‘For me it was the first time I’ve ever been involved in anything like this. It was momentous and slightly life-changing really. These people were plucked out of an emergency situation.’

VAUTREY: There are excellent examples of services around the country

‘These people were plucked out of an emergency situation’

Logistical challenge The evacuees were all seen and many have now been moved to other areas of the country. Several doctors told The Doctor the process as run by the Home Office has been confusing and lacking communication – with people moved around the country often with little warning or explanation and others then moved into an area from a different part of the country. It is a system which has presented great problems in terms of continuity of care and relationship building with patients. In Luton and Milton Keynes there are at least 250 people in bridging hotels – and the majority are expected to live in the area. Local GP surgeries have agreed to register them and Dr Whiteman and her team are committed to appealing for politicians and health leaders to

‘All of a sudden people from all over the country were volunteering to help us’

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ED MOSS

empower them to put longer-term support plans in place. ‘We would like to set up a more formal response for the future,’ Dr Whiteman says. ‘There was an overwhelming emotional response to the voluntary effort and that was great, but the fact that it was needed shows we should formalise our response for the next time and stand up some proper support. ‘I think there would be a willingness to do that but obviously we need resource.’ In the days after the first period of helping in the quarantine hotels Dr Whiteman and her colleagues held a virtual meeting for everyone involved to discuss next steps. In an NHS where frontline staff so often face hierarchy, bullying and blame, the tone was almost shockingly kind and collaborative. Doctors and managers shared their emotions and stories, and their fears and anxieties about the future – and set about creating documents which would guide their efforts in future and look to build learning into everything they do. Local health leaders have already bma.org.uk/thedoctor

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begun to share their experiences and work with organisations from other parts of the country, but if this meeting is anything to go by there may be lessons to be learned beyond the practicalities of providing care for refugees. The work in Milton Keynes and Luton shows the value general practice has – and the extraordinary lengths frontline staff will go to, to protect the vulnerable and help their communities. BMA GPs committee chair Richard Vautrey says: ‘There are some excellent examples of dedicated services around the country that have been resourced by their local health systems to meet the specific and often complex needs of those who have fled from their home country and sought sanctuary and care in the UK.’ He adds that the BMA has recently supported the Doctors of the World toolkit, which provides guidance to practices on how they can register patients who may not have the usual documentation that many longer-term residents have. bma.org.uk/refugeeandasylumseekers

WHITEMAN: ’It was the first time I’ve ever been involved in anything like this’

‘We should formalise our response for the next time and stand up some proper support’

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SARAH TURTON

DADA: Questioned whether she even belonged in medical school

Melanin Medics is a charity focused on increasing representation of people of African and Caribbean heritage in the medical profession. Olamide Dada, junior doctor, founder, and chief executive, tells Jennifer Trueland why – at the age of just 18 – she decided to set it up

A SHARED STRUGGLE W

hen Olamide Dada began medical school in Cardiff, very few of her classmates looked like her. As a Black student from a fairly deprived part of Luton, she was, to say the least, atypical. Of 270 medical students, only 10 were of African and Caribbean descent – around 4 per cent. Life looked very different from multi-cultural and diverse Luton, and at first, she didn’t know what to make of it. ‘Starting medical school was a bit of a culture shock for me. Everyone in Cardiff was very friendly, but other students of Black African and Caribbean heritage were few and far between, and there also weren’t many students from other ethnic minority backgrounds. ‘I think for a lot of time, particularly in my first year, I questioned whether I deserved to be in that space, or whether I belonged in that space. I’d say it challenged my identity.’ When she started to make friends, she found that other Black medical students had faced similar

struggles. At her own school, although they were accustomed to sending people to people to medical school, Olamide still experienced a number of challenges when applying and her father had to fight to get a predicted A-level grade changed to keep her in the running during the application process despite her proven academic capability. ‘Many of us had the same experience – whether it was teachers that didn’t want to give us the right predicted grades, or finding it difficult to get work experience or find mentors. That got me thinking in terms of setting up Melanin Medics, which stemmed from the desire to see more people like me.’

Outreach and support Today, Melanin Medics is a largely volunteer-led and run charitable organisation that has supported thousands of young people in the UK through outreach, and hundreds of current and future doctors with African and

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‘It was very challenging – sometimes I’d have to go to Caribbean heritage. The organisation provides practical London from Cardiff for conferences or meetings and support through a number of programmes, events, go back the same day, and it’s a long journey, so I’d be engagements, outreach, networking opportunities and tired, then there would be lectures the next day, then mentorship. Even throughout the pandemic the charity more meetings. It was a lot, but I’ve always enjoyed continued its work, although most of its activity went online. Its impact report for 2020 shows that it supported what I’ve done.’ 270 aspiring medics, had 267 doctors and 408 medical Her parents kept her on track with her studies, she students in its networks, and had a combined social laughs. ‘They would say “if you’re not a medic, what is media following of 12,030. There were Melanin Medics?” to make sure that 560 workshop attendees and 664 I was passing my exams and doing people attended events. my best. But it’s good because I also ‘I think people The charity campaigned to raise think it taught me fundamental time awareness of the disproportionate management skills, and how were waiting impact that the pandemic was to prioritise.’ for something having on Black medical students Dr Dada, who hopes to enter general like this’ and doctors. It also developed of the practice, also has an interest in public Mind Us Project, initiatives focused health, particularly health inequalities on supporting the mental health and the role of race in health and wellbeing of Black African and outcomes. She is keen on leadership Caribbean medical students and doctors, which was and management; she is an alumnus of the Healthcare supported by the BMA via BMA Giving. Leadership Academy and is studying for a post-graduate Dr Dada remains chief executive, having built it up certificate in leadership. from what was basically an idea for a blog in 2017. Dr Dada describes Black History Month, which runs ‘I spoke to my friends when I got into medical school throughout October, as one of her favourite times of and said I was going to document the whole journey, year when she was at school. ‘It was seeing things from and I was going to call it the Melanin Medic, referring to our culture being put on full display for other people to myself. And then I got scared, and I didn’t do anything embrace. It’s just so beautiful to see.’ about it for 10 months. And then I mentioned it to one Highlight achievements of my friends and she designed a logo – my friends really encouraged me to go for it, and that made it come to life.’ She also believes it’s important to shine a light on the achievements of Black people in healthcare – and cites It started with a Tweet, which had 200 retweets (a as her own particular ‘sheroes’ the GP in Luton who lot for 2017) and then a blog that had 1,000 views in encouraged her to apply for medical the first 24 hours. ‘I was like, oh wow, school, and the pioneering nurse and maybe people are interested in this,’ academic Professor Dame Elizabeth she says. ‘I think people were waiting for Anionwu. something like this. There’s just been ‘You have to ‘It’s very encouraging for people such a need and it’s been great to be choose to be who might not be surrounded by able to fill that space.’ people who look like them all the time Having set up the organisation with anti-racist’ to see people who had gone ahead the aim of increasing representation of of them and achieved great things,’ African and Caribbean doctors in the she says. UK, Dr Dada quickly realised it wasn’t Although there is obviously a long just about the numbers. ‘It wasn’t just way to go, Dr Dada is optimistic that change is happening the lack of Black students – there was a lot more to the for the better. ‘Last year was a bit of a breakthrough issue. You have to look at people’s experience of the year, particularly with the Black Lives Matter movement education system, and of being a medical student, and following the death of George Floyd. then going into their careers as well; there are so many ‘I think that was the point where people realised it different factors they’re having to navigate.’ wasn’t enough to be not racist – you have to choose to Challenging experience be anti-racist. Dr Dada combined running Melanin Medics with life as ‘It’s easy to say “I’m not racist” but you have to consider what am I doing to make sure that racism a medical student and now as a doctor – she is in her doesn’t continue to exist in our society, and when I see it, first foundation year and works in general surgery in am I actually doing something about it?’ Kent. Sometimes this could be tricky, she concedes. bma.org.uk/thedoctor

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MATT THOMAS

The future barges in COVID forced through digital changes in weeks that might have taken years to implement, while bureaucratic bogeymen were slain, at least for the duration of the pandemic. Is this the future, and is it the one that doctors want? Tim Tonkin reports

‘It requires a set of examination skills that we were never taught at medical schools’

he challenges of COVID-19 have seen widespread changes to the ways in which health services are designed and delivered, and to the dayto-day lives of doctors and patients. In many cases this change has resulted in the accelerated adoption of policies and technologies that had previously been absent or at an early stage of implementation. Examples of such ‘innovations of necessity’ include genetic vaccines, wearable health technology, virtual reality and artificial intelligence. The pandemic has also seen changes to policy, such as granting healthcare providers with greater freedom to adapt their working practices through more flexible approaches to national regulatory guidelines, changes that have been generally welcomed by health professionals. Yet with change comes uncertainty about how new technologies and ways of working might affect patients and practitioners in the future, and whether these will result in challenges of their own such as the exclusion of

certain patient groups or new barriers to care. ‘The pandemic has forced everyone to start accessing healthcare in a very different way,’ explains Cheshire GP Tom Micklewright. ‘Doctors had to suddenly become a lot more familiar with doing remote assessments and consulting and that required a set of examination skills that we were never taught at medical school. ‘Doctors had to learn to start adopting new technologies to consult remotely. All these pressures mean that there has been a massive shift in how we consult.’

Quality assurance Dr Micklewright also works as a primary care lead for a digital health firm, the Organisation for the Review of Care and Health Apps. He says the increased use of digital health apps and medical wearable technology brought about by the pandemic is likely to be a fixture of future healthcare delivery. ‘Speaking for general practice, we’ve been so under resourced for so many years with increasing demand on our services, there’s

never been the resource, investment or headspace to think in terms of digitally revolutionising practice,’ he says. ‘I think patients now are accepting and acknowledging that this has to be the way forward and doctors are a lot more open to using others means to examine patients remotely, and that includes wearables.’ In addition to apps related specifically to COVID, Dr Micklewright said that there were now a wide variety of similar digital tools that could be used to monitor conditions such as asthma and diabetes. He accepts, however, that such new technologies have limitations and, in many cases, need to be subject to more rigorous assessment and standardisation. ‘You’ve now got lots of other apps that perhaps aren’t COVID-specific, but they offer a potential way to de-load the pressure in the system in terms of managing other chronic disease,’ he says. ‘[However] clinicians in particular still lack confidence in a lot of digital health tools, and it’s understandable why as there’s very few ways that you can quality assure these apps.’

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MATT THOMAS

MICKLEWRIGHT: Clinicians’ lack of confidence in digital health tools is understandable given quality assurance is hard to obtain

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EL-GHAZALI: Expects virtual platforms to carry on being used

PURBRICK: More focus on clinical care enabled by a cut in bureaucracy

Virtual communication

‘The pandemic has made it a lot easier to institute particular ideas because we’ve had to work so quickly’

‘Clinicians in particular still lack confidence in a lot of digital health tools’

Technology played a significant role in how doctors communicated and worked together during the height of the pandemic last year. Like many hospital doctors, London-based consultant anaesthetist Sally El-Ghazali worked in intensive care during the pandemic, often alongside doctors redeployed from other specialties. She says being teamed up with people she did not know or had ever worked with before, along with the barriers posed by PPE (personal protective equipment) and other COVID restrictions, mean virtual means of communication become increasingly important. ‘We had to be forced into very weird teams very quickly just to be able to manage the situation,’ she says. ‘There were a lot of people who we didn’t necessarily know face-to-face, but we had to work with them on shifts. One of the things we relied on were things like WhatsApp and Zoom to disseminate information. ‘We would have a morning brief via MS Teams, everyone would log in at a certain

time and then we would go through any particular issues or absences to consider when looking at the rota. That was something that we didn’t have before the pandemic when [back then] we usually had one room where everyone met. ‘It all focused on just trying to establish communication and establish ways of making the best use of people and their skills.’ She says virtual platforms played a big role during the height of the pandemic and she expects this trend to continue in the post-pandemic era. ‘The pandemic forced us to do, or think about doing, things in a virtual way, such as virtual learning. That is something that I think I can definitely see continuing after the pandemic and established for some time. ‘The flexibility that it provides not just in terms of communication with the team but from an educational point of view. My colleagues can log in to a particular meeting or listen to training even if they’re off work, they don’t have to come into the hospital to access these things. ‘The pandemic has made it a lot easier to institute particular ideas because

we’ve had to work so quickly. Before it used to be that if you had an idea it would take a long time to get the right people involved. With COVID, everything had to be done so quickly.’

Cut in bureaucracy Changes to the regulatory process and efforts to reduce the burdens posed by paperwork and bureaucracy were another by-product of the pandemic. In March last year, the CQC (Care Quality Commission) suspended its inspections for a period of more than six months, with appraisals for GPs similarly halted for a time. While regulatory processes have since been restored, the GP appraisal process has returned in a far different form to that which it had previously encompassed, an annual appraisal conducted virtually with an enhanced focus on professional development and wellbeing. GP partner at the Hadleigh Practice in Broadstone, Dorset, Andy Purbrick says he feels that many of the changes aimed at reducing the bureaucratic burden on GPs during the pandemic

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GETTY

VIRTUALLY: Online meetings and consultations have become commonplace

had made a significant difference to refocusing doctors’ time back to clinical care. He said the suspension of CQC inspections in particular had dramatically freed up time for him to care for patients, and for those running the business side of things to adapt to the challenges of the pandemic. ‘CQC was the biggest one, not just for the GPs but for the practice managers that took the pressure off us,’ he says. ‘Practice managers were able to be focused on changing the way the practices worked to meet the health and safety regulations relating to COVID, [while] we [GPs] were able to put our energies into all those other things that we were asked to do like adapting to new ways of working and adopting new technologies. ‘It felt like we had much more freedom to adapt. I think we showed that when primary care doesn’t have too much regulation it can adapt to anything. You just have to look at how we set up home monitoring of oxygen overnight, how we set up the COVID vaccination bma.org.uk/thedoctor

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programme overnight, how we did adopt that new technology to do remote consultation and developed hot and cold sites within practices. All of that just came because we are small, flexible businesses that can adapt to change providing we’re not hamstrung by bureaucracy.’

Appraisal changes Last year also saw the temporary suspension of GP appraisals, and although the appraisals process resumed in October 2020, their return saw a new ethos and rebalanced approach. Dr Purbrick says the new appraisal regime has been a breath of fresh air, one which he hopes to see continue. ‘To have appraisals as much more of a supportive conversation rather than a tick-box exercise to make sure that you had done 50 education credits and feeling that you have to jump through a large number of hoops for mandatory training was really welcomed,’ he says. ‘The hope is that will stay like that moving forward.’ Other areas where paperwork burdens have been reduced as a result of COVID

include the suspension of GPs’ requirements around DVLA medical enquiries and more flexibility around the death certification process, both of which Dr Purbrick says had accounted for a significant amount of GP workload in the pre-pandemic era. ‘That has freed up significant GP time and the hope is those death regulations, although they were part of the emergency bill, will be taken forward. We’ve been trying to get those of changes for years and they’ve managed to come in overnight because of COVID, so it’s another example of removing bureaucracy and getting rapid beneficial change. ‘I’d hope that they’d look at the way it’s been adopted, how we’ve worked with the new recommendations and how there have been no adverse outcomes for patients and how it has freed up GP-time to be more efficient and hope that they could roll [this approach] out to other areas.’ How has COVID affected the way you work – and is it how you think it should remain? Email thedoctor@bma.org.uk to let us know.

‘Appraisals as a supportive conversation rather than a tick-box exercise’

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Your BMA What do you do when you’re on leave but the work emails keep mounting up? We need to protect ourselves and support each other to take proper breaks I have spent the last three months, working with a team of BMA staff and elected members, organising our annual representative meeting. Despite the expected minor technical glitches, I am pleased to say this year’s ARM was a success and fulfilled its primary and most important objective of providing a voice and a listening ear to BMA members’ concerns. The most crucial function of the ARM is to allow those attending (also known as the representative body) to discuss, challenge, debate and vote on important issues and form policy which instructs us, as a trade union and medical association, to work on our members’ behalf. Following the meeting I took a period of annual leave, not only because I needed it physically and mentally, but also because this ARM was the first time I had had to spend an extended period of time without my infant daughter, who needed my undivided attention. Despite being on annual leave, I continued to respond to text messages, phone calls and emails about work. Although I tried really hard to put it out of my mind, seeing the little red counter on my phone grow as the number of unread emails piled up was not pleasant. These emails, I knew, would have to be read and responded to at some point, so my options were to read them a little at a time while on leave, or to face a mountain of admin upon my return to work. Ultimately, I chose to respond to messages a little at a time while still on leave, a habit that I’ve grown used to and one in which I know I’m not alone. This time, however, I found that I had to confront myself with a question: ‘Are we on annual leave if we’re taking work with us?’ This question is equally applicable to our behaviour when we are at work and other members of our team are not.

@drlatifapatel When you know a colleague is on annual leave do you continue to send them emails or do you purposely exclude them so they’re not disturbed? Do you leave work for them to complete on their return or do you make an effort to ensure they return to an emotional to do list? Annual leave and rest have never been more important for our colleagues. Our members, you, continue to tell us, that your well-being is at risk. As a system, the NHS is at risk of burnout. Now should be the time when we all prioritise rest. We should all have access to places to rest, places to reflect, to sleep, food and drink 24/7. We should all be given the time and space to take annual leave. If you are a manager or a leader do you find yourself in a position to enable this, or do you often feel helpless in supporting your team to rest? Are you someone who has been able to switch off from work completely? Or someone, like me, who has struggled? We know our colleagues are struggling with our well-being services continuing to see a much higher demand and need for the service than they had previously. It is all our responsibility, collectively, to ensure that the system, our NHS and every individual within it is able to rest and repair to in turn ensure that we continue to be there for our patients. A reminder that your BMA well-being service is free to all medical students and doctors and their dependants regardless of membership status. We’re here if you need us. And finally, thank you to all our colleagues; medical students and doctors for everything you’re doing, we know it’s hard right now. Do let us know if there is anything more we should be doing for you. Dr Latifa Patel is interim chair of the BMA representative body

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

A doctor who covered shifts on a COVID ward, then succumbed to the virus, received lamentably low sick pay until the BMA stepped in The health service has needed all the doctors it can get throughout the pandemic. This was particularly the case during the early days, when doctors were being drafted in from other specialties, and some retired doctors were given the chance to re-register. The doctors who put themselves forward did so at considerable personal risk. But when one doctor covered shifts on a COVID ward, and contracted the virus, the sick pay was lamentably low. The junior doctor was hit hard by the illness. She was off for three weeks, and then four more following a brief return to work. When she asked about sick leave, she was told that locums on zero-hour contracts normally did not receive it at all. But, given COVID presented such risks to doctors, the employers had decided to average out previous earnings over a reference period and pay sick leave on that basis. The problem for this doctor is that she had

been recovering from an unrelated illness prior to the COVID locums, which significantly reduced the average earnings in the reference period chosen by the employer. The doctor’s BMA employment adviser took the matter up with the HR department. HR was initially reluctant to budge but, after several discussions with the BMA, it agreed to apply the reference period in the most favourable way possible and base the sick pay on the time when the member had previously worked the most shifts. The BMA adviser said the case took a considerable amount of discussion with the employer, but it had produced a more positive outcome for someone who was putting her own health at risk by looking after COVID patients at a time of national crisis. The member said the adviser had been ‘fantastic’. To talk to a BMA adviser about work-related issues, call 0300 123 1233 or email support@bma.org.uk thedoctor | October 2021 23

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Interview skills week Join us for a week of interactive skill-building webinars to help build your conﬁdence and prepare you for a stand-out interview.

All webinars will focus on interview preparation for speciﬁc career stages – hear what interviewers are looking for – get branch of practice speciﬁc advice – have your questions answered by experts

Interview skills and preparation for SAS doctors 9/11 Specialty interview preparation for ST1 10/11 Interview skills for securing your ﬁrst or next GP role 11/11 Interview skills for securing your ﬁrst or next consultant role 12/11 Interview preparation and skills for higher specialties (ST3+)

thedoctor

bma.org.uk/careers/interviewskills The Doctor BMA House, Tavistock Square, London, WC1H 9JP Tel: (020) 7387 4499

Editor: Neil Hallows (020) 7383 6321 Chief sub-editor: Chris Patterson

Email thedoctor@bma.org.uk Call a BMA adviser 0300 123 1233 @TheDrMagazine @theBMA

Senior staﬀ writer: Peter Blackburn (020) 7874 7398 Staﬀ writer: Tim Tonkin (020) 7383 6753 Scotland correspondent: Jennifer Trueland

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 July 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 July be obtained from the publishers on written request.

Feature writer: Seren Boyd Senior production editor: Lisa Bott-Hansson Design: BMA creative services Cover photograph: Simon Bolton Read more from The Doctor online at bma.org.uk/thedoctor

The Doctor is a supplement of The BMJ. Vol: 375 issue no: 8314 ISSN 2631-6412

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