The Doctor, March, 2021, issue 29

The magazine for BMA members

thedoctor

Issue 29 | March 2021

Hard lessons

COVID’s impact on doctors’ training Around the corner...

Coping with an avalanche of unmet need

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Hi-vis heroes

The volunteers boosting the vaccine roll-out

Lest we forget

A doctor’s photographic record of the pandemic

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thedoctor

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

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Staff writer Tim Tonkin (020) 7383 6753

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.

Scotland correspondent Jennifer Trueland

The Doctor is a supplement of BMJ vol: 372 issue 8283

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

ISSN 2631-6412

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Senior staff writers Peter Blackburn (020) 7874 7398 Keith Cooper (020) 7383 6390

Feature writer Seren Boyd Senior production editor Lisa Bott-Hansson Design BMA creative services Cover Ed Moss

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In this issue 4-5

Briefing

Urgent change needed to pension rules, a persistent gender pay gap, and an oddly-timed white paper

Welcome Chaand Nagpaul, BMA council chair NHS performance figures from last month, which reveal almost 225,000 people in England are now waiting more than a year for treatment, show there is a growing tsunami of work to come for doctors when this pandemic abates.

And, as a feature in this issue of The Doctor suggests, the reality is only part of this mountain of work is quantifiable – with the knock-on effects of delayed appointments and treatments and patients with illness and disease remaining in the community yet to be seen.

As diabetes consultant Partha Kar says on page 11: ‘It’s a case of holding our breath and seeing what comes.’

In the last issue we told the stories of doctors who have been fighting this pandemic on the front line for a year – revealing the damage done to a workforce working under extraordinary pressure for so long. This is a profession which cannot be asked to leap immediately from one crisis to another.

Doctors across the NHS are exhausted. We need ministers to come up with a detailed plan which will support doctors to rest and recover while investing in staff and services to tackle the immense amount of work ahead.

We also look at the volunteers who are helping drive the vaccination effort, the effect of COVID-19 on training and opportunities for junior doctors, and extraordinary moments from the pandemic’s front line captured by the camera of consultant gastroenterologist Ray McCrudden.

We feature an interview with Sir Michael Marmot about building back fairer from this pandemic. Sir Michael’s latest report identifies COVID-19 mortality rates in the most deprived communities as being about twice as high as those in the least deprived. Black, Asian and minority ethnic groups are more likely to die than the white majority; the better paid and more highly educated had coped financially more easily during the pandemic and children from poorer families have been disadvantaged struggling with schoolwork and missing school.

It is a sorry picture given many of us doctors saw huge inequalities in our daily work before COVID-19 struck. As such, it is hard to argue with Sir Michael’s assertion that, as a country, ‘we’ve got things badly wrong’ and placing an intention to reduce health inequalities at the heart of policy making in the future could be crucial.

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

6-7

Lest we forget

How a consultant is recording this extraordinary time

8-9

Marshal plan

The volunteers boosting the vaccine roll-out

10-13

Lockdown’s legacy

How will an already overstretched NHS catch up with the avalanche of unmet need?

14-17

An uncertain path

Thousands of junior doctors have seen their training and future plans disrupted by COVID

18-19

Shelter in the storm

A novel approach to reducing long stays in hospitals

20-21

The power of knowledge

How the BMA Information Fund helps raise people out of poverty around the world

22-23

Reset and rebuild

Sir Michael Marmot on creating a fairer society after the pandemic

24-25

Breathing space

A tireless campaigner for patients with asthma

26-28

A problem shared

Doctors with long COVID form their own support group

29-31

Life experience

Tackling an unsafe work place, improving the BMA annual representative meeting, and a retired doctor wishes he could do more

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briefing Current issues facing doctors

NAGPAUL: Campaigns against wasteful procurement rules

LET DOWN: The private sector’s provision of PPE raised concerns

This time, engage with staff Ministers have often said ‘now is not the time’ for an inquiry into COVID, and yet it does appear to be time to publish a white paper confirming plans to reform the NHS and its relationship with the health secretary.

The document, ‘Integration and Innovation: working together to improve health and social care for all’ outlines a significant number of reforms. These include removing existing competition rules, formalising the collaborative workarounds developed in recent years such as integrated care systems, and repealing the section of the 2012 Health and Social Care Act which requires commissioners to put services out to competitive tender, instead placing a duty of collaboration on NHS bodies.

These reforms could offer an opportunity to right some of the wrongs of the 2012 Act – to remove the constraints that hold doctors back in their daily working lives and the restrictions which lead to fragmented services for patients.

But timing matters, as does genuine clinical engagement with staff.

Important though some of the reforms may be, there will be doctors who question the wisdom of subjecting the health service to the immense work and distraction of reorganisation when it has a pandemic to deal with, and a mountain of unmet need.

As BMA council chair Chaand Nagpaul puts it: ‘Proposals for sweeping reorganisation on such a scale will need greater time for

consideration and must not be rushed through while doctors are still tackling the winter surge in infections, hospitalisations and, tragically, deaths.’

Giving doctors a realistic chance to engage with the proposals is important not just because it offers a chance to avoid the mistakes and missed opportunities of the past but because the stakes are so high. The issues covered by the white paper, such as private outsourcing, really do matter.

Dr Nagpaul says: ‘Since 2012 the BMA has campaigned against wasteful and bureaucratic NHS procurement rules that require all contracts to be put out to competitive tender. While the white paper proposes ending these competition rules, the BMA has previously expressed concerns that this could lead to awarding contracts without sufficient scrutiny to outsourced providers at huge expense to the taxpayer.’

And how has this borne out? In the provision of personal protective equipment and test and trace services, the private sector has been given a huge role, and the failures have mounted with sometimes tragic consequences.

In contrast, what has been the first reason people have had to smile during the pandemic? The NHS – repeat, NHS – vaccination programme. It’s a lesson learned from the pandemic, which must not be forgotten.

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Gender pay gap remains Another March means another International Women’s Day – but for some doctors, it might feel more like Groundhog Day. Despite decades of campaigning, female doctors still earn less than men, even when factors such as actual working hours are taken into consideration.

Just before Christmas, the Department of Health and Social Care in England published its long-awaited review of the gender pay gap in medicine. It found that, on average, women hospital SHORT doctors earn 18.9 per cent CHANGED: less than men, based on Women a comparison of full-time are underrepresented equivalent mean pay, while in the highest women GPs earn on average paid positions 15.3 per cent less than men.

Please note this is not about equal pay – the law insists men and women cannot be paid different amounts for the same work – but rather about the differences actually felt in the pay packets of male and female doctors who are, on the face of it, working the same hours and doing equivalent jobs. Numerous factors contribute to the gender pay gap, and many of them were discussed at a webinar organised in January by the BMA and the Medical Women’s Federation.

Many of the underlying reasons are complex.

Yes, women are under-represented in the highest paid positions, grades and specialties, but the gap remains even when this is taken into account. Less simple factors include the unequal effect of caring on men and women – in terms of looking after children. This contributes to the funnelling of women into lower paid ‘family-friendly’ career paths.

In heterosexual medical couples, it tends to be the man’s job which is prioritised, which contributes to the pay gap, the review says.

The DHSC has promised an implementation group and the BMA fully expects to be represented on it. Maybe on a future International Women’s Day there will be something different to report.

Keep in touch with the BMA online at

Pensions freeze may damage care SHARMA: Tough decisions over Instead of using the moment pensions may force doctors to to thank frontline staff for their leave the profession extraordinary work fighting this pandemic for a year, and to outline policies which would reward their sacrifice, chancellor Rishi Sunak used the Budget to implement a policy which could prove disastrous for retaining doctors.

Mr Sunak froze the lifetime allowance for pensions. The potential effect on the profession was made clear by a BMA survey, to which more than 7,000 doctors responded, which found that 72 per cent would be likely to leave the NHS earlier and 61 per cent would be likely to work fewer hours or part time if the policy was put in place.

And all this comes as the Government recommended a pay increase of only 1 per cent for doctors in England, which BMA council chair Chaand Nagpaul described as a ‘total dereliction of the Government’s moral duty’ to the workforce.

BMA pensions committee chair Vishal Sharma says: ‘Freezing the pension lifetime allowance is a bad decision and is creating the perfect storm – forcing an exhausted workforce – many of which are already planning to work fewer hours – to make some very tough decisions such as working less hours or leaving the NHS long before they would naturally retire.’

Dr Sharma says the potential effect on patient care, especially during the pandemic and in tackling the backlog of work it has created, is unthinkable.

There is a solution at hand. Last month, the Ministry of Justice announced that the judges’ pension scheme would no longer be ‘tax-registered’, essentially meaning they will no longer be subject to an annual allowance of lifetime allowance taxation.

This was proposed because of ‘unprecedented’ recruitment and retention problems in courts.

Sound familiar? The case is being strongly made by the BMA. Now is not the time to tax doctors out of the health service.

Read more online – Pensions freeze triggers doctor exodus fears – Effort to tackle COVID’s effects on ethnic minorities ‘too slow’ – Have your say on the SAS doctor contract – Doctors felt ‘abandoned’ by the Government Read all the latest stories at bma.org.uk/news

instagram.com/thebma

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Senior intensive care nurse Trish Whitmey comforts a patient in pain in the intensive care unit

A consultant and talented photographer is capturing these extraordinary times for posterity.

Seren Boyd reports

Lest we forget T

here has been no such thing as normal on the COVID front line recently. Rotas, roles and routines were jettisoned to meet the tidal wave head on.

For a time, at The Royal Bournemouth Hospital almost everyone was redeployed.

Surgeons proned COVID patients on ventilators, consultants did tea rounds and bed baths, military personnel mucked in.

Cruise-liner staff on furlough administered hand sanitiser and face masks at the entrance.

And, for consultant gastroenterologist Raymond McCrudden, it’s been important to capture this extraordinary moment – to record for posterity what the NHS has gone through and what its people are made of.

At the peak of the second wave, hospital managers asked Dr McCrudden, a keen photographer, to take up his Nikon. In snatched moments after work and on his days off, Dr McCrudden documented it all: the teamwork and frustration, the compassion, grief and exhaustion, the mundane and the mortuary.

‘Even before this second wave, the workforce were on their knees,’ says Dr McCrudden. ‘People outside need to know that the people I work with are inspirational…

‘When I asked colleagues if I could come and take photos, they said, “We want you to cover this”. ‘This is a moment in history and we need to record it.’

Doctors tend to a patient following an overdose, as the pandemic takes its toll on people’s mental health

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Senior porter Ian Dudley makes another visit to the mortuary for COVID patients.

Some weekends, the death toll exceeded the mortuary’s capacity and appropriate temporary storage had to be found

Intensive care consultant Emma King phones a family to let them know their son’s condition has deteriorated and he requires transfer to ITU for intubation and ventilation

A patient in his twenties who has had to be resuscitated and intubated in the emergency department is transferred to ITU, via the CT scanner

Consultant urologist Luke Hanna makes his rounds on the urology ward: first an earlymorning surgical ward round, then the afternoon tea round

When the orthopaedic theatres become an extension of ITU for COVID patients on ventilators, orthopaedic surgeons are redeployed to take on proning rotas

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EDDY AND CAROLINE PEARCE

Ahmet Erkan (left) and Dee Curtis (right) at the recuperation marquee at Bridport Medical Centre in Dorset

Marshal plan A huge and intensely good-natured community effort has underpinned the success of the vaccination programme. Seren Boyd speaks to volunteers

T ‘Come driving rain or arctic winds, everyone’s smiling and feels a strong sense of community’

hey signed up to serve their community, fight off a national emergency – and, frankly, to get out of the house.

Across the UK, an army of volunteers in high-vis and high spirits have been braving the elements and marshalling society’s older and most vulnerable people towards their COVID vaccinations.

Their ranks have been boosted by students and pensioners, retired medics and mayors. Even Lord Grantham of Downton Abbey, appearing as his alter ego, Hugh Bonneville, has been spotted marshalling in Midhurst, West Sussex.

The role of vaccination hub volunteer has required huge versatility, from dog-sitting to

jumpstarting cars that have been SORN’d for 12 months, rather like their owners.

But it is all going very well.

Tears of relief Bridport Medical Centre, the vaccination hub for the local PCN (primary care network), has been notching up more than 1,100 jabs per session since January.

Its 180 volunteers have been drawn from the Dorset town’s community support group which has burgeoned during COVID – and nothing fazes them, says team leader Caroline Pearce.

There is the mad scramble to organise volunteer rotas and liaise with the council about traffic cones, signage and parking spaces

when a vaccine delivery is announced at short notice.

There’s setting up the heated marquee for recuperating patients on a Pfizer day, and there is keeping an eye out for those with rusty driving skills.

‘A vital part of the marshal’s role is preventing people reversing into each other, it seems,’ says Ms Pearce.

‘But it can get emotional too, particularly when you see how fragile and frightened some patients are. We fasttrack them and stay with them throughout, and the medical staff are brilliant at taking time out to reassure people and not rush them.

One lady who was very upset at the start was crying with relief by the end.’

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Carnforth volunteer marshals councillor Elizabeth Jones, Margaret Watkins and councillor Malcolm Watkins and, below, a volunteers’ briefing at Bridport Medical Centre

‘It can get emotional too, particularly when you see how fragile and frightened some patients are’

Ms Pearce attributes the town’s success to ‘a really strong relationship between medical staff, administrators and volunteers, oiled by humour and good will’. The brownies, bacon rolls and golf umbrellas donated by local businesses really help, too.

‘Come driving rain or arctic winds, everyone’s smiling and feels a strong sense of community. As one volunteer put it, “The quicker we get everyone vaccinated, the quicker we can all get back to the pub”.’

Friends reunited

Sue Bird marshals people arriving for vaccination at Bridport Medical Centre

At another vaccination hub in north Lancashire, some of the marshals’ tabards bear the words ‘Carnforth Carnival’. The town’s annual celebrations may have been mothballed by COVID but the atmosphere here is positively festive.

Former mayor Malcolm Watkins, who represents the town council and Carnforth Rotary, is helping coordinate volunteers for the PCN’s vaccine roll-out at Ash Trees

Surgery. So many came forward, they had to close the list.

‘And we’ve used fewer than 20 volunteers because people find the vaccine clinics so fulfilling they keep coming back, to see all the smiling faces,’ says councillor Watkins.

Generally, people have been just as keen to get their jabs. ‘They’ve been arriving half an hour early, even in the snow,’ says Cllr Watkins. ‘They just want to get there and get the vaccine, so they can feel those dark days start to disappear.’

Cllr Watkins has been reunited with old school friends he has not seen for more than 50 years. ‘There’ve been amusing moments too, like when four wheelchairs converged on the clinic entrance. Who gets in first?’ he says.

‘The relationship between the medical staff and those receiving the vaccine has seemed so positive. If people go in afraid, they come out smiling.’

Community bonds Relationships between health and social care partners, councils and community groups have grown stronger in Bridport and Carnforth during the pandemic. For David Wrigley, GP partner at Ash Trees Surgery, Carnforth, the local vaccination programme demonstrates the success of the locality-based integrated care community he chairs.

‘Community relations have grown significantly and they’re key to enhancing wraparound care for patients,’ says Dr Wrigley, who is also BMA council deputy chair.

‘I’ve worked here for 20 years. But now, with the vaccine effort, you’re known as a local GP and people are much more trusting, positive and encouraging.

‘General practice has delivered amazingly well with this vaccination programme but we couldn’t have done it without local community groups and the council.

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NEIL TURNER

KAR: ‘An overwhelming sense of uncertainty’

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Lockdown’s legacy With millions added to waiting lists and serious conditions going unmanaged, how will an already overstretched NHS catch up with an avalanche of unmet need after the pandemic?

Peter Blackburn reports

‘I

t’s a case of holding our breath and seeing those things have all dropped off and that could have what comes.’ consequences.’

The future worries Portsmouth diabetes The national specialty adviser for diabetes to NHS consultant Partha Kar. England adds: ‘There are patients understandably Across the health service doctors are anticipating worried about end organ damage affecting their eyes, being hit by an avalanche of unmet feet or kidneys for example. And need as the health service begins ultimately these could be the impacts to shift from a near total focus on of these last 12 months. And the COVID-19 to facing the conditions added concern is that if we pick up ‘This is going to patients have kept to themselves or a mountain of these issues you will be a huge legacy doctors have tried to manage in the always only have the finite funding of trying to pick these community. the NHS to deal with that pressure.

BMA analysis suggests that Throw in the lack of any time for people up’ between April and December 2020 recovery and professionals are worried there were 2.7 million fewer elective about the possibility of all that work procedures and 18.66 million fewer coming our way and, ultimately, what outpatient attendances. And the number of patients that means for the health of our patients. waiting for over one year for treatment has now risen ‘It’s a very tricky position and it’s a case of holding to 153-fold its 2019 value – consistently rising since our breath, seeing what comes, and also trying to the early days of the pandemic in March 2020. pre-empt that too.’

For Professor Kar, the overwhelming sense of uncertainty – ahead of the mountainous, but recorded, Admissions down waiting lists – is the greatest fear.

It is a worrying future for doctors from a wide range ‘There are several areas of real worry for me. If of specialties. you take away some of the checks and the ongoing Consultant cardiologist Charlotte Manisty says: management of patients with diabetes you miss out on ‘There are obviously huge signs of long-lasting impacts foot issues like ulcerations that can progress to needing on healthcare, particularly in areas like cancer and amputation, the second worry is people’s eyes and the cardiology, where I work. We know hospital admissions issues you would pick up in screenings and this third for heart attacks went down by a third in the first wave and admissions for heart failure went down by a half. is the impact on kidneys which needs checking on an Those aren’t people not having heart attacks or heart annual basis. failure, they are people not coming to hospital. This is ‘We have good outcomes because of our clinics going to be a huge legacy trying to pick these people and because staff in primary care do an amazing job up and will need extensive input.’ at annual check-ups and managing patients – but thedoctor | March 2021 11

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BROOKS: ‘If someone has a clinic cancelled it comes to us as our responsibility’

MANISTY: ‘Hospital admissions for heart attacks went down by a third’

pandemic seeming to have an incredibly long and East London GP Farzana Hussein has seen the cases relentless tail. The number of patients waiting more in the community which provide the context for the than one year for treatment is a 12-year high, fall in demand that Dr Manisty outlines. the waiting list now stands at 4.52 million and there are She says: ‘Just last week I had two people with chest pains that sounded like heart attacks and I had to tell large numbers of patients still waiting to be referred on them not to wait for me to phone to the waiting list – with the published them. But they were worried about figures likely to only skim the surface getting to hospital and getting COVID. of the actual volume of unmet care.

‘We are going to And they’d heard the hospitals were ‘A lot of this will come to fruition in see deaths and overrun. the coming year,’ BMA council deputy complications ‘People are not going to hospital. chair David Wrigley says.

But I can’t manage a heart attack. I’m The north-west GP adds: ‘We as a result’ not a rural Scottish GP with the skills had huge waiting lists prior to this to thrombolyse. I’m seeing a lot of this pandemic, we were woefully underand we are going to see deaths and doctored and very low on hospital beds complications as a result.’ and nurses for our population. Going into a pandemic Dr Manisty adds: ‘It all just feels like a big unknown. with no slack and with the healthcare system under All the balls have been thrown up in the air but where immense pressure was always going to be a problem. they and we don’t know yet. We know there’s all this It meant all that routine – and some emergency work – disease out there – but we aren’t seeing it. The worry is has had to be put aside.’ that there are people out there not receiving the care It is hard for patients and doctors to see this growing and the follow up they are entitled to and should have unmet need, Dr Wrigley says. ‘We are seeing patients in order to improve their clinical outcomes. But nobody who are really struggling and don’t have an idea when knows quite what is to be expected.’ their follow-up will be. I saw a patient These are likely to be problems the other day who needs another ‘Going into a faced across the country in every injection into his spine for his crippling area. The BMA’s latest tracker survey back pain but there’s no sign of that pandemic with – which is responded to by thousands happening. It is hard as a doctor no slack was always of doctors – revealed that urgent nonwhen there is a limit of what you going to be a COVID care, such as cancer, had been can do for people. The NHS will have problem’ delayed in around half of members’ to try and get through this but there’s workplaces. And eight in 10 doctors such a volume of need that heaven knows how.’ reported delays or cancellations for These frustrations have also been felt keenly by non-urgent routine care.

York GP Abbie Brooks. She says: ‘That’s been one of Huge waiting lists the most difficult things and something people don’t Every month the NHS’s performance statistics become necessarily understand. If someone has a knee clinic or more stark – with this second or third wave of the pain clinic postponed or cancelled it comes to us as our 12 thedoctor | March 2021

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WRIGLEY: ‘We need to look at how to tackle this huge backlog and mountain of work for patients’

responsibility – we are holding that person as our risk, trying to get them through those painful weeks. It can impact mobility, then mental health and can have other impacts later on.’

Cut bureaucracy

to meet the threshold for PTSD, severe anxiety or problem drinking during the COVID-19 pandemic, says the end of the pandemic must not mark an immediate move to tackling waiting lists and facing another crisis. He says: ‘We need a huge programme of rest and recovery – if not reward too.’

There will be many questions asked and many answers required when it comes to addressing all of this vast Exhausted doctors unmet need: Will the NHS continue to use private It is a big problem in an NHS which already has some sector support? Will the Government come up with a 100,000 frontline vacancies with a mountain of patient proper funding package to support the service working need looming. But, it would be a false equivalence through the backlog? to view these problems as either supporting staff or The BMA estimates that the number of elective providing patient care – because Government ministers treatments missed between April and health leaders cannot have the and December last year alone latter without providing the former.

‘We need the will cost up to £5.4bn to work As BMA council chair Chaand through. And what lessons can be Nagpaul says: ‘Doctors are physically Government to learned from the last 12 months and emotionally exhausted, and we devise a plan for – a reduction in bureaucracy and desperately need the Government to how the NHS will the effects of the Care Quality devise a thorough action plan for how support staff’ Commission and GMC, for example. the NHS will support and invest in staff For Dr Wrigley these are a must: ‘It’s and services to tackle the immense back to that old mantra of let doctors amount of work ahead.’ get on with being doctors – don’t divert them away Dr Wrigley calls for a ‘taskforce’ to tackle these with needless paperwork.’ unprecedented issues. He says: ‘We need to look at Perhaps the biggest question of all – and one how to tackle this huge backlog and mountain of requiring the most comprehensive and creative answer work for patients who need care and attention but – is around the well-being of the workforce though. also to look after the staff who have been through a How can exhausted doctors be expected to simply dreadful year.’ move from one crisis to another?

In the early days of this pandemic health secretary In last month’s issue of The Doctor Kevin Fong, a Matt Hancock was keen to stress that the NHS would London consultant anaesthetist, who was seconded as have ‘everything it needs’. And prime minister Boris national clinical adviser to NHS England’s emergency Johnson was keen to be seen applauding the health and preparedness resilience and response team for care workers who have been facing the greatest danger for more than a year now.

COVID-19, described frontline staff as having suffered For the sake of patients, doctors and the NHS, it will ‘definite injury’. soon be crucial those words and gestures are followed Dr Fong, who co-authored a study published last month which found that nearly half of ICU staff are likely by action. bma.org.uk/thedoctor

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GETTY

An uncertain path Thousands of junior doctors have seen their training and future plans disrupted by COVID. Tim Tonkin finds out what needs to be done to support them

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SARAH TURTON

CAPANNA: ‘We will have issues with retention’

‘The pandemic is going to have a big impact on our generation of doctors’

‘W

e haven’t been trainees in a year, we haven’t had a chance to train in our specialty because it’s a case of constantly fighting fires and filling gaps,’ says junior doctor Maria Vittoria Capanna.

‘You don’t really get a chance to get any sense of what your specialty really does.’

Like so many of her colleagues, Dr Capanna is exhausted by the present and increasingly concerned about the future.

She is just one of thousands of junior doctors – themselves part of an even vaster healthcare workforce – which has spent the past 12 months focused on combatting the COVID-19 pandemic.

While it has undoubtedly been a gruelling and continuous struggle for all branches of practice, the wholesale upheaval of COVID-19 has had significant repercussions specific to doctors in training.

With the health service having to mobilise against

such a vast public health crisis, it often became necessary for resources and staff to be redeployed to meet the evergrowing tide of infections.

As a result, many aspects of junior doctors’ training, education and opportunities for gaining clinical experience in the workplace have either had to be compromised or curtailed, with many juniors increasingly concerned as to what implications this might have for their personal development and career progression.

Opportunities denied Such fears are not just anecdotal. Last year’s GMC national training survey, which drew feedback from more than 28,000 junior doctors across the UK, found that 95 per cent felt their day-to-day work had changed either significantly (57 per cent) or slightly (38 per cent) because of the pandemic.

When asked what effect the pandemic had had on their ability to gain the required curriculum competencies

for your stage of training, 81 per cent of juniors said they had faced slight or significant reductions in such opportunities.

Similarly, 74 per cent either agreed or strongly agreed that COVID-19 had disrupted their training.

The pandemic has also seen huge shifts in the way job recruitment is conducted, with online and telephone exams replacing what would have traditionally been in-person assessments.

Added to these pressures is the fact that thousands of young and relatively inexperienced doctors have had to contend with the immense psychological burden of fighting a disease that continues to claim the lives of their of patients, and sometimes colleagues, on a daily-basis.

Like so many of his contemporaries, urology core trainee 2 Tom Fonseka was redeployed to an ITU role during the first wave of the pandemic in the spring of last year.

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ED MOSS

FONSEKA: ‘We felt left in the dark’

‘Many training opportunities have been compromised’

going to have a considerable impact on our generation of doctors,’ he says.

‘Understandably, there have been many training opportunities that have been compromised in our generation with the true fallout from the pandemic likely to be felt many years down the line.’

Now back in his chosen specialty he has recently applied for registrar training for this year but is all too conscious of the struggles he and others have had to face, particularly when navigating the much-changed recruitment process.

‘While huge efforts have been made to continue recruitment processes in a socially distant format, the ever-changing landscape has resulted in a lot of uncertainties for trainees applying to higher level training. An example of this is the rapid change in the long-standing self-assessment scores with minimal notice.

A considerable way to improve the process would be in communication,’ he says.

‘While efforts have been made to communicate with all parties involved, late changes

due to the nature of the times has often left trainees feeling in the dark about outcomes after an appeals process or securing places for interviews.

In January this year, Health Education England announced that the rotation of junior doctors in London scheduled to take place in February was to be put on hold for four weeks, in order to ‘support the delivery of patient care and to protect and maintain pastoral and well-being support of trainees’.

Dr Fonseka said that while he understood the need to safeguard patient services, he felt that the actions of education bodies were sometimes difficult to accept, due to the perceived lack of trainee consultation and input. Inevitably this will have consequences to people’s lives both in and out of work.

Mental toll Weariness and disillusionment are sentiments which Dr Capanna, a CT2 in general adult psychiatry, can unfortunately relate to all too well.

Working in a mental health placement at the time the pandemic struck, she says

she struggled to contain a disease among patients who often did not understand the importance of adhering to infection control measures.

At the same time, she said that she and other staff in mental health posts were perceived and even criticised for not being sufficiently at the sharp end of fighting the pandemic.

She says that the physical and mental toll of COVID-19 on many junior doctors could see an entire generation making very different career choices as a result.

‘I’ve heard so many times over the past few months of people just saying that they are considering walking away [from medicine] because this just isn’t good for me, my life or family,’ she says.

‘I think definitely we will have issues with retention just because [so many] people will need a break. If we don’t allow people to do this then there will be an issue with workforce.’

Dr Capanna says that, while services offering support existed, many trainees either did not have time to access these or were too worried that doing so would be seen as a

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‘I’ve heard so many people say they are considering walking away’

sign they weren’t able to cope.

She adds that a more flexible and understanding attitude from employers towards staff being able to use sick days as a way of protecting their mental health would a simple and effective way of supporting junior doctors.

‘People are just scared to say that they’re not OK and that they’re struggling,’ she says. ‘That was already the case before the pandemic, but it’s just been further highlighted by it.

‘We need to put something in place that will allow juniors to take time off to attend counselling or well-being sessions without this affecting your Annual Review of Competence Progression.’

‘There needs to be a culture shift towards it being “OK to not be OK” and to look after yourself.’

Research lost

‘People are now starting to think about what they want from their career’

Concern with the implications of COVID-19 on the junior workforce is not limited simply to doctors in training.

Consultant cardiologist Mamas Mamas, who serves as a professor at Keele University saw himself and many of the junior doctors under his tutorship pressed into COVID-19 frontline clinical service for several weeks during the first wave of the pandemic.

He says that while redeployment had been necessary to meet demand and had enabled his trainees the opportunity to learn clinical skills that they might not otherwise have acquired, he shared concerns over the uncertain future faced by many junior doctors.

‘In the first wave many of

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the trainees who were out doing research degrees had to come back into programme to support the clinical service because it was being overwhelmed at the time,’ he says.

‘Many of the trainees may have lost three to four monthsworth of research time and that they’re not going to be able to make up for. That will impact on many individuals’ ability to deliver on a higher research degree.’

Prof Mamas says there had also been an issue affecting procedural specialties such as his own, with the huge drop in elective surgeries taking place during the pandemic depriving trainees of opportunities to undertake and learn from these.

‘For many of the procedural-based specialties, many of the trainees are going to be compromised in that they’re not going to have had the volume of training experience at the end of training programmes,’ he says.

Plans to leave Professor Mamas says it is imperative the Government, NHS and medical education bodies begin to consider now what sort of steps needed to be taken and in the years ahead to support junior doctors and ensure the effects of the pandemic did not indelibly affect their career progression or professional outlook.

‘A lot of juniors are talking about “leaving the rat race” or maybe going abroad for a year or two after COVID,’ he says.

‘It is a concern, because people are now really starting to think about what they want from their career.

‘If we suddenly have a whole generation of doctors who are suddenly deciding to change their specialties or taking time out, that won’t work for workforce planning or recruitment to the acute specialties.’

BMA junior doctors committee chair Sarah Hallett says the pandemic has had the single biggest effect on doctors’ training for a generation.

She says the disruption and the intense mental strain inflicted by COVID-19 would require the Government and leaders of the NHS to reconsider the needs of junior doctors and how these could be supported to ensure the NHS’ next generation of doctors was not lost.

She says: ‘We need junior doctors to be able to continue to progress through their careers, to ensure patients can access appropriate care, and to avoid gaps in service opening up [but] it’s important to acknowledge the mental health and well-being impact that the pandemic has had, no matter what part of medicine you are working in.

‘The psychological impacts of that are going to take a while to unfold, and those in charge of the NHS will need to prioritise how they can support the whole workforce in the NHS with their mental health. There needs to be a chance for staff in the NHS to “take a breath” and pause before we move to take on the backlog of clinical need which we know is waiting. Each junior doctor will have a different set of requirements that will need to be tackled in order to get them back on to their training track again.’ thedoctor | March 2021 17

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Shelter in the storm Mental health trusts are working with housing providers to help patients who might otherwise be stuck on wards for weeks or months.

Keith Cooper reports

A

fter 18 months in Forest Lodge, a mental health rehabilitation unit, Nyoka Mitchell* stepped towards independence by moving into a new home arranged, in unusual fashion, by SHNFT (Southern Health NHS Foundation Trust), Southampton.

She had arrived on the unit feeling helpless, suffering badly with anxiety, and left ‘blessed by the gods’.

‘I have come through a lot of trauma but I feel safe, finally,’ she says. ‘I have been given a second chance.

Not everybody gets that.’

While it isn’t uncommon for mental health hospitals to help find patients somewhere to stay before leaving, SHNFT’s approach for Ms Mitchell and four other patients is.

Instead of waiting months for the right accommodation to come up, SHNFT lines it up in advance. It’s just one of several ways some trusts use to shrink unnecessary stays, bring patients home from far-off private hospitals, and to offer an alternative to clinical wards to the acutely unwell.

Millions more could be saved by bringing back home patients from private beds, a report last month by the Centre for Mental Health and the Mental Health Network claims. Most trusts just lack the know-how, it adds.

So-called delayed discharges can leave patients stuck on wards for weeks, months, even years, making it harder to settle back home. ‘It’s like Humpty Dumpty fell off a wall,’ says Ms Mitchell, who has had multiple admissions to acute wards. ‘You have to rebuild yourself each time you leave.’

SHNFT clinical lead for rehabilitation services Mike Groves says secure housing can help make the rehabilitation admission the last one – a chief aim of his specialty.

‘Knowing they have somewhere warm to stay is key,’ Dr Groves adds. ‘It’s a foundation for their mental wellbeing. It means they can put down roots, stretch themselves, move out of their comfort zone.’

Bricks and mortar

By arranging the housing and support itself, SHNFT can pick properties on bus routes to friends and family, the hospital, and away from areas they need to avoid. Flats are found by Abri, a housing association and managed by The Society of St James, a charity. More intensive support is provided initially by the trust’s rehabilitation outreach team. The society’s light-touch support is covered by housing benefit, leaving no extra cost to cover.

So why is the NHS moving into housing? What’s in it for the service and its patients?

One reason is financial. Mental health trusts spend more than £1m a month keeping patients stuck on wards, waiting for housing with the right kind of support attached, The Doctor analysis of NHS Digital figures shows.

Savings available

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‘It’s a foundation for their mental wellbeing’

Other trusts which work in like fashion with different housing associations include BEHNT (Barnet, Enfield, and Haringey NHS Trust), ELNFT (East London NHS Foundation Trust), and Sheffield Health and Social Care, where NHS England’s national clinical director for mental health, Tim Kendall, is consultant psychiatrist for the homeless.

Sheffield’s mental health trust has worked with South Yorkshire Housing Association for years to return patients home from locked wards in hospitals far away. One patient spent years between hospitals in Bradford and Nottingham before being found somewhere back in the city.

ELNFT and BEHNT work with Look Ahead Housing and Care, a major provider of mental health alternatives to the NHS. Among other services, it supports people in ‘crisis’ or ‘recovery’ houses, as alternatives to hospital wards, and finds homes for patients in ELNFT’s forensic service.

According to a recent report on its work by Europe Economics, the NHS could save £1bn if arrangements similar to its own were rolled out across England.

NHS lead From the outside, such arrangements seem sensible, even simple. Yet they take months, even years, to agree.

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a limited pool, largely reserved for the homeless.

The bureaucratic barriers are legion.

SHNFT’s model was brought off the ground by the Keep Well Collaborative, an organisation commissioned to get heads and organisations together by the Hampshire and Isle of Wight sustainability and transformation partnership. Internally, it’s driven by Jon Pritchard, perhaps the first and only director of housing in a mental health trust.

He believes other housing associations, many of them charities, could make similar arrangements but that trusts must take the lead. Unlike the NHS, associations have access to billions of pounds of investment.

‘But no housing association, or local authority, is going to come to the NHS and say, do you want some properties?’ Mr Pritchard says. ‘This needs to be driven by the NHS because it serves our purpose. We can’t do it on our own and we can’t pay for it.’

BMA mental health policy lead Andrew Molodynski says: ‘These alternative arrangements, however successful, are exceptions to this rule: most trusts in our national health service seem reluctant to move into housing to the detriment of patients.’

‘With rising pressure on beds, little sign of extra investment to increase them, and a move toward more care in the community, it’s a rule that many will soon have to break.’ * Name changed to protect the patient’s identity thedoctor | March 2021 19

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TONY ATKINSON

IN CLASS: Edukid works with schools, like this one in Uganda, which are often crowded and lack textbooks and IT

Access audio content on the online version of this feature / at bma.org.uk r to oc ed th

The power of knowledge The BMA Information Fund helps raise people out of poverty by providing access to resources and learning. Keith Cooper considers the effect on those who have benefited

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‘This award is so important to the rural health centres. Without it, access to these vital materials would be completely out of reach’

s a young child, Bonnie Nang picked, hauled, and sold for scrap huge bags of rubbish, cans and plastic bottles, for an income for her family. Now, as a testament to the power of education and books, she works as a doctor, in the same village in which she grew up.

Dr Nang, from Cambodia, was helped by Edukid, one of a dozen organisations to receive an award from the BMA Information Fund in its twentieth year. Since 2000, it has helped hundreds of similar organisations in more than 70 low-income countries to access books, and more recently, digital resources.

The resources awarded to

Edukid in 2020 is for its work in Uganda to help children out of poverty and give girls and young women opportunities which would otherwise be out of their reach, says Nicky Morgan, a trustee, and associate specialist in sexual health based in north Devon.

Decades on from the end of its civil war, a generation of former child soldiers suffer psychological problems. HIV and poverty are prevalent.

‘As a result of the conflict and gender norms, there’s a lot of gender-based and sexual violence,’ says Dr Morgan, who sponsored Dr Nang’s education through the charity.

‘Girls who had been sexually assaulted often have to marry

the men who assaulted them.

People in the villages feel this is wrong but think that is just how it is. There is a huge lack of knowledge and understanding and COVID has made all this worse.’

Tackling stigma Books from the fund will tackle gender and social norms linked to sexual violence and the spread of HIV and also the stigma of disability, which stops children in rural areas from going to school.

‘We want to do something to help get children with disabilities into school, train teachers how to educate them, and tackle the stigma,’ says Dr Morgan.

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TONY ATKINSON

INSPIRATION: Bonnie Nang (right) on a visit to a UK school

‘These projects demonstrate the power of medical education to make a real difference in the lives of healthcare workers and the populations of some of the poorest countries of the world’

‘Some of the books are going to be used to help tackle that.’

The BMA Information Fund is run with Practical Action Publishing, which sources and distributes practical and accessible health information and educational materials for use in areas where they are scarce. Successful applicants show how the resources would help significant populations and help meet one or more of the UN Sustainable Development goals.

Rural reach Another successful applicant, the Kaloko Trust, operates in Luansobe and Kashitu, rural but mineral-rich, copper belt regions of Zambia. Some of its books will be housed at Kaloko RHC (rural health centre), one of 360 across the country, which acts as an information and reference hub for 42 health workers in surrounding centres.

‘There is no computer at the rural health centre, and there is no access to resources on the internet,’ says the trust’s UK director Madeleine Bates.

Resources on water, sanitation and hygiene

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LEFT OUT: Children in Uganda, sitting outside a school they are no longer allowed to attend because they cannot afford the fees

programmes will be kept at its central office in Zambia where staff plan, deliver, and evaluate health improvement projects.

‘Health workers at the RHCs have very little access to upto-date clinical information appropriate to the context in which they are working, where diagnostic and treatment options are limited,’ Ms Bates adds. ‘This award is so important to the rural health centres. Without it, access to these vital materials would be completely out of reach to these health workers.’

Raise awareness The Navtarang Foundation, a not-for-profit in India, will use its resources to reduce neonatal and maternal mortality, and stem the spread of infectious disease, including COVID-19.

‘It will help medical students, community health workers, doctors, nurses, researchers, nutritionists, mid-wives, paramedical staff and pharmacists,’ says co-founder, Abhishek Mittal.

‘The books and educational

material will be used to conduct training programmes, seminars, group discussions for disseminating information about various health issues such as neonatal mortality, maternal and child health, nutrition, lifestyle disorders, menstrual hygiene, COVID-19 pandemic,’ he adds.

BMA representative body chair Helena McKeown, who helped assess applications, says it is humbling to see their effects in communities, with little reading resources but dedicated clinicians and students.

‘These projects demonstrate the power of medical education to make a real difference in the lives of healthcare workers and the populations of some of the poorest countries of the world,’ she adds. ‘The role of the BMA Information Fund can only become even more important as we continue to battle the historic pandemic of COVID-19 and redouble our efforts to meet the UN Sustainable Development goals by 2030.’ thedoctor | March 2021 21

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Reset and rebuild The pandemic has exposed the UK’s serious health inequalities, and may make them even worse. Professor Sir Michael Marmot, who wrote a landmark report on inequalities, sets out how society can be rebuilt more fairly. Peter Blackburn reports

‘I

MARMOT: ‘We’ve got things badly wrong in our society’

f it was serious – maybe.’

Professor Sir Michael Marmot smiles politely when asked whether he would be willing to chair the eventual inquiry into the response to the COVID-19 pandemic in the UK. Sir Michael’s suitability for the role was first trumpeted by the Labour mayor of Greater Manchester, Andy Burnham, in December 2020, at an event launching the former’s most recent report looking at the relationship between health inequalities and COVID-19.

‘I want to put all my energies into how we can get a national conversation MATT SAYWELL

for building back fairer,’ Sir Michael tells The Doctor.

‘If chairing an inquiry were a successful way to get that conversation going then great – if it’s just a way to beat Government round the head I wouldn’t be so interested.

That’s not where I want to put my energies. My interest is not in criticising the Government but in getting positive action.’

For many, the role and the individual would seem like a good match. Sir Michael’s work on health inequalities, now dating back three decades, has never been party political – even if much of his current and recent work is assessing the effects of the policies of Governments led by the Conservative Party and its response to this brutal pandemic.

And his latest report – Build Back Fairer – which highlights the ‘damaging’ levels of social, environmental and economic inequality in society, the effect of those inequalities on health and wellbeing and the troublingly exacerbating effect of COVID-19 – feels, at

‘Inequalities may get even wider coming out of the pandemic’

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least in part, like a blueprint for the seemingly inevitable public inquiry. The report identifies many of the reasons for the extraordinarily high death toll in this country as well: poor governance and political culture; widening inequities in power, money and resources; Government austerity policies and the reality that health had already stopped improving before the pandemic struck.

Rebuilding society Issues around governance and political culture are not new – the report suggests these were present before the pandemic and have undermined the sense of common good in this country. But problems in these areas have been highlighted further during the past year.

‘When you read in your newspaper one morning that schools are completely safe, says the prime minister, and that same evening he says the schools are closing… If I wanted an illustration about quality of governance, that’s it,’ Sir Michael says, before going on to reference Government failure around areas of testing and inability to grasp the notion of paying people to self-isolate and the inequity of the furlough scheme.

‘The furlough scheme is great but 80 per cent of a marginal salary puts you even lower below the poverty line than you were before,’ he says.

The report’s revelations and analyses are stark. Mortality rates in the most deprived communities are about twice as high as those in the least deprived; black, Asian and minority ethnic groups were

more likely to die than the white majority; the better paid and more highly educated had coped financially more easily; children from poorer families have been disadvantaged struggling with schoolwork and missing school; and the young have felt the economic consequences; with the under25s more than twice as likely as older workers to have lost jobs.

Sir Michael outlines required actions to rebuild society – fairer – in a number of areas, with extremely detailed recommendations for policy and debate including around early childhood, education, employment, working conditions and community and housing.

Sir Michael adds: ‘The inequalities from COVID-19 look pretty similar to inequalities of mortality from all causes but even bigger. The problem for the future is the inequalities getting slowly wider in the decade from 2010 to 2020 may get even wider coming out of the pandemic.’

Time to invest Ultimately, economics will require discussion too, because following the blueprint of this report will cost money – these are recommendations which require significant investment not seen in this country for some time. But, for Sir Michael, this is exactly the right moment to make that investment.

He says: ‘This will cost money. The objection is always “you want us to spend money at a time of unparalleled public debt?” That’s right, I do. Interest rates are zero, if not negative. Government can borrow money cheaply.

Government can print money.

And Government can tax. When you have a depressed economy a bit of Keynesian stimulus might not be a bad thing to do.

The things we are talking about will stimulate the economy.’

Professor Sir Harry Burns will be focusing on health inequalities during his time in the role as BMA president and will be launching a project looking to collect stories from around the UK of where people, working on the front line, have been involved in transformational change in their communities.

Sir Harry says projects across the country have shown that local people can drive improved health in their areas – but that the best work is often not shared far and wide.

He adds: ‘The intelligence is out there. What has been shown is that you need to knock on doors and ask how we can help. It’s a compassion driven thing, not about rules and regulation, but about knowing who is in trouble and asking them what help they need. Time and time again reports have proven this.’

BURNS: Need to pinpoint who is in trouble

‘The objection is always “you want us to spend money at a time of unparalleled public debt?”

That’s right, I do’

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LEVY: ‘Each case I’ve been involved with has demonstrated preventable factors’

Mark Levy campaigns tirelessly for asthma patients to have the specialists they need, and for better management of the condition. Until he succeeds, he tells Peter Blackburn that lives will be needlessly lost

Breathing space ‘T

o be honest, I lose sleep over some of the stories. It is really tough.’

North London GP Mark Levy is speaking to The Doctor just weeks after providing expert witness at an inquest into the death of 22-year-old Kalila Elizabeth Griffiths, who sadly passed away on 1 February, 2019.

Senior coroner for the Eastern area of London, Nadia Persaud, found that Ms Griffiths’ death had been contributed to by a ‘lack of recognition of the seriousness of the decline of her respiratory state’, that she required a review by a respiratory physician and had such a review taken place ‘on the balance of probabilities, her death would have been avoided’.

These would be shocking findings for many people. And

the coroner felt the failings were significant enough to require a regulation 28 ruling which aims to prevent future deaths by calling for specific actions to be taken.

In this case, the coroner raised concerns about the management of asthma patients within the NHS as a whole, that 18 of the 19 recommendations in the National Review of Asthma Deaths (NRAD), 2014, have not been implemented nationally, discrepancies between asthma treatment guidelines and a lack of training for GPs and emergency department staff.

Ultimately though, for Dr Levy, who was born in South Africa but has been working as a GP in England since 1977, the details of Ms Griffiths’ case were less shocking and rather came with a deeply dispiriting sense of déjà vu.

This was the fifth inquest

at which Dr Levy has given expert witness since NRAD, for which he was clinical lead, reported its findings. Each death revealed a tragic list of miscommunication and failures in care; each death exposed a health service starved of resources in which children and young adults with asthma are falling through the cracks.

Preventable deaths ‘People say there aren’t many asthma deaths in the UK therefore it’s not a problem – but those deaths are mainly preventable,’ Dr Levy says.

‘That is a problem. Each case I’ve been involved with has demonstrated the same preventable factors.’

Dr Levy’s case for change is backed up by stark statistics.

The UK has the worst record for childhood asthma deaths in the whole of Europe and

‘There were 11 opportunities where someone could have intervened’

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SARAH TURTON

the fifth worst in children and young adults among all developed countries in the world.

On top of that the NHS is short of some 200 asthma specialists in hospitals, has lost training capacity and expects GPs to manage patients with this common condition while also having intimate knowledge of upwards of 400 other diseases and increasingly scant resource and staffing.

The result is that asthma care is often delegated to nurses and other healthcare professionals who themselves are often not in receipt of the specialist training required.

Future reforms to the NHS are also only likely to further concentrate care in primary care and GPs are likely to be asked to do more and more – as Dr Levy says, that cannot continue to be more and more with less and less. bma.org.uk/thedoctor

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As a result, one of the most defining factors in the outcomes for patients is luck: are they lucky enough to be seen by a GP specialising in the area or to have arrived in hospital on the day when the respiratory specialist is overseeing admissions?

Unfortunately, some patients – and families – are not lucky.

Thirteen-year-old Tamara Mills, from the North East, was attended to by medical personnel on 47 occasions but was never referred for specialist help. ‘That could have happened after any one of those attacks,’ Dr Levy says.

And nine-year-old Michael Uriely, from London, had six attacks in the year before he died. ‘There were 11 opportunities where someone could have intervened,’ Dr Levy adds.

For Dr Levy, one of the hardest things is the moment at an inquest where a family realises the death of their child could have been prevented, that they weren’t receiving the most expert care, and that had they known what to say or whom to demand to speak to things could have been different.

‘That moment of realisation is quite a shock,’ Dr Levy says.

‘It is hard to see.’

A blueprint for change The most galling truth surrounding all this tragedy is that the answers to many of these problems have been available to ministers and health leaders for many years.

In 2014 the NRAD provided a blueprint for better care – a series of realistic recommendations which may well have changed the

outcomes for these families.

Those recommendations include that patients with asthma are referred to a specialist service if they have required more than two courses of systemic corticosteroids in the previous 12 months, that follow-up arrangements be made after every attack regardless of where it was managed, that secondary care follow-up should be arranged after patients have attended A&E two or more times with an asthma attack in 12 months.

The report also suggests electronic surveillance of prescribing in primary care be put in place.

These are not overambitious demands – they describe fairly basic management of a serious condition, the resourcing of specialist posts and services, and a modicum of integration between different parts of the NHS. Yet, as Dr Levy says, ‘things haven’t changed. We keep seeing the same things over and over again’.

Dr Levy adds: ‘In my view a simple directive from NICE or the departments of health in all four nations to focus on one thing – people who have had attacks should be reviewed urgently to identify potentially modifiable preventable risk factors – would make a huge difference. But I don’t know how long we will have to wait.’

The good news though?

Dr Levy’s campaigning days are not over. Asked whether he has the energy and will to keep fighting for better care for these patients, Dr Levy is absolute: ‘This is what keeps me going. I know I have a role to play.’

‘We keep seeing the same things over and over again’

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A problem shared Doctors with long COVID have found support and validation through an online group.

Jennifer Trueland reports

I ‘Talking to others who are going through the same experience is helpful’

t’s 11am on a Wednesday and a group of people are joining a Zoom call. Although mostly strangers to each other – at this point – they have certain things in common: all are doctors, and all have long COVID. The group meeting has been organised by Doctors in Distress, a charity set up to help reduce suicides in the medical profession, which steps in where there is a specific need.

For the next 75 minutes (with a 10-minute break) doctors from a variety of clinical backgrounds and geographical locations share their experiences of long COVID – whether that be symptoms and their attempts to access medical care, or their feelings about how they came to contract COVID in the first place, and how supportive their employers had been; they

did this for nine weekly sessions, and many of them still keep in touch.

One of the participants in the call last Autumn was consultant rheumatologist Richard Campbell (see ‘Amongst peers’ on p28 ), who says it was particularly helpful to be able to discuss these things with people who understood where you were coming from – with fellow doctors who shared many of his experiences, and who spoke the same (medical) language.

‘Talking to others who are going through the same experience is helpful from a practical point of view, such as signposting for support, but also for emotional support,’ says Dr Campbell. ‘It is also helpful for validation. For example, we were all on sick leave together

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and we reassured each other that this was appropriate and sensible for ourselves and our patients.’

Build a rapport ‘A sense of them being together and having some peer support’

BURNS: ‘A space where people can come together in a stable group’

The support group was the brainchild of Sarah Burns, a Southampton GP who contracted COVID-19 in March of last year – the virus left her with continuing symptoms and she has been diagnosed with myocarditis. Seeking support and information about what was beginning to become known as long COVID, she became one of the original administrators of the Facebook UK Doctors #longcovid group.

Although the group now has more than a thousand members, she and some others felt that they needed somewhere else to meet and discuss the issues they were facing.

‘The group grew really quickly, but although it’s a private group and we screen people as carefully as we can, and we require GMC numbers [from potential members] and try to make sure it’s only doctors, you can’t really have the same sort of free discussion or support that you can get away from social media. Around the end of August there were some doctors that were really struggling, so I decided to write to Clare Gerada [chair of Doctors in Distress and BMA council member] to ask if she could run a support group.

‘It’s basically a space where people can come together in a stable group (it’s the same people every week), so they get to know each other, and each other’s stories, and develop some

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rapport and deeper trust and understanding.’

Sue Warren, a GP, was one of the facilitators and describes the issues raised in the groups.

‘There was something about coming to terms with the illness, but also coming to terms with being a patient,’ she says. ‘People were also sharing symptoms. I think long COVID has lots of different manifestations and it’s not the same illness for everyone – some people might have myocarditis, and some people might have neurological symptoms. So it was about sharing information about what’s going on and also sharing resources.

‘That was important, but I think the sense of them being together and having some peer support, and having other doctors to talk to validated for them that they had an illness – and some were not getting that validation from the rest of the medical community because it was a new illness and people weren’t always very understanding.’

Validated concerns Participants were ‘icebreaking their way through a new illness while feeling ill’, adds Dr Warren. ‘That’s very difficult.’

This was certainly the case for Dr Burns, who was previously a salaried GP but is now a GP retainer, working three sessions a week clinically on top of a new non-clinical job. She had tried to go back to work too early then ‘crashed completely’ and had to take more time off. She had to ‘advocate’ for herself to be referred for investigation into what turned out to be myocarditis, although she adds that her own GP was excellent and very understanding.

The support from the group was invaluable.

‘Sharing experiences and getting validation,’ she says, when asked what she found most useful. ‘Quite a few people had struggled with neurocognitive symptoms and fatigue, and I think we don’t really talk about that much as doctors.’

Doctors in Distress, which is funded by donations and other sources, including grants from BMA Giving, had 60 participants in the first cohort and a second cohort started early this year. Dr Burns hopes that the initiative will continue if required. ‘I think the people who took part found it really useful – we all had a reason to be there,’ she says. ‘They were a really good space for reflection and for developing self-compassion, and that’s really important.’

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Amongst peers Being able to discuss his illness with fellow doctors helped Richard Campbell find common experiences and feelings Richard Campbell is a consultant rheumatologist with King’s College Hospital NHS Foundation Trust. In October, The Doctor reported how he had developed COVID after working on the medical take, where many patients had the virus. Although he tried to go back to work, his symptoms persisted, leaving him off sick and extremely worried.

He heard about the Doctors in Distress support group via Facebook, and found it hugely helpful. ‘I have never been unwell before. Being an unwell doctor is a unique experience because some of my concerns are different from those of lay patients. Our work is not just a job, it’s also an identity and a career. My non-medical friends told me to “just take time off”, but it is not that simple as a doctor.’

Themes of guilt and responsibility came up a lot in the group, he says. ‘It was helpful to talk to others who understood that you need to be 100 per cent switched on as a doctor because we have to function at such a high level.’

‘Those taking part were all suffering with a new disease and all reported different presentations,’ Dr Campbell says. ‘The uncertainty that comes with having a new disease is frightening, especially as a doctor because we know the possible differential diagnoses for our symptoms and worry when we are not investigated in the way that we would if we were seeing the patient. I had persistent cognitive problems and headache which I found particularly concerning. I found it helpful to talk to others who spoke medical language and shared my concerns, rather than trying to reassure me, which is what some of the doctors looking after me tried to do.

‘They did so with the best intentions, but false reassurance is empty without supportive facts or data.’

The group facilitator was also a doctor who had experienced illness and understood the problems of being a patient who is also a doctor, says Dr Campbell,

adding that the group was able to share experiences of CAMPBELL: ‘The experience will accessing medical inform my practice as a doctor’ care and support.

‘We shared our frustrations about disjointed care and care that was not centrally coordinated. We also discussed financial concerns and whether or not our employers were being supportive.

‘We discussed whether we thought PPE had been adequate and whether we thought guidelines had been financially and operationally motivated rather than by applying common sense.

For those who felt PPE had been inadequate, we explored whether not being properly protected against potentially high levels of viral exposure may have contributed to our terrible post-COVID experience.’

He has found the experience of being in a patient support group helpful.

‘I continue to keep in touch with those from the support group meetings. Some of these doctors continue to have more serious problems than I have and some are recovering. We continue to support one another. I feel like I know many of them, even though I have only met them digitally and not personally yet.

‘I am now recovering and the experience will inform my practice as a doctor. I have some residual symptoms, but am now back at work with some temporary adjustments; I expect to make a full recovery.’

‘My non-medical friends told me to “just take time off”, but it is not that simple as a doctor’

Employment advice is available to BMA members by calling 0300 123 1233, emailing support@bma.org.uk, or chatting with an adviser online via the BMA website.

BMA Counselling is available to all doctors and medical students, regardless of membership, on 0330 123 1245

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

A ‘safe’ working space left a vulnerable doctor at continuing risk ‘COVID-safe’ and ‘COVID-secure’ are phrases we hear a lot and are likely to hear far more as society reopens. But the problem with claiming environments are ‘safe’ and ‘secure’ is that they appear to offer guarantees, when no such guarantees are possible.

The ‘safe’ office provided for one member was not nearly as safe as her employers could have made it.

The doctor was pregnant, from a black, Asian or minority ethnic background, and had underlying health conditions. But her ‘safe’ office involved sharing with two consultants who were still seeing patients. They had to share phones, a kitchen and toilets. It was located within a hospital department which included procedures with a high risk of transmission of the virus.

She had originally asked to work from home, as per the advice from the occupational health department. As she was carrying out clinics over the phone, this should not have been a problem, but her trust said no. Instead it said she could stay at home with no work, but she wanted to support her colleagues, and so reluctantly agreed to come to work as long as the safe office was provided.

Her working environment made her deeply concerned about the risk to her and to her unborn baby. She took the matter up with a manager, in a series of phone calls and emails,

bma.org.uk/thedoctor

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but was told only that she could try to find an office for herself.

After a week of this, she contacted the BMA, and was so stressed and upset by this point that she had gone on sick leave. The BMA employment adviser immediately contacted the employer, reminding them of their obligations. In response, the employer belatedly started the process of helping the doctor to work from home.

But the damage to the working relationship had been done. The doctor’s initial, reasonable proposal to work from home had been turned down, while the trust’s commitment to provide a safe working environment had not been honoured. The doctor remained off sick, and no longer felt able to work, even from home.

The BMA adviser contacted the trust and suggested a way by which it might repair some of the damage done. She said that the period off sick, and through to the start of maternity leave, could be recorded as COVID special leave.

Given the doctor’s vulnerable situation, and the circumstances which had led to the absence, this would be a kinder outcome, given that doctors only receive a finite amount of sick leave.

The doctor said she had a great sense of relief.

She thanked the adviser for her support and said the outcome had helped restore faith in her employer too. thedoctor | March 2021 29

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Your BMA BMA representative body chair Helena McKeown and her deputy Latifa Patel explain why the association’s annual representative meeting is under review and what they hope it will begin to offer members This pandemic has changed so much, in so many areas of society. And it is no different for the BMA. In the past the association has felt, to some, like a building in London, or a group of familiar faces, rather than an organisation truly representative of 160,000 members.

In a year where we have had to alter the way we do everything – and when the profession has worked under extraordinary pressure, faced so many obstacles and risen to such great challenges – it has become abundantly clear that we can, and should, be more representative of our members.

In our roles we have always felt we are the servants of the membership and we want to take the lessons of this past year and your experiences to make sure we are the best we can be in the future, for the benefit of doctors, patients and the NHS. And we know there are areas where we need to be better.

One of the most important of those areas is in our annual representative meeting where we make BMA policy and take forward vital issues on which to lobby Government and provide a voice of advocacy or critique in wider society.

That is why, as part of its broader governance review, the BMA has commissioned a review of our ARM to establish its efficacy, value for money and the degree to which it is able to represent the interests and secure the engagement of grassroots members.

Strands of this review have been appraisals of value for money, effectiveness as a vehicle for policy setting and prioritising, how representative the activity is in engaging and reflecting grassroots interests and assessments of other models used by other organisations and alternative ways of doing things.

In recent years we have had great successes with policy made at the ARM – policies which often begin with the courage and perseverance of individual doctors or small groups of colleagues, such as around period poverty, the relationship between the NHS and climate change or the pensions annual allowance.

But we know that sometimes the ARM can seem like the same faces, from similar walks of life, coming

together year after year. And we know that there are thousands of doctors around the country who have had experiences which could help us make better policy, who may have found local solutions to national problems, or who are a powerful voice for a particular community.

Given the continuing pandemic this year’s ARM is unlikely to take place in its usual form. We will need to balance providing an opportunity for representatives to propose and debate policy with the demands of vital work and much-needed rest at such a difficult time. This is the perfect time to get to work finding out the best ways for us to serve as representatives – with a view to making next year’s ARM the best it can be and improving all areas of our work.

Some of us may have found ourselves watching online webinars while doing the dishes or making dinner – perhaps that sort of technology should play an increasing role in what we do? We know we can host meetings for upwards of 500 people and those events can be recorded so many more can join in the debate and discussion.

Perhaps we should be debating the big issues of the day in a more regular format with events to talk around important topics such as physician associates, tax-free childcare, medical apprenticeships or assisted dying.

Ultimately, however, this is not about our ideas. It needs to be about yours. We would like this process to be about what you think would work – what would enable you to become a voice in this association or help you to feel better represented? We want the concerns or opportunities you have found in your workplace to be given a platform to become BMA policy, for you to look at your representatives and feel advocated for, or even to understand how we can support you to take on a representative role yourself.

Please get in touch and tell us how we can represent you better. We believe this is an opportunity not to be missed – an opportunity to ensure the BMA continues to strive to represent every single one of its 160,000 members and be much more than a building in London or those familiar faces. This is your BMA – a powerful voice for doctors. We want it to be the very best it can be.

Contact us at rbchair@bma.org.uk

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And finally…

V&A

Stories from the medical profession on a lighter note

When the pandemic is over, and even now while it is still ruthlessly active, the question may arise: ‘What useful contribution did you then make or are you making now?’

It is reminiscent of a 1915 poster where a man was asked by his daughter, ‘Daddy what did you do in the Great War?’, though the thrust of her question was meant to be in the present tense, as the conflict had three more years to run. This was a crude piece of propaganda aimed at spurring or shaming men into signing up for combat. It worked because it stimulated patriotism, embarrassment or guilt.

That world conflict lived in the memory of many for years perhaps in the same way the war on COVID may do. Unfortunately, as tens of thousands of doctors, nurses and healthcare workers will testify, we are still in the midst of this war. Hopefully, the time will soon come when we can look back on COVID, and for all those involved in healthcare it will surely be a time to reflect with pride for what was achieved but also with regret for the lives lost and marred and with profound anxiety for the long-term effect on our health service and its future personnel.

There will also be those, like me, who wish they could have done more.

The pandemic has been personally formative.

Like many, I’ve loved the purity of the air, the kindness of strangers, and the songs of the birds. I’ve also gained new skills with my partly successful efforts at DIY dentistry (my refitted crown remains secure but for how long, who knows).

I’m 81, I had a long and enjoyable career for decades in the NHS, and was locuming into my 70s. My age may give me something of a free pass, but I, and I suspect others of my generation, still feel a burden of guilt

and responsibility that we are not actively contributing.

It’s a two-way street. There were retired doctors who were anxious about coming forward, but there were also thousands who took advantage of easy renewal of their licences to practise last year but were disappointed to discover that their services were not required by the NHS. I would be also more than willing to vaccinate, as, I suspect would many others, but it seems that at times NHS bureaucracy, despite its brilliant achievements, struggles to keep pace with the pandemic.

It’s easy to make empty promises, so here are two selfish reasons why I would love to be back in the workforce. First, I wouldn’t be at home all day listening to the daily litany of deaths, new variants, and hospitals close to breaking point – do we really need this overload of information on such a regular basis? Unlike some of the news junkies out there, I tend to find this simply harrowing. Secondly, I wish to care for others at least as well as I should wish to be cared for myself.

Jab giver available if required.

Peter Docherty is a retired consultant ophthalmologist from Derby thedoctor | March 2021 31

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