The Doctor – issue 20, April, 2020

The magazine for BMA members

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Issue 20

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April 2020

05/04/2020 12:58

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

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

The Doctor is a supplement of The BMJ. Vol: 369 issue no: 8241 ISSN 2631-6412

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Editor Neil Hallows (020) 7383 6321 Chief sub-editor Chris Patterson Senior staff writers Peter Blackburn (020) 7874 7398 Keith Cooper (020) 7383 6390 Staff writer Tim Tonkin (020) 7383 6753 Scotland correspondent Jennifer Trueland 07775 803 795 Senior production editor Lisa Bott-Hansson Design BMA creative services FRONT COVER: The children of BMA members of staff say a huge thank you to doctors fighting COVID-19 on the front line with their artistic contributions. They are: Ada Helm, aged 8, Aran Patel, aged 8, Archie Gay, aged 6, Brooke Gay, aged 4, Daniel Lamont, aged 10, Emily Lamont, aged 6, Ella Jennings, aged 6, Flora Hallows, aged 9, Hollie Jennings, aged 8, Herbie Clark, aged 9, Lyla Patel, aged 10, Jake Patel, aged 5,​ Molly Bulger, aged 11, Orla Bulger, aged 8, Oscar Taylor, aged 6, Izzy Taylor, aged 9, Toby McSpadden, aged 10, Georgia Karikari, aged 10.

In this issue 4-11

United front Doctors from across the profession describe their experiences fighting the coronavirus

Welcome Chaand Nagpaul, BMA council chair There are no words too stark for these unprecedented times: our NHS is facing its greatest-ever challenge, our society its most significant peacetime threat – and doctors across the UK are responding with remarkable daily courage and compassion at the very front line of this crisis.

And while doctors have been at the heart of the fight against coronavirus, the BMA has also worked relentlessly to ensure we are able to go about our vital work and treat patients in the knowledge we are as safe and supported as possible.

The heroism of NHS staff has been recognised by colleagues, members of the public and patients – but it is not acceptable for this heroism to go unsupported, for doctors to be left without the vital equipment and resources to face this pandemic. The Government promised it would give the NHS whatever it needs – and it must make good on that promise.

In this issue of The Doctor – and through our work across the media and lobbying politicians and engaging with other organisations – we have ensured the needs of doctors are at the very heart of debate. We tell the stories of doctors on the front line, treating patients with COVID-19, who are being expected to put themselves at unacceptable risk of serious illness due to a lack of protection. We highlight the doctors who have been forced into self-isolation after reporting flu-like symptoms owing to a lack of testing. We also raise concerns about supervision and technology concerns in primary care – with the coronavirus outbreak leading to a rushed move to video and online consultations.

The lead feature in this magazine shows the amazing work doctors from every corner of the profession are doing, and the extraordinary pressure they are under in this crisis. The BMA is a voice for each and every colleague, particularly during this difficult time, and will continue to demand the support we require to stay safe – and to save lives.

Also, in this issue is an extraordinary feature investigating suggestions of involuntary organ donation in Chinese prison camps.

12-15

Lack of protection A severe shortage of protective equipment is putting lives needlessly at risk

16-19

Testing times Self-isolating doctors say better access to testing would have restored them to the front line sooner

20-21

A virtual revolution GPs have turned to online consultations at a rapid pace – how are they going?

22-23

On the ground Some of the employment, training and wellbeing issues raised by members with BMA staff

24-29

At what price?

Human-rights abuses are still being perpetrated in Chinese organ transplantation, some suggest

30-31

Pensions tax Will the changes announced in the budget be enough to limit the damage done to medical staffing?

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United front In this, the greatest challenge the NHS has ever faced, the pressure on doctors is relentless. The Doctor hears from BMA members across branches of practice about the problems they have encountered and how they are fighting back. Jennifer Trueland, Peter Blackburn, Tim Tonkin and Keith Cooper report

Student support

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KHAN: Established portal for volunteer medical students

Keep in touch with the BMA online at 04 thedoctor | April 2020

undreds of medical students have offered to play their part in the struggle against COVID-19.

Sheffield medical society president Hasnain Khan is running a portal to link fellow Sheffield Medical School students up with hospitals, surgeries and doctors who need volunteers. ‘A lot of our students have had placements and lectures cancelled and they want to help in any way they can.’

Working with Lucy Pinder and Leah Lam, also third-year students, they created a database of 400 students and had requests for help from hospitals and surgeries across South Yorkshire.

‘We have had three or four hospitals get in touch and are talking to Sheffield teaching hospitals about setting up a proper induction process so students know what they can and cannot do,’ he said.

Third- and fourth-year students have already started volunteering at GP surgeries and hospitals. Those in their earlier years of training look in on older people in the community, shopping for them and helping doctors in work with babysitting.

Some 40 parents have asked for such help so far. ‘We are still looking for more volunteers because of the demand out there,’ Mr Khan said.

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EDWARD MOSS

Heart-wrenching decisions POONI: ‘I’ve not been caught in these scenarios before’

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or many doctors, such as for West Midlands intensive care consultant Jagtar Pooni, it does not end when they return home after a long shift. Even the human instinct, at times of stress, to hold one’s family close has to be overridden.

He said: ‘When I go into my house there’s a pathway for me to take off my clothes and get to the washing machine and then shower upstairs without touching anything else – we have gels and we practise social distancing even in the same house.’

The West Midlands had, as of late March, one of the highest numbers of COVID-19 infections and deaths in the country. At the time of speaking to The Doctor, Dr Pooni’s unit was treating between 16 and 20 patients who had contracted the virus.

Although the number of cases was forecast to grow, he said difficult treatment

decisions were already having to be made.

‘We are using admitting criteria because we don’t want to get to the Italian experience where we started admitting everyone. These are prolonged-stay patients, so we are admitting those we are confident are going to get better. We have pulled away from those people we might usually give a trial of treatment to.’

Dr Pooni said the aim in his trust, which had been very supportive, was to meet an initial surge to 48 ICU (intensive care unit) beds. His principal concern was finding enough staff to run them.

‘I can say to the silver command, I have this amount of ventilators, I can expand into this area or that area, we can get equipment from the stores, but when it comes down to staffing those beds and escalating this care to

less-qualified individuals looking after the patients, and them being supervised by more senior nurses, that is a big challenge.

‘There is lots of activity stopped in the rest of the hospital and what we have to do is train those people up and see if they can provide the basic level of care that we can supervise, but that is a challenge in itself.’

Achieving the surge to 48 ventilated patients will be challenge enough but, as he understands it, the Government’s plan is for his trust to accommodate at least 80.

Dr Pooni, who is a member of the council of the Intensive Care Society, said: ‘We can’t staff 80. The only way to do that is literally to put somebody on the ventilator and not have bedside care.

You would have one person looking after maybe three thedoctor | April 2020 05

VENTILATORS: Set to increase, but will there be the staff?

patients and that is a massive deviation away from normal practice.

‘If there’s another person who needs ventilating do I say, I can’t take you, which means you are going to die or do I accept that I take you and the staffing level is unsafe – that is where the real decision making and ethics come in. It is going to be very difficult. What do you tell that person’s family? What about the impact on the rest of the patients?

‘I am experienced, but I’ve not been caught in those scenarios before. Usually our staff can flex up and we can pull one or two nurses in from elsewhere if we really need more capacity or someone will do an extra night shift at the 06 thedoctor | April 2020

last minute to tide us over, but on this point it would be challenging.

I am just not thinking about it. I can’t, I don’t want to and it’s a coping mechanism.

I will worry about that when it happens, I’ve got plenty else to worry about in the meantime.’

An early perception of COVID-19 was that serious harm would be confined to those patients who were older and had relevant underlying conditions. But Dr Pooni said that not only had he seen more younger patients than he expected, but the older ones had tended to be fit and active.

And Dr Pooni, speaking just before the first two UK doctors died of COVID-19, said it was vital that all NHS staff were adequately protected with proper PPE (personal protective equipment).

‘There is a big concern among doctors obviously with us at the front line – at my trust we are very lucky here on the ITU that we are supported by hospital management that there are adequate masks and equipment but there’s still a very big concern among doctors that it is not a matter

of if, but a matter of when we contract this virus.

‘On intensive care there are more high-risk procedures of course – for example on Sunday I was examining a patient and before I had put the stethoscope on the patient the ventilator became disconnected so that it was then blowing COVID-19 infection into the ICU – I picked it up instantly and reconnected but in theory while I had the PPE on there is still that risk.

‘The reality is that just because you have got it on you are not absolutely safe, with moving about and the mask moving and the pressure of the situation and the discomfort of the mask.

You are exhausted and if the mask slips a bit you could be exposed. That causes concern.

‘We do other procedures like tracheostomy to help patients get off the ventilator – there’s a time where there is a possibility of the ventilator ventilating because you have disconnected the patient for this virus to be sprayed around the unit.

‘Not many ICUs around the country have had one tracheostomy so far in this – we have done five.

That is not without its risk to the consultant. There is absolutely a lot going on in your mind.’

Dr Pooni said shifts were longer and more intense, with the arduous donning of uncomfortable PPE contributing to an overall sense of exhaustion.

Hard months ahead nsufficient access to PPE has put many doctors at needless risk, and the BMA has been pressing the Government urgently to ensure supplies.

BMA junior doctors committee chair Sarah Hallett said that while access to PPE had not been an issue at her own workplace, she had heard disturbing reports.

‘I have heard reports from some of our [JDC] reps that they have run out of PPE even on COVID positive wards, so there are still problems with the supply chain that need to be rectified. We need it on the front line now.’

Dr Hallett, a specialty trainee in paediatrics in London, went into isolation having experienced

symptoms associated with COVID-19 (see pages, 16 to 19). On returning to work, she said: ‘Our entire trust has been completely reorganised.’

Dr Hallett said: ‘We have a lot of patients with COVID and we are having to turn lots of areas of our hospital into critical care areas. Many of our staff who would normally deal with surgical or medical issues are being redeployed to intensive care.

‘All of the resources of my trust are now going into ensuring that we’re in the best position we can be to deal with lots of very sick patients.

‘Everyone that I’m aware of and coming into contact with is preparing themselves for a hard couple of months.’

MATT SAYWELL

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HALLETT: PPE needed on the front line now

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ISTOCK: JOHNNY GREIG

STREETS BEHIND: A woman crosses a deserted London Bridge in what would have been rush hour

BAYLEY: ‘I think we’re on top of things. How long that will last is difficult to say’

Massive change in general practice

I

n general practice, there have also been profound changes to how doctors work.

Derby-based locum GP and medical director of Derbyshire’s GP taskforce Susie Bayley said: ‘We’ve been under a huge amount of pressure.’

Dr Bayley said that a number of practices across the county had reported staff absences of up to a third of their workforce, clinical and non-clinical, either owing to people self-isolating or because of underlying health conditions which put them at greater risk.

She credited NHS England, her local clinical commissioning group and the BMA for the support they had been providing, and for the understanding around relaxing normal working practices to free up capacity for urgent-care services.

‘There was a bit of dragging of heels but now there’s been a massive understanding that we need to stop things that aren’t urgent face-to-face care,’ she said.

‘General practice has been massively galvanised by this – we’ve seen practices working together and making seismic shifts in the way that they work within a very short space of time.

‘Practice teams have been amazing in the way they’ve come together despite being short-staffed.

‘We’re doing everything we can to make sure we can cope with the demand and at this stage I think we’re on top of things. How long that will last is difficult to say.’

While her practice has made as many changes as it can to its working practices, such as moving to a telephone-only triage service, making physical changes to the patient waiting room to maximise social distancing and converting rooms into self-isolation areas, continued external support was vital.

08 thedoctor | April 2020

On 19 March Dr Bayley put out a request on social media asking schools whether they could donate science-lab goggles to supplement PPE supplies.

‘We do have PPE in stock, [however] the adequacy of that PPE is slightly questionable so we’re looking at innovative solutions to try and make sure we have got the stuff and are as protected as possible and able to continue in the day job.

‘We also need to get the testing of healthcare workers sorted. There are people off work who do not have coronavirus and don’t need to self-isolate – getting these people tested and back to work will help the workforce.

‘We are also still uncertain with regard to what is happening with childcare for key workers as there seems to still be a lack of clarity and clarity will help our staff with workforce planning.’

A lifetime’s planning put into action or Richard Jarvis, this is something he has been preparing for ever since his first pandemic flu exercise, six weeks after becoming a public health registrar in 1996.

The Cheshire and Merseyside consultant in health protection and communicable disease specialist said: ‘Once you realise this is a global emergency you remember you have been planning for this for a long time – we got the plans out to become familiar and it gave us the confidence to take those first few faltering steps to begin to deal with this.’

It has been a relentlessly busy time since the first news of the dangers of this coronavirus became clear in January this year. Dr Jarvis has been helping to organise the response – bringing specialty registrars into positions created to help respond to the outbreak, training them up and backfilling the normal public health jobs, which have not gone away, such as monitoring other illnesses.

There are around 50 staff working in health protection in Cheshire and Merseyside and Dr Jarvis says the secondments could increase that figure by up to 70 per cent, with a further 15 or 20 recently retired public health doctors also potentially coming back into the fold.

Initially, Public Health England’s work focused heavily on tracking and isolating cases of the virus – monitoring movements and trying to halt the spread. But once cases come into the hundreds that sort of work with current staffing levels is ‘near impossible’, Dr Jarvis says. Other countries with greater resource and more data monitoring of citizens have been able to do more.

More recently the work has been largely moved from contact tracing to ‘incident and outbreak management’, managing and shutting down transmissions and outbreaks in hospitals and care homes.

For Dr Jarvis, the responses of the health system’s institutions and organisations have been excellent, but there is a feeling that the political response may have slightly missed the mark.

He said: ‘I sense that there may have been a political reluctance to move on this quite as early as might have been useful but that is said in hindsight and I wasn’t making those political decisions. If we had started the ramp up [of restrictive measures] two weeks earlier than we did I think that would have been very useful.

‘The next thing is the speed of the changes in the social measures has been quicker than I would have anticipated – if you put something in place to say “we are all going to be social distancing now” then you would normally want to give it enough time to see if that measure is working in and of itself.

‘Some of the things that we put in place, we haven’t been able to see the evidence on whether they were working or

MATT SAYWELL

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JARVIS: The damage austerity has done will become clear

not – that isn’t necessarily important now but it will be when we start to step back because we won’t know how far we can step back.’

There are also concerns about how 10 years of austerity politics will affect the outbreak. Dr Jarvis identifying a total ‘lack of slack’ in the NHS and widening health inequalities – with life expectancy stalling, and childhood poverty soaring.

‘It’s bad for their health and social equity and all of those things combine to weaken the country as a whole at a time when we need to respond to something exceptional,’ Dr Jarvis said. thedoctor | April 2020 09

Back on duty

TOOBY: ‘I feel there is something I can do’

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ne of the most striking features about the pandemic has been the willingness of thousands of doctors and other healthcare workers to return to help deal with the crisis.

Since leaving general practice almost seven years ago, Hugh Tooby has been a ‘citizen scientist’, conducting nature surveys for organisations including the British Trust for Ornithology.

Now, however, he wants to use his skills, knowledge and expertise to contribute to the pandemic effort.

‘I’ve never regretted getting out of medicine at all – people ask if I miss it and I always say I don’t,’ said Dr Tooby, 58, who lives in the Forth Valley area of Scotland. ‘And then we arrive with an international health emergency. I think the time out has cured the “burnout” and now I feel that if there’s something that I can

10 thedoctor | April 2020

do, commensurate with the residual skills that I still have, then that would seem to be a very sensible thing to do.’

Dr Tooby’s 28-year medical career spanned working as a GP in Bradford, a three-year stint in the Army (with tours in Kosovo and Germany), some time in medical management with GP outof-hours cooperatives, and locum GP work in remote parts of Scotland.

He decided to retire at the very early age of 52 partly because he felt worn out, but also because he wanted a more outdoor life.

So why does he want to come back now?

‘I think on a general level as a human being, and perhaps the way I was brought up, I feel we all have a duty to contribute to society; we’re not here just for ourselves.

For human life to carry on, we have to act collaboratively.

‘But more specifically, I’ve always fought a little bit with guilty feelings about retiring early. Rationally I know that I did 28 years in the NHS, including three in the Army, but that still doesn’t stop you having that little bit of a “hum” feeling about it.

‘I know that what I’m doing now as a volunteer is providing valuable data that’s important for the health of the planet, but in a time of crisis, given that I’ve got that medical education and experience behind me, it would seem the entirely natural thing to do to see if there was some way that that can be brought back into

play, given that we know that the NHS is going to be very, very pressed very, very soon.’

Having been out of practice for more than three years, Dr Tooby does not fit the criteria for the first wave of retired returners but talking to friends working in the health service has convinced him that it is only a matter of time before the categories are expanded.

He is aware of his limitations – he is not up to date with the latest prescribing protocols, for example, and has not performed physical skills, such as inserting a cannula, for a long time.

Nevertheless, he believes his years of experience would bring benefits to the NHS, partly by freeing up doctors performing more ‘back-room’ functions, such as triaging out-of-hours calls, so that they can be redeployed.

He also believes that retired doctors will complement the contribution of medical students, who have the up-todate knowledge and physical skills required on the front line, but don’t have that depth of experience to call on.

‘In June it will be seven years since my last day of actively seeing a patient, which is quite a long time.

Not everything is like riding a bike – it won’t all come back immediately. But there are skills like taking a medical history, talking to people on the phone, being able to reassure people – these are all the things where experience tells.’

Desperate to help

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ther doctors are desperate to help, but are stymied by bureaucracy.

Priyadarshini Bhattacharjee is stuck in limbo, unable to offer her skills to health services either in the UK or at home in Kolkata.

On 10 March she travelled from India to Manchester in preparation for sitting her Professional and Linguistic Assessments Board 2 exam in April, so that she could realise her dream of working for the NHS. Despite assurances from the GMC that the exam would go ahead, on 17 March she was told it would be postponed until July. Meanwhile, India announced its borders would

close from 18 March.

‘I frantically tried to get on one of the last flights, but I wasn’t able to get a ticket,’ said Dr Bhattacharjee, 27, who hopes to enter specialty training in internal medicine.

‘So I’m stuck here, unable to work in the UK, and unable to get back to India.’

It’s particularly painful for her being unable to take part in the enormous medical effort to mitigate the effect of COVID-19.

‘I’m a doctor and have worked in critical care in my country, so if I could be of any help, I’d like to extend it to the NHS, but I don’t think the law permits that. Even so, if I could

help by offering support by telephone, or social media or even WhatsApp, if someone is experiencing any problem.’

Dr Bhattacharjee has set up a support group with doctors in the NHS and friends from India, Nepal, Sri Lanka and Myanmar, some of whom are in the same situation as she is.

The aim is to share information BHATTACHARJEE: ‘I’m unable to work in the and help each other cope UK, and unable to get back with the situation. But it is still to India’ frustrating for her not to be able to do more. ‘I’m missing home,’ she said simply.

‘And if I was at home I could be useful, because India is also facing a crisis right now and they also need doctors. I can see my friends working in the isolation wards. It’s very hard for a doctor to just sit at home, see situations go from bad to worse and not do anything. I know I have the knowledge and the training to help people and I just wish there was any way I could do that, either back home or here in the UK. It would have been at least something.’

Doctors manage a ‘micro-wedding’

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hile the pandemic rages, lives have been put on hold, plans radically altered.

When they realised that their wedding plans coincided with the likely UK peak of COVID-19, medical couple Dominique Thompson and Simon Bradley knew they had two options.

‘We got engaged on New Year’s Eve, and were planning the wedding for 13 June. It wasn’t going to be massive, but we would have had family and friends at the registry office, and a nice big lunch at a local restaurant in Bristol. We had people coming from Orkney, France – all over the place.

‘Last week when we were looking ahead, we realised that in 12 weeks’ time we would be hitting the peak of the pandemic in the UK. So we thought we could delay the wedding, or, because we just wanted to be married to each other, and these are difficult times, we can get married now and then we can focus on what’s going to be needed from us personally in the next few weeks.’

While her partner is still working as a GP, Dr Thompson had swapped general practice for other roles, including as an author and a speaker and specialist on child mental health.

With the advent of COVID-19, however, she is one of the many, many doctors who have rushed to offer their services, and expects to hear shortly what her duties will be. This did, however, leave a

small window in which the wedding – now a ‘microwedding’ – could take place.

‘I called the registry office, who already HAPPY COUPLE: ‘We knew we couldn’t have many guests’ knew we were going to be married, and they had two slots available. We knew we couldn’t have many guests, but we had our 10-year-old son, Jack, and one of my stepsons was one witness and a friend was another witness.

We sat six feet away from each other.’

Mindful of infection control, they didn’t even take taxis, and the wedding cake was a ‘Colin the Caterpillar’ effort from Marks & Spencer.

Wedding over, she can now focus on working for the NHS once more. ‘We all have to do our bit – we really are all in this together,’ she said. thedoctor | April 2020 11

‘This Government expects NHS staff to put themselves at risk of serious illness’

LACK OF PROTECTION UNMASKED 12 thedoctor | April 2020

If you’re tackling a deadly virus you’d expect to be afforded protection.

Not so in the UK where doctors have to make the best of inadequate supplies. Keith Cooper reports

T

he lives of NHS staff and their families are being put at risk owing to poor access to PPE (personal protective equipment) as they fight COVID-19, many doctors have warned.

With low supplies and conflicting advice from managers about the level of protection needed, doctors have been forced to improvise: to source their own sealed masks from DIY stores, builders’ merchants and garages. To beg, and in one case, borrow safety goggles from their nine-year-old daughter’s party bag. ‘I wish this was actually a joke,’ a consultant says in a posting to a BMA portal which has collected more than 200 experiences from frontline doctors fighting the virus.

Access to PPE was the ‘biggest issue’ facing doctors as they battled the virus, BMA council chair Chaand Nagpaul told an inquiry of the parliamentary health and social care select committee in late March. ‘This Government expects NHS staff to put themselves at risk of serious illness, or even death, by treating highly infectious COVID-19 patients without wearing proper protection,’ Dr Nagpaul had said in a strongly worded statement the previous day.

The BMA has flagged doctors’ concerns with prime minister Boris Johnson and is pressing PHE (Public Health England) to offer ‘When we run out and clearer advice on PPE, which the agency admitted is now under review, under questioning by committee chair and former health ring up the helpline secretary Jeremy Hunt. we’re told to buy BMA consultants committee chair Rob Harwood reiterates them ourselves’ doctors’ lack of confidence in supplies of protection equipment following the tragic death of Amged El-Hawrani, an ENT consultant working at University Hospitals of Derby and Burton NHS Foundation Trust.

‘Any death, be it doctor or patient, is a death too many,’ he adds. ‘Our hearts go out to Mr Amged El-Hawrani’s family.’

Communities secretary Robert Jenrick pledged on 29 March that tens of millions of masks, gloves, apron and gowns would be delivered to hospital trusts as part of the Government’s National Supply Redistribution Response, aided by the armed forces.

Protection sparse Concern about poor supplies of PPE and its risk to the lives of themselves, their colleagues and families is a common theme in postings to the portal. Almost eight out of 10 (77 per cent) raised concerns about access to PPE. A quarter expressed concerns for the health of NHS staff and their families.

So how is poor access to PPE affecting doctors on the ground? And what is being done about it? thedoctor | April 2020 13

PA MILITARY ASSISTANCE: Supplies arrive at St Thomas’ Hospital in London

facepiece 3)] masks, apparently surgical masks are OK. The consultant microbiologist came up and told the nurses on the COVID ward today PPE is running out and when it does, they will just have to cope.’

‘The situation is horrible regarding the PPE, there is a severe shortage,’ an emergency medicine registrar from the West Midlands says. ‘Every couple of days they are changing our PPE guidance.’

They’ve seen that there are higher standards of protection in guidelines on protective equipment by the World Health Organization and the internationally respected CDC (Centers for Disease Control and Prevention) in the US – compared with those enforced by managers on the say of PHE. Doctors point to shortages across the UK, in GP practices, hospitals, in emergency departments, intensive care units, and in community settings, including mental healthcare, via the online portal set up by the BMA for them to highlight their experiences and focus the association’s campaigning.

‘We’ve been sent just six personal protection kits,’ says a GP in Northern Ireland. ‘We have given them to the district nursing team so the doctors have nothing.’

‘Situation so grim we have started to try and source our own PPE,’ a consultant physician posts. ‘I was one of a group of five consultants who sat in a huddle yesterday morning using our mobile phones to try to find and buy PPE for us and colleagues using our own money. Much sold out. No confidence employer will protect us.’

Unreliable equipment

While watching counterparts in Europe on TV wearing higher-grade protection and hearing stories of staff deaths, they’re offered ‘flimsy paper masks and plastic aprons’. When offered ‘fitted’ masks for riskier patients and procedures, there’s no alternative tests to ensure they haven’t failed.’

‘I have failed my fit testing on all masks,’ one doctor said. ‘No alternative has been provided nor is available on my ward. This has been escalated to my clinical director.

I will be the primary doctor responder to acutely unwell patients on a COVID isolation weekend from Saturday night. I am worried about what to do if I am called to such an unwell patient as I won’t have PPE. My bosses don’t seem to be able to help.’

Most of the posts came a week after the major armyRisky strategies aided resupply effort announced by ministers.

Those working outside of acute hospitals appear to have ‘Even this morning, I’ve had emails from doctors worse access and fear they themselves could unwittingly that masks have run out,’ Dr Nagpaul told the select spread the infection for want of committee in the week of the access to adequate infectionresupply effort. ‘In general ‘There is a severe shortage’ control equipment. practice when we run out and ‘It seems we have been ring up the helpline we’re told deemed bottom of the priority pile,’ a specialty trainee 2 to buy them ourselves.’ in paediatrics reports. ‘While I totally appreciate our adult Royal College of Emergency Medicine president colleagues are taking the brunt of this, we know that Katherine Henderson told MPs the production of children can be asymptomatic or have mild symptoms protection should be ‘ramped up’. so treating paediatricians as lesser priority is a high-risk ‘It would be good to hear about the production strategy that puts staff and the population at large at and call for manufacturers to be making face shields, huge risk.’ visors, and masks ‘We have no PPE at all for working in outpatients or in the same way HENDERSON: those working with inpatients,’ a psychiatry associate as we are hearing Ramp up protection specialist said. ‘Managers have told us we don’t need it.’ about ventilators,’ production Other doctors spoke of conflicting and changing she added. advice from health bodies and managers, changes Public Health they fear are driven by rationing a scarce, though England medical improving, supply. director Yvonne Doyle ‘The goal posts are changing depending on the told the committee supply,’ says one. ‘As soon as we run out of [FFP3 (filtering there was not 14 thedoctor | April 2020

DOCTORSEXPOSED

‘[Staff told] the PPE is running out agreement on PPE in risky gloves, face shields and and, when it does, they will just settings between public health surgical masks could reach the have to cope’ agencies, such as itself, the UK in two weeks.

WHO and CDC. NHS guidance Cabinet Office minister had been ‘written on the basis of best infection control’, Penny Mordaunt indicated on 24 March that the Prof Doyle added, but was ‘under review in the light of Government would not use these supply sources. people’s anxieties’.

‘We have chosen other routes,’ she told Parliament.

PHE was due to issue new guidance, but the main ‘Geography, not politics, dictates we must work with concern of doctors was about supply. our European partners to win this fight,’ Dr Nagpaul said.

Separately, Dr Nagpaul also urged NHS England It is vital that the Government does whatever it takes to protect staff. As Dr Nagpaul told the select committee, director for acute care Keith Willett in a letter to tap thousands of doctors and frontline staff were risking into EU stockpiles and procurement processes to their health and lives caring for COVID-19 patients. ‘They compensate for the UK’s shortfall of medical equipment, should not have to do so without the right protection.’ such as ventilators and PPE. Much-needed masks,

Staff on the front line share their experiences through a dedicated BMA portal Staff who haven’t had fittesting are still expected to be on the crash team.

No apologies, no remorse at all from management. It’s put forward as though it was totally acceptable despite young, fit, Italian doctors dying. Some of our staff have other health conditions as well such as poorly controlled asthma.

Foundation year 1 Went to Screwfix to buy goggles for my team. They’ve run out.

I’m borrowing my nine-year-old daughter’s safety specs she got in a science party bag. I wish this was actually a joke.

HIV consultant We have no PPE at all for working in outpatients or those working with inpatients.

Managers have told us we don’t need it.

Psychiatry associate specialist

We are testing our patients for coronavirus using only surgical masks, aprons and gloves then also wearing the same once they are confirmed. I find this crazy as we are already short staffed and not only risking our immunocompromised patients but also risk losing more staff.

Junior doctor I was thinking about taking up a semi-permanent post locally so that I could be helpful. Tonight, I read that two consultants are in hospital on ventilators. I have diabetes.

It’s rarely gotten in the way of work before but this feels different. I’m a bit scared. I have a really strong sense of duty but with the horrendous provision of masks, I feel like I’m exposing myself to certain severe illness.

Foundation year 2

I’m scared for myself, my staff, and my patients.

The Government has seemed slow to react at each turn.

Really disappointed with PPE. I remember the swine-flu kit; this is rubbish in comparison.

GP We are asked to risk our lives and our loved ones’ lives in flimsy paper masks and plastic aprons. I don’t know if I can do it.

I just don’t know if I can. I don’t think it is fair to expect this of us.

I am terrified. Terrified. How can this risk to practitioners, other patients, practitioners’ families be justified? My husband is not a medic and I cry every day thinking I am going to infect him. I feel like I will be asked to sacrifice myself for this, it feels suicidal. I am seriously considering quitting.

Junior doctor Share your experiences at bit.ly/2WW4MUt thedoctor | April 2020 15

Testing times A lack of testing for COVID-19 has forced many doctors into self-isolation because they have reported flu-like symptoms – leaving the front line weakened at a time of crisis. Tim Tonkin reports

‘I think we’re underestimating how this is going to hit us’ 16 thedoctor | April 2020

A

t a time when the NHS is coming to terms with the most significant and unprecedented public-health challenge it has ever faced, the idea of pulling desperately needed doctors out of frontline service for up to two weeks is hugely daunting.

While the two defining symptoms of COVID-19 – a fever and a persistent cough – are well known, the only definitive way to know if someone has been infected is through testing.

Despite this, many doctors have reported having to go into isolation without having positive results for the virus, with many taking to social media demanding to know why testing is not being made more readily available for NHS staff.

Cumbria-based specialty trainee 1 Rebecca McCauley went into self-isolation on 17 March having developed a cough.

Despite feeling well enough to work she was told she couldn’t be tested and had to selfisolate at home for the next seven days.

‘I asked to be tested and said that I was willing to work if my result came back negative and was told “sorry” and that I just had to selfisolate,’ she says.

‘There’s not even an option of being tested at the moment.’

‘It’s March, everybody has coughs, colds and fevers at this time of year and they’re often nothing. Without testing us, people are having to stay away from work for up to 14 days.’

After setting up a petition on 15 March calling for testing of all NHS staff to be made a priority, PA

VALLANCE: Pledged to ramp up testing for COVID-19

the campaign has since garnered more than a million signatures.

Under the previous guidance, only those with fevers and coughs who had recently visited highrisk regions for the virus were being swabbed.

This guidance was extended to anyone admitted to hospital with respiratory symptoms.

Unsafe practice Dr McCauley says guidance for healthcare staff was ‘so unclear’, and that the lack of access to PPE (personal protective equipment) was also a huge concern for staff.

She says that, unless action is taken to increase testing to enable those staff who are fit and able to work to do so, the staffing of the health service is going to become unsustainable.

‘Even at the best of times when we’re running at full staff, we [the NHS] struggle. I think we’re underestimating how this is going to hit us.

‘I worry that if more than half the workforce is off sick for up to two weeks at a time, either because they or someone in their family or household has symptoms, that we’re not going to have a workforce.’

While the Welsh and Scottish governments have formally pledged to prioritise testing for frontline NHS staff, health leaders in England have equivocated.

Speaking at the Parliamentary health select committee on 17 March, the Government’s chief scientific adviser Sir Patrick Vallance said the UK had carried out around 44,000 tests with PHE (Public Health England) having a testing capacity of around 4,000 per day.

He admitted to the committee, however, that this was ‘clearly not going to be enough going forward’, while insisting that PHE is aiming to ramp up testing for key workers, which includes those who work in the NHS, as a matter of priority.

A letter sent by NHS England to all trust chief executives on 29 March explains that the number of daily tests being processed at laboratories would be doubled by 3 April.

Trust leaders have also been told they must now prioritise testing for those staff ‘working in critical care, emergency departments and ambulance services’ and staff in 14-day isolation be the very first to be tested.

GP registrar Hannah Barham-Brown put herself into self-isolation on 13 March after developing a cough – in line with the Government’s official guidance. thedoctor | April 2020 17

BARHAMBROWN: ‘There is definitely a shortage of resources’

‘I am very aware that there are quite a lot of worried and frustrated people out there, particularly among medical communities,’ she says.

‘If somebody had been able to swab me or do a serology test and definitively say whether I had the virus, I could be back at work.

‘Instead I’m now sitting at home thinking “this is ridiculous, I want to be at work”. There is so much going on and I’m very aware that my colleagues are really struggling. To be sat at home feeling like I can’t help is hugely frustrating.’

Little guidance

‘Selfisolation does seem appropriate and timely, but it could be that we just have a normal cough or normal cold’

After starting to feel unwell Dr Barham-Brown, who is working in a community nursing home for older people, contacted her supervisor and then put herself into isolation.

She says, however, she was not offered any testing – something she believes might be owing to a lack of resources.

‘I think there is a problem with resources: I think there is definitely a shortage of resources,’ she says.

‘While I’ve spent a lot of time travelling around for the past few weeks and while I have contact with a lot of people, none of them as far as I’m aware have been confirmed as having the virus.

‘According to the official guidance I don’t need testing and one of the problems of the guidance we’re having is there’s very little guidance specifically for healthcare professionals.

‘We [doctors] seem to be getting different information – a lot of it coming from trusts themselves, so I think there is a lot of confusion out there about what doctors need to do and how we can get testing if we feel we need it.’

‘I think we do need more guidance for healthcare practitioners. I think there are obviously problems in that this is a very new virus.’

Dr Barham-Brown says that while there needs to be more guidance for healthcare professionals, she recognises the pandemic poses significant challenges owing to it being a newly discovered virus about which there was

18 thedoctor | April 2020

BRASH: ‘The Government’s policies lead to confusion’

still much to learn.

‘There’s definitely some things we need to consider in terms of testing, but I think given there’s so much confusion, and it’s such a fastmoving situation, we really need to be keeping doctors abreast of what’s going on as there is a lot of confusion out there unfortunately.’

Newcastle foundation year 2 Claire Brash went voluntarily into self-isolation while on annual leave on 11 March, after she and her partner, who is also a doctor, had contact with someone who was suspected of having the virus.

After consulting NHS 111, she was initially told she did not need to self-isolate, but after developing a very mild cough two days after her isolation, Dr Brash was told by her employer not to come into work.

This was despite the fact the person responsible for Dr Brash’s potential exposure was never confirmed to have had the virus and had already returned to their home country before being tested.

To add to the confusion, while Dr Brash was told to isolate herself, her partner was told by their trust that they could continue to come to work, until they too developed symptoms and joined Dr Brash in isolation.

‘It’s been a really confusing time. We both have argued that we should be tested. We have both developed symptoms so self-isolation does seem appropriate and timely, but it could be that we just have a normal cough or normal cold.

‘My trust has been very supportive and covered my on-call shifts and has done the same to other colleagues in the same position, but it seems odd to a lot of medics that testing isn’t being offered because it could eliminate the need to self-isolate.’

Dr Brash and her partner asked their respective employers whether they could be tested and were told it wasn’t something that was at the time being offered and they were simply advising staff to self-isolate.

‘It’s been a really confusing time’

At times, the official guidance on how to appropriately respond to an exposure to the virus appeared to send mixed messages.

Previously, Government guidance for healthcare workers states that those who come into contact with a patient with COVID-19, even if not wearing PPE, could still remain at work, but must notify their line managers and immediately self-isolate if they develop symptoms.

This guidance was, however, withdrawn on 29 March with updated guidelines emphasising how ‘prompt recognition’ of viral infection in healthcare staff is essential to limiting the spread of the disease.

It adds that doctors and other healthcare staff with influenza-like illness, must not come to work and that staff who ‘provide care in areas for suspected/confirmed patients’, should ideally not be involved in providing care to other patients.

Anyone with symptoms is obliged to remain in isolation for a period of seven days from the onset of their symptoms. However, this period of isolation is doubled in the event that

someone in an individual’s household or family develops symptoms.

This means that a doctor whose partner or children became ill would need to remain in isolation for a fortnight, even if they themselves were not displaying symptoms.

Dr Brash adds that the various lengths of isolation depending on the type of exposure are confusing and potentially problematic when it comes to ensuring the NHS remains adequately staffed.

‘I have colleagues who have a sick child who are now taking 14 days off and who feel perfectly well themselves,’ Dr Brash says.

‘The Government’s policies keep changing which leads to confusion for the public and it also has an extra burden on the health service’s resources for staffing.

‘If I have not had the virus and I have not been tested, I may go back to work again [and] develop a cough [and] I will not know whether I have any immunity to COVID-19 and would have to start the process of self-isolation again.

‘That’s a huge burden on the NHS [and] it doesn’t seem sustainable.’

Waiting in the wings BMA junior doctors committee chair Sarah Hallett went into isolation after experiencing mild symptoms associated with COVID-19 infection.

Despite not having a formal diagnosis through testing, Dr Hallett’s symptoms meant her two housemates – junior doctors who also work on the NHS front line – have had to isolate themselves for two weeks.

‘I completely understand why the self-isolation guidelines exist and it’s incredibly important that the public follow them to limit the spread of the infection among the public,’ says Dr Hallett.

‘It’s frustrating for health professionals because we may be self-isolating for no reason and if there’s a test that can tell us whether we can go back to work, we should be having access to that.

‘We know that we had an overall shortage of doctors and medical staff in general even before this pandemic, so we’re coming from a position of being understaffed anyway so every single one of us who has to self-isolate

potentially unnecessarily, each of those instances has an impact on the front line.

‘The irony is that we heard that Boris Johnson and Matt Hancock have tested positive with mild symptoms,’ she says.

‘They haven’t fitted what is currently the criteria for who we’re testing. It highlights to me how there’s one rule for politicians and a different one for medical staff. I imagine that there’s going to be a lot of medical staff throughout the UK who are going to want to know why MPs and senior Government officials are getting different treatment to medical professionals.’

Since her return to work, Dr Hallett says her trust had made huge changes to adapt to the pandemic, with rotas being completely re-written.

She adds that, while staff accept the necessity of the changes, there is also a realisation that the struggle against the virus will not end quickly and that the NHS is in it ‘for the long haul’. thedoctor | April 2020 19

SAFE DISTANCE: Online consultations set to be the new way of working

A virtual revolution C

COVID-19 has required GPs to change at pace to delivering most consultations online.

How are they managing, and what are the pitfalls to consider?

Keith Cooper reports

20 thedoctor | April 2020

OVID-19 has created a ‘burning platform’.

It has accelerated the move to telemedicine in primary care, although a number of practical and ethical issues remain.

Health secretary Matt Hancock called for ‘digital first’ in primary care and hospital outpatient departments on 12 March.

‘Unless there are clinical or practical reasons, all consultations should be done by telemedicine.’

So how has this rapid switch to help combat the spread of the virus fared?

BMA GPs committee IT lead Anu Rao says COVID-19 had prompted a rapid reaction from doctors and the national arms of the NHS to get

consultations online fast.

‘There was a little bit of inertia in the system before COVID-19 happened towards moving to IT technology, video consultation, and online platforms,’ she adds.

‘But because of coronavirus it seems to have built a burning platform, where people have had to adapt and move at pace.

This is not such a bad thing, as long as it’s done properly, ensuring patient and staff safety are maintained.’

The BMA has published a guide on remote consultations during the COVID-19 outbreak, listing NHS-approved IT packages and tips on confidentiality and home working (see box: Top tips on home working

Supervision anxiety One foundation year 2 doctor on a GP rotation became frustrated and concerned about carrying out consultations on the phone when staff were unable to supervise.

‘I have experienced periods already where so many of the other GPs in my practice are self-isolating due to symptoms in themselves or their family.

‘I am the only doctor left in the practice with only a phone number to call a GP at home as my supervision.

I worry that we are sitting ducks for legal action in the GP setting as it stands.’

Dr Rao, also a GP trainer and partner at Forest House Surgery, Leicestershire, says trainees should take up concerns with their trainers and escalate them to their programme directors if necessary.

‘The last thing you want is for trainee GPs to feel under pressure to do something completely out of their remit,’ she adds. Telephone triage is an essential part of working as a GP trainee, she says.

Kent local medical committee medical secretary John Allingham raises concerns about delays in accessing laptops for remote working. While the NHS had set aside funding for hundreds, the LMC was told they must wait up to eight weeks for them to arrive.

‘Every man and his dog wants a laptop at the moment.

I get that,’ Dr Allingham says.

‘There’s a big demand but everything has to come through the NHS supply chain.

We could get them fairly easily from Currys or Argos.’

There is a ‘mixed economy’ of remote working across the county, he adds. Doctors in east Kent were well supplied during contingency planning for the no-deal Brexit. But in Medway there was concern for older GPs running singlehanded practices.

‘They should probably be isolating. We are rapidly trying to come up with solutions where they don’t see patients face-to-face and only remotely.’

Physical contact Dr Allingham has only physically seen one patient in two recent days of clinical working. ‘We are doing hardly anything face-to-face. We’re down to about 5 per cent and that is probably mirrored elsewhere.’

Dr Rao agrees there is a problem with supplies of NHS equipment. ‘We are looking at how that could be mitigated,’ she says.

‘We are looking at getting people to use their own laptops through a single portal where they can safely and securely log on to get into the system.

‘These things were supposed to be introduced over six months to a year.

They are having to be done in a week.

‘These are unprecedented times,’ Dr Rao adds. ‘We need to ensure footfall into surgeries versus face-to-face goes down to the minimum level required. The more we

MATT SAYWELL

and confidentiality).

Doctors have, however, flagged some concerns about the switch to online consultations through the BMA’s COVID-19 reporting portal.

RAO: Doctors have had to adapt and move at pace

‘This is almost certainly going to be a game changer for how we consult in general practice’

can spread the importance of embracing technology in this crisis situation, the better.’

And after the COVID-19 crisis has passed? The days of the routine face-to-face consultation and waiting rooms full of patients may well be numbered, too.

‘This is almost certainly going to be a game-changer for how we consult in general practice,’ Dr Rao says. ‘Three months of this can actually prove that technology can play a big role in consultations. It is going to change the mindset for patients and practitioners.’

Top tips on home working and confidentiality –– Record all information of care, as usual –– Avoid storing patient data on your device –– Transfer any stored on to patients’ health and care records as soon as possible –– Delete any personal information, including back-up data –– Ensure internet access is secure –– Use strong passwords –– Employ encryption technology

thedoctor | April 2020 21

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

Coronavirus One of the reasons for the eventual victory against COVID-19 will be the immense flexibility shown by doctors, and their willingness to work new hours, in new places, under new and often highly challenging conditions.

There have been comparisons to mobilising an army. It is meant as a compliment. But such parallels tend to overlook the fact that there is an immense number of practicalities to resolve. When it comes to informing, enabling, and reassuring the workforce, a lot of work needs to be done. This is where BMA member relations staff have played such a vital role.

Usually, with On the Ground, we look at a single problem raised by a member and how it was successfully resolved. We thought it would be more useful this month to instead give an idea of the range

Professional status Doctors have been raising questions about whether they will be in professional jeopardy if they undertake work in different specialties, whether they will still be covered by indemnity and whether they will be supervised well enough.

22 thedoctor | April 2020

of questions which have been asked.

The two biggest areas have been personal protective equipment and testing, which we have covered elsewhere in this issue. But there have been many others, a flavour of which are below. We do not have the scope to answer them all here and, in any case, some will depend on local circumstances.

But the BMA website has a large amount of guidance about working during the crisis. BMA members can also call 0300 123 1233, email support@bma.org.uk or talk to an adviser online – those with COVID19-related questions are advised to check the website first, as many areas have been covered there.

Here are some of the issues which members have raised with the BMA:

Junior doctors’ education and training The rota change planned for April has been postponed, leading to concerns as to how long it will be before doctors can start their next jobs.

Study leave has become impossible to take, because of service commitments and because none of the courses or conferences which serve it are taking place. And doctors have also asked whether they will be able to meet all of their requirements for the Annual Review of Competence Progression if they no longer have the same breadth of exposure.

Childcare There have been commitments made that the children of key workers will be able to continue at school if alternative provision cannot be found. Staff who find their schools closed, and are unable to organise childcare so need to stay at home, have wanted to know if they will be financially penalised by not attending work.

– some of the issues raised Wellbeing

?

Employers should show the same level of goodwill to staff as staff are demonstrating to the service. Questions have been asked about wellbeing and support services, whether there will be additional rest facilities, and catering available around the clock.

Staff in areas of particular intensity, such as emergency medicine, have said they need protecting from burnout given that some will be waiting longer before they rotate to a different specialty. And doctors have asked whether absence ‘trigger points’ – the formal meetings which swing into place after a certain period of time off sick – are to be abolished, given the likely increased rates of illness among staff, from the workload as much as exposure to the virus.

Call 0330 123 1245 or visit bma.org.uk/yourwellbeing

Go to bma.org.uk/covid-19 for more information

Annual leave Advice on working while pregnant

Capacity Most doctors are veterans of some particularly arduous winter pressures in recent years, and have had experience of elective work being temporarily postponed. They are asking whether such work will stop altogether, and also whether local ethics committees will consider issues of prioritisation of treatment.

The NHS has a duty of care to its employees, and no doctor should be exposed to unacceptable risks if they are pregnant or have underlying health conditions which would make them more likely to suffer serious illness if they contracted COVID-19. These are among many issues covered in the COVID-19 section of the BMA website under ‘terms and conditions’.

Most employment contracts specify a maximum number of days (if any) which can be carried over into the following leave year. Doctors have sought clarity as to whether, given the circumstances, this will be permitted.

There is also the prospect in many trusts of leave being cancelled, and there need to be arrangements in place to compensate in money or time – the latter being hard to imagine if the crisis continues. thedoctor | April 2020 23

At what price?

China insists it relies on voluntary donations for organ transplants but many suggest human-rights abuse involving oppressed ethnic minorities continues to be practised.

Keith Cooper reports

24 thedoctor | April 2020

PA

I

t sounds like science fiction or an echo of a past horror. People rounded up into prison camps, their healthy organs removed without proper consent by unscrupulous surgeons for transplantation, all under a veil of state secrecy.

Yet, this isn’t fiction, according to many doctors, scholars, and campaigners. They say it’s been routine practice in China for decades and still is, a claim its government denies and the CMA (Chinese Medical Association) calls ‘groundless’.

So, what is fact and fiction in this alleged atrocity?

To find out The Doctor has examined the evidence and spoken to doctors and scholars involved, from both sides of the divide of this highly contentious issue.

China has admitted much: that executed convicted criminals were its prime source of organs in tens of thousands of transplant operations through the 1980s, 1990s, and the early part of this century. It claims, however, to have banned this unethical practice in 2015 and relies now only on voluntary donations. Autonomous informed consent, that fundamental principle of medical ethics, cannot be obtained from people in the coercive environment of prison (see box, below).

Decades of relying on this readily available ‘source’ of death-row prisoners did, however, fuel a roaring commercial trade in transplant surgery in the pre-ban boom-time – including ‘transplant tourism’ – which it is struggling to stamp out. Hundreds of unregulated hospitals established themselves as transplant centres during that growth period.

At its tail, in 2006, a year before transplant tourism was ‘outlawed’, 11,000 foreign patients had transplants in China. So said Francis Delmonico, a World Health Organization adviser, to a US House of Representatives committee a decade later. Executed prisoners would have been the principal source.

The medical ethics of organ donation Organ donation is a gift which is recognised in the wellknown model of informed consent. This is valid only if it is given freely without the threat of punishment or coerced through reward.

Without proper consent, the act of organ donation has the potential to become coercive and a breach of human rights.

Informed consent is well established in the UK and worldwide. Under this, people must understand the benefits and risks presented to them and have the mental capacity to make rational decisions.

BLOODY RESISTANCE: Falun Gong practitioners protest against alleged ‘organ harvesting’

China’s doctors say voluntary donation is now the sole legal source of organs post-2015. Transplant centres must also be registered. Some 170 are, they say, a huge drop from the 600 previously operating, according to a 2015 paper in the Chinese Medical Journal. A few of the major centres have been visited by senior doctors from outside China – but only to help its healthcare professionals to improve practice (see graphic overleaf: Major transplant centres and areas of ‘re-education’ camps in China).

A national IT system now allocates organs in line with ‘internationally recognised principles’.

Greater transparency is promised for a ‘new historic stage’. Annual reports will be published in Chinese and English, says the first one from December 2019, seen

by The Doctor. This admits to continued problems with illegal ‘organ trade gangs’ and the need for a ‘crackdown’ but says ‘hostile forces’ are ‘spreading rumours’ their progress is being ‘dismissed’.

Harvest claims China has, however, repeatedly denied another serious but related charge: that it has and continues to ‘harvest’ organs by forcibly removing them from oppressed Restrictions to liberty in a prison environment make it highly unlikely prisoners are truly free to make independent decisions. Valid autonomous informed consent for donation under such conditions can therefore not be obtained.

Offer of payment to prisoners – or their families – for organs is another form of coercion. It creates incentives to increase commercial supply, which is linked to organised crime and unlicensed practice instead of expanding ethical voluntary donations with informed consent. bma.org.uk/consent

thedoctor | April 2020 25

Major transplant centres and areas of ‘re-education’ camps in China

Transplant operations reported to the World Health Organization 2003

2005

Major transplant centres visited by doctors from outside China

11,000 operations on ‘transplant tourists’

2006 2007

8,500 transplants declared to WHO observatory ‘Transplant tourism’ banned

2008 2009 YEAR

Areas of ‘re-education’ camps in China

China admits to using executed prisoners

2004

Ürümqi Dabancheng Kashgar

2010

CHINA NEI MONGOL (INNER MONGOLIA)

XINJIANG

2011 2012

SHAANXI

HENAN

2013 XIZAN (TIBET)

2014

SICHUAN

Ban on executed prisoners comes into force

2015 2016

HUNAN

Tongji Medical College Hospital of Huazhong University of Science and Technology and Zhongnan Hospital of Wuhan University

2017 2018 0

5,000

10,000

15,000

20,000

25,000

TRANSPLANTS

Source: WHO / Australian Strategic Policy Institute

Despite China’s denials, allegations of ‘organ harvesting’ from prisoners of conscience are taken seriously by politicians, campaign groups, and medical institutions, including the BMA, the American Medical Association, and the World Medical Association to which they belong.

They’ve been probed by powerful politicians abroad, including a US House of Representatives committee on foreign affairs in 2016 and Australia’s equivalent in 2018. Hundreds of thousands of organs had already been ‘harvested’ from prisoners of conscience, the United Nations Human Rights Council was told last year.

Gross violation FINLAY: ‘prisoners of conscience’.

Could doctors This ‘source’ has also perpetrate been linked by doctors crimes against humanity? and investigators to ‘transplant tourism’.

It includes followers of Falun Gong, an illegal belief system in China, described as a ‘cancer’ by its embassies, and Uighurs, a largely Muslim ethnic minority, a million of whom are believed to be held in prison camps in Xinjiang, a remote province. Conditions in China’s ‘penal institutions’ for political prisoners are described as ‘harsh and often life threatening and degrading’, in the US State Department’s 2019 report on human rights practice published last month.

26 thedoctor | April 2020

HUBEI

BMA medical ethics committee chair John Chisholm last year described ‘forced organ harvesting’ as a ‘gross and continuing violation of inalienable, fundamental human rights’. He was speaking in June after the final judgment of the Independent Tribunal into Forced Organ Harvesting from Prisoners of Conscience in China.

This ‘people’s tribunal’, a kind of unofficial jury, was established by the International Coalition to End Transplant Abuse in China, an advocacy group.

It concluded last year that ‘organ harvesting’ had been practised on ‘very substantial numbers’ of prisoners of conscience.

MEC member Baroness Ilora Finlay told the UK House of Lords last October that ‘extensive evidence’ in its judgment made ‘harrowing reading’.

GUANGZ

Decades of denial 1966

China’s first kidney transplant

An era of rehabilitation?

1978

First liver transplant (unsuccessful)

Beijing

N

JIANGSU

Beijing Friendship Hospital, Capital Medical University

The First Affiliated Hospital of Xi’an Jiaotong University Shanghai Renji Hospital Shanghai Jiao Tong University School of Medicine

ZHOU

Hong Kong

1993

Exponential growth in transplant centres begins (and continues to 2005)

1999

Persecution of Falun Gong starts

2001

The First Affiliated Hospital, Zhejiang

China dismisses claims it ‘harvests organs’ from executed prisoners as ‘vicious lies’ in the New York Times

The First Affiliated Hospital, Sun Yat-sen University

2005

China admits executed prisoners are its main source of organs

‘Is it possible that some doctors could perpetrate such crimes against humanity?’

The tribunal’s full evidence file, released last month, runs to hundreds of pages. Much relates to events before the 2015 ban on the use of executed prisoners.

It does, however, include some more recent evidence to support the tribunal’s claims that organ ‘harvesting’ continues in China and that its victims include prisoners of conscience. This more recent evidence also casts doubts on China’s claim to greater transparency.

One of the tribunal’s most controversial allegations – which Chinese doctors deny – is that China has ‘fabricated’ its official figures on transplant activity since 2015.

The claim comes from a 2019 paper in BMC Medical Ethics, a respected journal, and is quoted in last month’s US State Department report. Its authors include Raymond Hinde, an Australian PhD in statistics, and two long-term campaigners against ‘organ harvesting’ in China, Jacob Lavee, immediate past president of the Israel Transplantation Society and Matthew Robertson, a former journalist at Epoch Times, linked to Falun Gong.

Using forensic statistical analysis, they claim China has since 2015 used a mathematical formula, a quadratic equation, to ‘fabricate’ its official figures. ‘A variety of evidence points to what the authors believe can only be plausibly explained by systematic falsification and manipulation of official organ-transplant data sets in China,’ the paper concludes.

The path to reform 2006

11,000 transplant operations on ‘transplant tourists’ (admitted in 2016)

2007

China bans ‘transplant tourism’

2010

Pilots for voluntary donation set up

2011

COTRS (China Organ Transplant Response System) put into service

2015

China’s ban on organs from executed prisoners begins

2016

The Transplant Society holds its conference in Hong Kong

2017

Chinese officials present at the Pontifical Academy of Sciences in the Vatican

2019

Chinese doctors admit to problem with ‘organ trade gangs’, promise ‘crackdown’ and a ‘new historic age’ of transparency

Their charge was met with vociferous response from China. ‘Report slandering China’s organ-donation data is laden with logical and academic fallacies,’ runs one headline in Global Times, a Beijing-based English language newspaper. The Chinese Medical Association says a retraction will be requested.

These allegedly falsified figures are emblematic of China’s claim to greater transparency and helped rehabilitate it in the eyes of the international transplant community (see ‘Decades of denial’, above).

They’ve been presented at international conferences, including at the Vatican’s Pontifical Academy of Sciences in 2017. They’re pulled from the COTRS (China Organ Transplant Response System) that China set up as part of its plan to improve.

Before 2015, China’s reports to a WHO transplant surgery observatory, while regular, are questionable.

The exact same figures appear for several years; the one for 2006 is thousands below the figure for the same year – reported by Prof Delmonico a decade later – for foreign patients alone.

Prof Lavee’s paper was examined for the tribunal by University of Cambridge statistics Professor Sir David Spiegelhalter. He describes its analysis as appropriate.

‘The close agreement of the numbers of donors and transplants with a quadratic function is remarkable,’ he adds. While ‘unable to ascribe specific reasons for the anomalies… they are certainly worthy of further investigation,’ Sir David’s review states. thedoctor | April 2020 27

Carrot and stick

DELMONICO: Trusts China

Another reviewer, questioned by TTS is committed to reform (The Transplant Society), found the Chinese data ‘plausible’. This reviewer, University of Michigan professor of biostatistics Jack Kalbfleisch, told The Doctor the authors’ alternative claim of a ‘bold scheme of data manipulation’ was ‘more incredulous’.

TTS is an influential membership body for transplant physicians worldwide. It has worked with the WHO – using carrots and sticks – since 2005 to help China improve.

Prof Delmonico is a former president and now chairs the WHO taskforce on organ donation and transplantation.

Following Prof Kalbfleisch’s review, TTS from this source would have been ‘tissue-typed’ China Relations Committee rejected the claims of for matching from ‘donors unidentified’ in China’s ‘falsification’ at a meeting in February last year, following official figures. a videoconference attended by Haibo Wang, China’s This alleged ‘alternative source’ is linked to prisoners head of COTRS, its IT system. This decision is described of conscience by what the tribunal judgment calls by tribunal lawyer Hamid Sabi as a ‘white-wash’, in an ‘indirect evidence’. Former detention camp detainees email to TTS, published on the tribunal’s website. The had testified to being ‘systematically subjected tribunal did not approach Prof Kalbfleisch for his views. to blood tests and organ examinations’, including Prof Lavee, a former member of TTS ethics ultrasound scans. Such tests are ‘highly suggestive of committee, says its response to the ‘hard evidence’ methods used to assess organ function’, it says. of his paper and the tribunal is ‘disgraceful’. TTS had Unethical testing adopted an ‘ostrich policy’ towards China, he told While many of these testimonies are from before the The Doctor. ‘The silence of the world in general to those 2015 ban, China has since 2017 taken blood from ongoing atrocities is unimaginable.’

The tribunal was, however, convinced ‘official Chinese millions of Uighurs in its remote Xinjiang province, according to US-based Human Rights Watch. transplantation statistics have been falsified’ and so The tribunal’s claim of an ‘alternative source’ is ‘disregards’ them. It instead considers ‘as credible’ a further bolstered with evidence of short waiting times. far higher range of transplant operations from another This is largely from records of more than 2,000 piece of evidence it examined. undercover calls to Chinese political figures, China’s latest figures show that 20,201 patients hospitals and doctors by researchers from the World received organ transplants in 2018 from around 6,302 Organisation to Investigate the Persecution of Falun donors. The range accepted by the tribunal numbers is Gong, an activist organisation, since 2006. Of the 60,000 to 90,000 transplants a year. very few relevant ones placed post-2015, some So how was the higher range arrived at? What does respondents do offer waiting times in weeks, according the alleged difference mean? to transcripts.

The range is an estimate of China’s capacity to This opens another ‘unexplained’ gap – between perform transplant operations. It comes from a 2016 the weeks-long waits offered in these calls and the report, Bloody Harvest / The Slaughter, by human months or years people typically wait for transplants in rights lawyer David Kilgour, former Canadian politician countries reliant on voluntary donation.

David Matas, and US investigator Ethan Gutmann. Their Together, this evidence of China’s previous practice estimates are based on bed and staff numbers, and likely of ‘harvesting’ prisoners in hundreds of hospitals, its activity, pulled from Chinese hospital websites, media oppression of those still confined in camps – including reports and academic papers before – and a short time unwarranted medical checks – alongside contested after – the 2015 ban. doubts about its honesty, helped move the tribunal to a Accepted as credible, the range opens an stark and certain conclusion. ‘incomprehensible gap’, the tribunal concluded, ‘There has been a population of donors accessible between it and China’s officially declared numbers of to hospitals in the PRC’ (People’s Republic of China) voluntary donors. This gap must have been filled, it ‘whose organs could be extracted according to demand concludes, by an ‘alternative source’ of organs. Organs 28 thedoctor | April 2020

for them’, their judgment states. Falun Gong members were ‘probably the principal source’ and there was ‘no evidence of the practice having been stopped’.

Tribunal member and consultant paediatric cardiothoracic surgeon Martin Elliott is a former medical director of Great Ormond Street Hospital, London, where he performed heart transplants and ran its thoracic transplant programme. Prof Elliott says he would find it ‘very hard’ to believe China on organ transplants until it stops it ‘being a state secret’ and ‘opens its books’. Its records on donations and transplants should be open for cross-checking by neutral parties as in other countries, he says.

The ‘mismatch’ between declared donors and the 60,000 to 90,000 range ‘requires explanation’, he adds.

He admits to not seeing ‘really hard evidence’ of what the unwarranted blood tests were for. ‘But you have to postulate explanations and they overlay with the other strands of evidence.’

WHO taskforce chair and Harvard Medical School professor of surgery Prof Delmonico has worked with Chinese doctors to improve practice for 15 years.

He says the range relied on by the tribunal is ‘not consistent with a reality of performing that many transplants in one year in one country’.

The international community ‘does not deny’ the abuse of blood tests in detention but ‘linking of this abuse to transplants is a speculation’, Prof Delmonico says. He trusts China is committed to reform because of ‘the assurance of the minister of health of China’ whom he met in Beijing in December.

So where does the evidence leave us?

Lack of trust For all the certainty of the tribunal’s conclusion, there remain many unanswered questions.

China admits that an illegal trade in transplants continues.

Who is the source of the organs? How many are illegally taken each year? How much effort is made to protect those China already oppresses from ‘organ trade gangs’?

After years of covering up unethical practice, it’s no wonder that trust levels run low, that scepticism about improvements runs high, and that the balance of evidence tipped against China in the tribunal.

Dr Chisholm believes such questions can only be answered by a fully independent inquiry into China’s transplant practice, past and present.

‘Only by truly opening up to scrutiny and independent audit can we ever be sure that China has ended its reliance on unethical sources of organs for transplant and that it is committed to stamping out such unethical sourcing.’

Transparency must be permitted

China insists it does not harvest organs from prisoners but the only way to be sure is to have an independent investigation, says BMA medical ethics committee chair John Chisholm Leading health and human rights organisations have expressed grave concerns for decades about allegations China has been trading in the organs of executed prisoners.

Far more worrying have been sustained allegations China has been executing prisoners of conscience ‘on demand’ to supply its commercial trade in organs.

The use of organs from executed prisoners violates international ethical and human rights norms: the threat of execution vitiates any possibility of informed consent. It is opposed by all leading international medical organisations, including the World Medical Association.

The practice of harvesting organs from prisoners of conscience on demand is a moral monstrosity – reminiscent of some of the most abhorrent practices of recent medical history. It has no place in medicine and must be absolutely prohibited.

As this thoughtful, painstaking and even-handed feature makes clear, China has admitted it has ‘harvested’ the organs of executed prisoners. It has also acknowledged they have been used to supply an extensive commercial trade in organs. It now says this practice is unlawful and is in the process of being stamped out. China remains emphatic in denying it has executed prisoners of conscience on demand to supply its organs. This is a deeply controversial area.

The Doctor’s investigation has not unearthed hard evidence the worst of these inhumane practices persist. But there is no doubt questions remain. A veil of secrecy hangs over China’s transplant system. In these circumstances, I believe it essential China agrees to a thorough, open and independent investigation of these allegations, commissioned by a reputable body, such as the World Health Organization. Only in this way can these grave concerns be properly addressed.

If what China says is true, it can have no good reason to oppose such an investigation. If it refuses, the world will make up its own mind. thedoctor | April 2020 29

explainer

PA

SUNAK: Raised the rate at which charges kick in but is it enough?

Pensions – a step in the right direction Following intense BMA pressure, the Government has made changes to pensions tax which means thousands of doctors will no longer be forced to leave the NHS or reduce commitments. But more needs to be done, says Jennifer Trueland After 18 months of campaigning by the BMA, there has at last been some good news on the pensions tax crisis.

Chancellor Rishi Sunak announced in March that the threshold income at which the charges kick in would lift to £200,000.

In practice, although it doesn’t remove the taper, it effectively means the vast majority of doctors will no longer be affected by it, so they will not be placed in the invidious – and ridiculous – position of paying to go to work.

As BMA pensions committee chair Vishal Sharma put it, it was ‘long overdue’. GPs and consultants in their droves had already reduced their workloads because of worries they would tip into the arena of punitive pension tax bills.

Dr Sharma said: ‘For the past 18 months patients have suffered, and doctors have faced an intolerable dilemma with many forced to cut short their service to the NHS, reducing hours or turning down vital additional work – not being able to care for their patients as they would want to.’

30 thedoctor | April 2020

Cumulatively, that’s thousands and thousands of hours each year lost to patient care and the myriad other things doctors contribute to health services.

Will they ever come back? It’s not like the Treasury didn’t know – the BMA raised it with them as far back as August 2018.

There are also concerns the chancellor’s moves don’t go far enough. Retention of the annual allowance at £40,000 means doctors earning far less than the new £200,000 threshold income could face tax bills following a modest rise in pensionable pay – for example, if they have ‘won’ clinical excellence awards or taken on extra responsibilities. Do we really want doctors not to do these things?

Also, with no change to the lifetime allowance, many more doctors will consider taking early retirement, further depleting a workforce already under pressure.

Doctors are doing the right thing by the nation – surely the nation’s Government should do the right thing for them.

Barts Health NHS Trust

and finally ...

ROCK IN HARD TIMES: A hospital that’s always there no matter what

To the hospital I love

Increasingly, you are being knocked for six as COVID-19 invades.

As a public health doctor, I will do my bit to limit the damage of this global threat, but you – the Royal London Hospital which has cared for me and my family for decades – will face the direct human cost, which will be in the thousands.

You will do it cheerfully and work long hours, and may not have enough supplies, tests, or ventilators. Your staff may have to make choices no doctor or nurse should, and they will have to live with that forever. Some may pay the ultimate price and, in saving patients, lose their own lives.

I walked along your façade today, past Victorian brick walls adorned with images from 100 years ago when you were a refuge for the poor of East London. Then, you delivered care without the effective medicines and shiny machines in the PFI-funded tower block that now casts a shadow over the pavement and your finances.

How well we know each other. You took my son’s tonsils out after years of sore throats – he’s now a six-foot-two surfer who fondly remembers your ice cream and jelly. I needed you when part of my baby’s placenta got stuck inside me and my haemoglobin dropped to six – you fixed me, and my daughter did not lose her mum. You sorted my damaged knee after I fell down an escalator at her graduation (for the record, it was lunch time and I was sober).

When my husband grumbled about tummy pain on the morning of our Christmas party, you confirmed he had a mass – the surgeon who did the emergency operation that night dropped by at 4am to show us photos of the biggest appendix he had ever seen. ‘Excellent,’ we said, admiring the smartphone image.

Which parts of my family haven’t you seen?

Last November we viewed my cervix together on a wide-screen TV. The giant, pink, moisturebeaded doughnut was unnerving, but medication made the experience surreal and almost pleasant.

I woke in agony at 5am two days later and was carried by aforementioned husband through your doors. Did I have an abdominal perforation from those cervical biopsies? Torrential diarrhoea gave the answer – food poisoning.

Your doctors and nurses tanked me up on morphine and IV fluids for three days and saved my kidneys.

You try your best. Staff are competent and cheerful and know what they are doing. I can see most of their name badges, although some still dangle at groin level, or have tiny print (a pet peeve). On your walls you have uplifting art. The food is not bad. Armies of volunteers explain the convoluted lift system.

You sometimes fail. Medical errors occur, as do hospital-acquired complications – but your complaint system responds.

Over the years, letters have been lost, phones gone unanswered, and there have been occasional delays in my appointments, but all have got much better in recent years. You are on top of things. A stream of fellow East-enders will head to your doors over the next days and weeks, and many will be frightened, breathless and terribly ill. You will be their port in the coming storm, as you have been mine. And this is why I write today, to tell you that I am grateful beyond belief you are there. I am proud of you.

Stay strong.

Mary E Black is board clinical director and director of health protection at Public Health Scotland. thedoctor | April 2020 31

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05/04/2020 12:59