The Doctor, issue 25. October 2020 by The BMA

The magazine for BMA members

thedoctor 20200365 thedoctor – p1 v2.indd 1

Issue 25 | October 2020

Long Covid The doctors still suffering, months after contracting the virus Austerity, the pandemic’s friend How spending cuts made the impact worse The other virus Indian doctors battle a swarm of misinformation A ‘moonshot’? The chaotic state of testing

05/10/2020 11:42

thedoctor

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

Email thedoctor@bma.org.uk

Editor Neil Hallows (020) 7383 6321

Call a BMA adviser

Chief sub-editor Chris Patterson (020) 7383 6978

0300 123 1233 @TheDrMagazine @theBMA The Doctor is published by the British Medical Association. The views expressed in it are not necessarily those of the BMA. It is available on subscription at £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 BMJ vol: 371 issue 8263

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

ISSN 2631-6412

thedoctor | October 2020

20200365 thedoctor – p2-3 v2.indd 1

04/10/2020 11:58

In this issue 4-7 Briefing

Why talk of a COVID-testing ‘moonshot’ is just a distraction and news from the BMA’s first virtual annual representative meeting

Welcome Chaand Nagpaul, BMA council chair As cases of COVID-19 continue to rise in the community and fears of a potentially overwhelming second wave of this pandemic grow, it is crucial the BMA continues to shine a light on the issues that are having an effect on doctors’ lives and remains a powerful voice in the debate around the Government’s response ahead of this most worrying of winters. In this issue of The Doctor we share some of the experiences and lessons learned by professionals dealing with the pandemic in India. We also speak to doctors dealing with the often traumatic symptoms of long COVID and we forensically trace the relationship between the pandemic and the austerity politics of the 2010s – ultimately, urging ministers not to make the mistakes of the past which set the scene for the spread of this disease and the UK’s disastrous response. Also in this issue we speak to consultant paediatrician Arvind Shah whose stellar career – including being principal regional examiner for South Asia for the Royal College of Paediatrics and Child Health and holding positions as associate professor at St George’s University in Grenada and as an honorary senior lecturer at University College Hospital – is still driven by a desire to give back to junior doctors in India, Myanmar and Nepal who are setting out on the same path he did around four decades ago. The October issue of The Doctor features a powerful piece looking at racial inequality in healthcare and society – particularly in experiences of mental health services. As this piece says, the tragic truth is that if you’re of black African or Caribbean background in this society, you’re far more likely to have had a bad experience of mental healthcare than if you were born white British. We speak to the doctors trying to tackle the systemic, structural and institutional factors causing these inequalities. Last month, the BMA held its 2020 annual representative meeting. While the pandemic meant we were not able to meet in person and the event was run virtually, it was a powerful reminder of the continued importance of the voice of doctors – and we debated, and set policy, on many of the most important issues of the day. Articles showcasing the discussion around some of the debated topics are featured in this magazine. Read the latest news and features online at bma.org.uk/thedoctor

8-13

Austerity – COVID’s little helper

How years of funding cuts have left the NHS vulnerable to the coronavirus pandemic

14-17

Doctors with long COVID

The doctors who have faced months of pain, exhaustion and – sometimes – suspicion

18-21

Minds apart

Working to tackle the disparity in mental health outcomes between black and white patients

22-23

Duty-bound

The paediatrician with a lifelong commitment to helping others in need

24-25

On two fronts

How India is fighting a pandemic as well as social unrest

26-27

Life experience

Why is it so hard to say ‘it’s not my job’, asks the Secret Doctor, plus the perils of multi-tasking

28-31

Writing competition

Two runners-up entries from this year’s competition – when words were not enough for a junior doctor having to break some devastating news, and the memory of an apology, not given

thedoctor | October 2020 03

20200365 thedoctor – p2-3 v2.indd 2

05/10/2020 08:34

brieﬁng News from the BMA annual representative meeting, held online for the ﬁrst time

ISTOCK: ALAN MORRIS

FLEXIBLE WORKERS: Doctors learnt new skills in critical care during the COVID-19 pandemic

NAGPAUL: Doctors have shown courage

Courage in the face of adversity BMA council chair Chaand Nagpaul called on chancellor Rishi Sunak to fulfil his promise to give the NHS ‘whatever it needs’ in his speech to the BMA annual representative meeting in September. Warning of an impending ‘triple whammy’ for the NHS – the non-COVID backlog, the ongoing risk of a second spike, and winter pressures – he said that ‘the citizens of this nation must no longer be punished from a failure to properly resource our health service’. Dr Nagpaul praised doctors for the ‘leadership, flexibility and courage’ they have displayed in responding to the crisis. He said: ‘We accepted wholesale overnight change to our lives working outside contractual arrangements. Many moved from their usual specialty to learn new skills and work in critical care. Others left their families to work in new hospitals. Our emotional resilience was tested as doctors held smartphones to patients fighting for their lives so they could see loved ones who were forbidden from visiting them. We did our duty in serving the nation.’ The Government, however, had been

responsible for ‘scandalous shortages’ in PPE (personal protective equipment). The BMA had raised the issue with a parliamentary committee as early as March, secured revised guidance on PPE better reflecting international standards, and provided doctors with ethics guidance and advocacy to help them challenge their employers when they were given inadequate equipment. Dr Nagpaul had called for an urgent investigation into COVID’s disproportionate impact on BAME healthcare workers and communities, which resulted in the Government commissioning Public Health England to conduct one. ‘The PHE report depicted unambiguously just how starkly unequal our society is, driven by longstanding structural and racial discrimination,’ he said. With face coverings, the Westminster Government had first rejected the BMA’s call for them, back in April, but then went on one U-turn after another, to mandate their use first in public transport, then shops, then cinemas and museums. The pandemic, said Dr Nagpaul, had vindicated many of the issues on which the BMA has been campaigning for years, such as the lack of capacity in the system. He said the NHS had been forced to become a ‘national COVID service’.

Visit bma.org.uk/arm for full coverage of the ARM

Mental health suﬀers Action is urgently needed to support the mental health of healthcare workers, doctors warned at the ARM. The eﬀect the COVID-19 pandemic has had – and continues to have – on the mental health of doctors must not be underestimated, and action is needed now. That was the very clear message from the BMA’s annual representative meeting, which has called on the Government and NHS to make resources widely and rapidly available for all healthcare workers who need mental health support.

thedoctor | October 2020

20200365 thedoctor – p4-7 v3.indd 1

04/10/2020 11:59

ACT NOW: Doctors’ mental health has suﬀered during the pandemic

Speaking for the BMA’s retired members forum, Buckinghamshire locum GP Gill Beck described the pressures that doctors had faced in 2020 – anxiety over a lack of PPE, the disproportionate impact on those from ethnic minorities, the grief, the damage of having to watch impotently as non-COVID patients suﬀered due to the withdrawal of investigations and treatment. She also cited the ongoing excess workload as doctors tried desperately to solve the backlog of care. ‘And there’s the increasing prevalence of neuropsychological symptoms associated with “long COVID” – the brain fog, cognitive dysfunction, reduced ability to process information, with the detrimental eﬀect on mental health as doctors fear losing their careers.’ Where, Dr Beck asked, are the NHS plan and government resources to help these doctors? It’s not as if it couldn’t have been anticipated – mental morbidity due to SARS was well-documented, she added. ‘So I ask again, where were the Government’s plans to manage the expected surge in mental ill health due to the pandemic?’ Existing support services such as the NHS practitioner health service lacked resources to deal with issues raised by COVID, and while the BMA’s wellbeing services were appreciated – and the fact it was working with the mental health charity Mind was welcomed – more needed to be done. Some LMCs were funding services for their GPs, other doctors were being referred to local talking therapy services with waiting times of up to six months. ‘What do our colleagues need – apart from a government that could give a damn?’ she asked. ‘Workplace recognition and support, rapid access to psychiatric and psychological services where needed, neuropsychiatric services integrated into multidisciplinary teams for long COVID patients.’

Visit bma.org.uk/arm for full coverage of the ARM Keep in touch with the BMA online at

instagram.com/thebma

Call for inquiry Doctors at the ARM voted overwhelmingly to call for a ‘full and frank review’ into the UK Governments’ management of the COVID-19 crisis. ‘A protective ring around care homes less real than the emperor’s new clothes’, ‘inadequate, patchy PPE with no minimum speciﬁcations’, ‘a world-beating app that couldn’t work on one island which makes up part of one English county’ and ‘public health interventions and restrictions changing as often as the direction of the wind’. BMA West Midlands regional council chair Stephen Millar’s list of serious failings during the pandemic response is as strong an argument as there could possibly be for a public inquiry into the UK Governments’ management of the COVID-19 crisis. And that is exactly what doctors at the ARM overwhelmingly called for on Tuesday, demanding, a full and frank review in order for the country to be ‘better prepared’ and to be able to ‘follow best practice during any future overwhelming health crisis’. The motion passed at the ARM said the remit must include the mismanagement of care homes, the provision and logistical management of PPE, testing strategy, health and care staﬀ wellbeing and the timing of interventions and easing of restrictions. Proposing the motion, Dr Millar said: ‘I do not call for an inquiry to attribute blame – who among us would have got these decisions all right? But I call for an inquiry so the nation can learn from this experience to better manage the next overwhelming crisis.’

twitter.com/TheBMA thedoctor | October 2020

20200365 thedoctor – p4-7 v3.indd 2

04/10/2020 11:59

ISTOCK: K NEVILLE

PAYING THE PRICE: Queues for prescriptions grow as coronavirus worsens

RAE: ‘Worrying things are happening’

A light shone on health inequalities The pandemic and the Black Lives Matter movement have demonstrated the importance of addressing health inequalities and racism in the UK, the ARM also heard. ‘Two phrases have stood out for me during this pandemic. The first is “shone a light on” and the second is “totally laid bare”. The two phrases have been very appropriate where I work in the North East of England as far as health inequalities during this crisis are concerned.’ For BMA North East regional council chair George Rae, health inequalities have always been a serious worry. In his region, there are sections of the population that face lower life expectancy than they did a decade ago in 2010. Those are the sorts of figures that suggest very worrying things are happening in communities and across a country. But, as Dr Rae told the ARM, the COVID-19 pandemic has put these issues into immediate, and powerful, focus. ‘We have the data to show that deprived areas have experienced double the death rates of those in more affluent areas in England. Is this not honestly a national shame? We all know that the social and economic environments in which we are born, we move among and we live in, have a huge impact on health inequalities.’ These are issues of huge importance and doctors at the ARM voted for a motion which said the COVID-19 pandemic and the Black Lives Matter movement have demonstrated the importance of addressing health inequalities and racism in the UK.

As a result, doctors will call for increased funding for public health to tackle ethnic, geographic and gender inequalities in the UK, greatly improved recording and analysis of ethnicity in the NHS and speciﬁc action based on culturally sensitive research to address the health, social and educational problems caused to BAME (black, Asian and minority ethnic) school children, and to make recommendations to reduce these inequalities. Dr Rae said: ‘We can’t do it alone as doctors and we must support public health – support them in getting the proper part of funding because without that we will all be in this situation again in the future and that is not acceptable.’

Visit bma.org.uk/arm for full coverage of the ARM

Call on pay Doctors at the ARM called for a survey of members as to their opinion on pay recommendations made by the DDRB in its last report, and what actions they believe the BMA should take next. They also demanded a significant above-inflation pay rise, voted for the formulation of an action plan in case doctors are not offered a fair pay settlement, and for withdrawal from the DDRB before the end of the year.

Read more online – Reduce time required for revalidation, say doctors – Push for progress on transgender rights in healthcare – Doctors back calls to continue remote prescription of early abortion pills – NHS backlog needs funds and planning, warn doctors – Government urged to tackle shortfall in public health investment – Warnings about a no-deal Brexit Read all the latest stories at bma.org.uk/news

thedoctor | October 2020

20200365 thedoctor – p4-7 v3.indd 3

04/10/2020 11:59

OPINION

ISTOCK

Howling at the moon Loose talk about a 50-fold increase in testing and breathy allusions to the space programme seem like unhelpful distractions when the system is going so chaotically wrong. Peter Blackburn reports Prime minister Boris Johnson has made yet another pledge on testing – promising 500,000 tests a day by the end of October. It is a pledge that harks back to the maelstrom of testing-target pledges, rattled out in the daily Downing Street press conferences, which were regularly being missed, tests counted more than once bulking up the numbers, or when ministers slyly shifted their promises from tests carried to promised capacity. Elsewhere, the prime minister’s chief adviser Dominic Cummings – the man some hold most responsible for the crumbling public adherence to restrictions and social distancing earlier in the year after his eye-sight testing trip to Barnard Castle – is reportedly revelling in installing a ‘NASA-style mission control’ in the Cabinet Office for a small group of Government policy advisers and ‘data gurus’ to coordinate the pandemic response. The terminology borrowed from all things space exploration does not end there. While planning for tighter restrictions on the activities of the public Mr Johnson outlined his great hope for a return to some semblance of normality. ‘Operation Moonshot’ hopes to accelerate testing from current capacity of around 200,000 a day to 10 million a day by early 2021 – and might cost around £100bn. Given Public Health England’s annual budget sits at around £300m, one might be forgiven for wondering whether the Government should focus on rebuilding the ruins of austerity before making presumably the biggest public spending pledge in history on a scheme the scientists in SAGE have themselves said would require ‘careful consideration’ to ensure it would provide additional benefit above investing in the speed and coverage of NHS test and trace.

BMA council chair Chaand Nagpaul questioned Mr Johnson’s plans, particularly in the light of the ‘huge problems’ being seen with lab capacity. Dr Nagpaul said the idea of allowing society to open up based on people testing negative for COVID-19 should be ‘approached with caution’ owing to the high rate of false negatives and the chances of missing people who are incubating with the virus. The situation with testing in this country has been a growing disaster for some weeks and months. Families have been told to travel hundreds of miles for tests, UK labs have been ‘maxed out’ and the availability of slots at testing centres have been curbed in a bid to help clear the backlog. And all that comes amid suggestion that the supply of vital materials and analytical equipment needed to hit targets are weeks behind schedule. There might be more cause for confidence if the person in charge of the test and trace programme, Dido Harding, had not got the day of the week wrong while appearing in front of the Commons science and technology committee recently – before going on to say that no one anticipated a rise in testing. Dr Nagpaul said: ‘We’ve heard concerning reports from doctors that they or their patients are unable to access tests and follow-up results at what is a critical time in the fight against COVID-19. These doctors are themselves frustrated but equally concerned for patients who are contacting them unsure of what to do.’ Ahead of a winter which could be more brutal than ever before for the NHS it is absolutely crucial that the Government gets testing in order. And that, ultimately, means more testing slots, more lab capacity and a quicker turnaround. It is crucial the Government gets this part of the pandemic response right – as without adequate testing, total suppression of the disease will not be possible. The woeful nature of testing is one of the factors that underscore the BMA’s call for a ‘near elimination’ strategy on COVID-19, meaning stronger measures in the short term to avoid a large-scale prolonged lockdown. The measures include: –A reconsideration of the ‘rule of six’ as it is currently applied indoors. Previously, only a maximum of two households could meet, and now it is six –C OVID-secure workplaces and offices, supported by clear government guidance –A ctive encouragement of working from home where possible, and unnecessary travel and social mixing to be discouraged. While the Government focuses on the moon, doctors have to focus on the real, workable, evidence-based measures which will tackle the virus. thedoctor | October 2020 07

20200365 thedoctor – p4-7 v3.indd 4

04/10/2020 11:59

Austerity – COVID’s little helper Severe public health cuts left the UK more vulnerable to COVID – while the huge bill from tackling the pandemic could make austerity even worse. Peter Blackburn reports on doctors’ determination to break a vicious circle of decline

08 thedoctor | October 2020

20200365 thedoctor – p8-13 v2.indd 1

04/10/2020 12:00

SIMON GRANT

eather Grimbaldeston was used to having to balance the books – all too familiar with making ‘the public purse stretch’. But, as director of public health for Cheshire East in 2016, it was simply no longer possible. Years of brutal cuts to public health services, following NHS reform legislation passed in 2012 which moved public health from the NHS to local authorities whose budgets were hit the hardest, had taken their toll. ‘I’ve always worked in areas which are under-resourced – I’ve done it and I’ve done it with the support of great colleagues and under difficult circumstances,’ Dr Grimbaldeston says. The years were tough. Mental health support services, smoking cessation support and sexual health services – among many others – suffered ‘extreme cuts’. Staff numbers dwindled and health protection, let alone health improvement, became notions of fantasy rather than reality. And eventually, it told. ‘I couldn’t make it work any longer,’ she admits.

Damage limitation Former director of public health for Stockport Stephen Watkins can identify with the experiences of

Dr Grimbaldeston. He says: ‘It has been heart-breaking to see the neglect of public health. I only retired about a year ago and for the last couple of years before that we had been trying to find ways to minimise damage. You couldn’t develop and extend services, you were in the business of trying to minimise damage.’ This bleak landscape was not isolated to these two areas of the North West. Nationally, local authority budgets were cut by nearly a third from 2010 to 2018, according to the National Audit Office and the public health grant fell by £700m in real terms between 2014/15 and 2019/20, as revealed by a Health Foundation report. Across society a decade was defined by the destruction of a safety net built over many years. From the closure of Sure Start centres and libraries to the crumbling estates and rocketing vacancy lists of NHS organisations – few public services were left unscathed. The results of these political decisions have been damning. Life expectancy across England has stalled, the inequalities in life expectancy between the most and least deprived areas of the country have increased and the amount of time people spend

thedoctor | October 2020 09

20200365 thedoctor – p8-13 v2.indd 2

04/10/2020 12:00

Fall in public spending as a percentage of GDP by 2019

2009/10

2019

MCKEE: ‘Austerity diminished government spending on social welfare’

in poor health has increased. At every step along the way doctors have felt the strain – whether in rocketing demand from patients or increasingly impossible working environments. ‘Health is telling us something fundamental about the nature of society,’ University College London professor of epidemiology and public health Michael Marmot tells The Doctor. ‘If health stops improving it means society stops improving.’

Austerity’s shadow ‘It has been heartbreaking to see the neglect of public health’

As Sir Michael’s landmark report in February, 10 years on from the Marmot review of 2010, said: ‘From rising child poverty and the closure of children’s centres, to declines in education funding, an increase in precarious work and zero hours contracts, to a housing affordability crisis and a rise in homelessness, to people with insufficient money to lead a healthy life and resorting to food banks in large numbers, to ignored communities with poor conditions and little reason for hope… Austerity will cast a long shadow over the lives of the children born and growing up under its effects.’

In his final report on the impact of austerity in the UK, United Nations rapporteur on extreme poverty Philip Alston, was damning of politicians, accusing them of the ‘systematic immiseration of a significant part of the British population’ and said austerity had ‘deliberately gutted’ local authorities. It is in these circumstances – in this seemingly broken Britain – that the response to the greatest public health threat in living memory was to be framed. ‘We were in a very bad state – and then came the pandemic,’ Sir Michael says. He adds: ‘In 2009/10 public expenditure was 42 per cent of GDP and by 2019 that had become 35 per cent. That is significant. And that reduction in public spending was done in a very regressive way, and this gets us closer to our lack of preparedness for the pandemic.’

Low capacity So, what did this effect of austerity on the state and society mean for the pandemic response? Firstly, it seems clear that the capacity of certain levers of state to respond quickly as cases

% of COVID-19 rocketed were deeply hampered: public health specialists deeply cut in number and resource were unable to track cases once they moved into the hundreds, the NHS relied on temporary hospitals in conference centres and cancelled swathes of non-COVID procedures, PPE stocks were out of date and unsuitable for the job in hand and testing capacity was very limited. London School of Hygiene and Tropical Medicine professor of European public health Martin McKee says: ‘Austerity had a number of elements – it was part of a package which included diminished government spending on social welfare and other related sectors and coupled with that was a hollowing out of the civil service, the instruments of state and a sustained underinvestment in the NHS and public health.’ One of the most devastating parts of the relationship between austerity and this pandemic played out, during the very height of the crisis, in the country’s hospitals. As the Institute for Public Policy Research recently

10 thedoctor | October 2020

20200365 thedoctor – p8-13 v2.indd 3

04/10/2020 12:00

SHOPS: in an inner city area. Many are boarded up and in disrepair

ISTOCK

‘If health stops improving it means society stops improving’

found, the decade of austerity left the NHS ‘extremely fragile’ before the onset of the pandemic – with more than four in five English hospitals operating with ‘dangerously low’ spare capacity. The ‘dangerously low’ capacity – the product of a decade of underinvestment in the face of increasing demand from increasingly complex patients – combined with poor staffing levels and a lack of crucial equipment like ventilators, provided a deeply concerning backdrop for a pandemic response. The result was a rushed response, in parts seemingly cobbled together, to avoid catastrophic death tallies. And, ultimately, that meant doctors working in unfamiliar roles desperately trying to cope with rocketing numbers of COVID-19 patients in potentially unsafe environments, £1.5bn emergency funding for fieldstyle Nightingale hospitals and wanton encouragement of hasty discharge from hospitals into care homes and the community to free up beds – encouraging a rapid spread of the virus. It was one disaster after the next. And the knock-on effect was huge. In total around 2.5

million patients missed out on investigations, treatments and procedures as the National Health Service effectively became the National COVID Service. Beyond the cancelled operations and shelved treatments there was an added hidden impact, as revealed by a BMA study earlier this year. It found that there had been up to 1.5 million fewer general and acute admissions, up to 2.6 million fewer first general and acute outpatient attendances, around 280,000 fewer urgent cancer referrals, up to 25,900 fewer patients starting first cancer treatments following a decision to treat and up to 15,000 fewer patients starting first cancer treatments following an urgent GP referral. For doctors, it was a remarkably difficult time. In August a BMA tracker survey revealed that 35 per cent of doctors were suffering from stress, anxiety, depression or burnout worsened during the pandemic.

Hamstrung response It is probably unfair to attribute all of these problems to austerity politics – clearly responding to the spread of a disease with such great risk of

transmission and fatality would always involve disruption, and indeed great change to the structure of services and facilities. However, there can surely be no question that the austerity politics of the 2010s left the NHS and the wider health and care system deeply hamstrung and simply hoping to avert total disaster. Nowhere has the impact of austerity on the pandemic response been more obvious than in public health. The system – described by Dr Watkins and Dr Grimbaldeston as being a near-impossible environment – had been so decimated it did not have the resource to lead and run a pandemic response. One public health consultant, who wished to remain anonymous for fear of repercussions if he spoke out, explains the struggles of public health to The Doctor. He says: ‘The earliest thing was that by mid-March PHE (Public Health England) had been overwhelmed – all of its contact tracing capacity was entirely flat out trying to keep pace and that’s the point at which contact tracing stops and it was just about the time the World Health Organization was saying we need to test, thedoctor | October 2020 11

20200365 thedoctor – p8-13 v2.indd 4

04/10/2020 12:00

WATKINS: ‘We need to adopt the right policies to change society for the better’

MARMOT: ‘We were in a very bad state – and then came the pandemic’

‘The reduction in public spending was done in a very regressive way’

test, test. The capacity of PHE had been run down over many years by austerity, we had cuts year-on-year on year, to the extent that the numbers of communicable disease consultants had fallen by about a third on where they were in the old days of the Health Protection Agency. We had lost a lot of expert public health specialist capacity over the decade of austerity and that certainly didn’t help.’ And when the Government decided significant public spending would be required to tackle the COVID-19 threat it placed its trust – and huge sums of taxpayer cash – in the hands of private firms such as Serco and Capita rather than investing in the structures of state decimated by a decade of starvation. BMA public health medicine committee deputy chair Richard Jarvis says this leads to fragmentation and inefficiency.

Risk factors While the implications of austerity politics hampered the UK response to the pandemic it has also influenced the very spread and impact of the disease. This may be a novel disease

but there already seem to be a group of major risk factors which make the coronavirus deadlier. Those factors include old age, pre-existing health conditions, ethnicity and low socioeconomic status. For example, it is now thought that COVID-19 can be about twice as deadly for the poorer among society. We already know that austerity politics – changes to tax and welfare payments and the removal of the social safety net – hit the poorest in society the hardest. We also already know that health outcomes are the worst in our most deprived communities, and that those inequalities are getting worse. And now, the evidence suggests COVID-19 is doubling down on all of these tragedies – it is at its most deadly in the most impoverished communities and among those who already suffer the greatest health inequalities. Those same health inequalities deeply exacerbated by the political decisions of the 2010s. Dr Watkins says: ‘There are a whole host of problems that have come to light as a result of this. And the truth is that, although they have been highlighted and

exaggerated by the pandemic, those inequalities exist in our society anyway, they have merely been exaggerated and brought to prominence by the pandemic. It also serves as a warning for where this country goes next if we look at the current state of health inequalities with much of that caused by policy over recent years.’ And Dr Grimbaldeston adds: ‘I think the pandemic has taught us that COVID has universally picked on and affected the countries with the greatest and most profound inequalities. There are some bugs that target various characteristics but I think if you had a tag that this bug held it would be that it targets the most disadvantaged, the least able, the least equal. The other thing it has highlighted is that in this country inequalities are everywhere and ingrained.’ And the relationship between austerity and this pandemic may continue into the future. Austerity set the conditions for the Government’s response and has clearly influenced the impact of the disease. With cases picking up and

12 thedoctor | October 2020

20200365 thedoctor – p8-13 v2.indd 5

04/10/2020 12:00

fears of a significant second wave growing, many will worry about the health and care system’s ability to cope without a major departure from the underinvestment of the past. It is a fear held by doctors, too. In the BMA’s August tracker survey half of doctors said they were not very, or not at all, confident in being able to manage a second wave of COVID-19.

Spiralling debt ‘Learn from these miserable experiences’

Perhaps most worryingly of all, given the UK economy has been the hardest hit among the world’s major economies – the economy contracted by 20.4 per cent from April to June and spending on the COVID response has taken the country’s debt to £2tn for the first time in history – there are fears that austerity will once again be the solution of a British government in times of financial crisis. ‘It’s absolutely essential as we come out of this that we think in a new way,’ Sir Michael says. ‘I wouldn’t start [designing the path forward] from here – we shouldn’t be here. We’ve made a complete mess of it from the beginning. But it’s absolutely key we put health equity at the heart of all our decisions going forward and that has practical implications. Take the furlough scheme for example – that will likely have reduced the

bma.org.uk/thedoctor

20200365 thedoctor – p8-13 v2.indd 6

damage as nine million people were saved from initial unemployment and it will be good for the economy in general because if these people have some income they can spend money.’ He adds: ‘The lessons from the last decade are that what we did damaged the health of the population. They stopped health improving and increased inequalities. If you want another decade where we fall further behind other countries and our inequalities deepen then go back to those policies from the 2010s – if that’s not what you want then learn from those miserable experiences.’ For Dr Watkins – who has seen the damage of austerity up close – those mistakes of the past cannot be allowed to be made again. He says: ‘There clearly has been damage to the economy but it should not be irreparable. But it will be irreparable if we go down previous paths. There are economic problems but we need to adopt the right policies to change society for the better.’ And Dr Grimbaldeston, who believes strong economic messaging tied in with health messaging is crucial, adds: ‘We must improve the health of the public and the economy – because without the economy we cannot do any of this and with good health will come a superb economy. We cannot afford to get this wrong again.’ Perhaps the greatest immediate concern is whether public health will, again, be among the major victims of the struggles of the country’s economy. This is a part of the health and care system

which urgently needs massive investment and a thorough rebuild, not the ruthless treatment of further austerity. And, those worries have become heightened for some in recent weeks after the Government announced it was to replace PHE with a specialist pandemic unit – in a move which could look like an attempt to pin blame for wider failings in the country’s pandemic response to an organisation which has coped admirably in the most testing of circumstances. BMA council chair Chaand Nagpaul says: ‘We already have public health expertise in this country which is of the highest quality but despite the hard work of our colleagues in the last six months, substantial budget cuts and fragmentation of these services over years have hampered the response to the COVID-19 pandemic. We must absolutely not allow PHE and its staff to shoulder the blame for wider failings and Government decisions.’ It was a message echoed at the association’s annual representative meeting last month – with doctors passing a motion which said the global pandemic has demonstrated the need for a well-resourced national health protection function to meet current and future communicable disease threats. If one thing is clear it is that the relationship between austerity and this pandemic has, to date, been a disastrous combination. For the sake of doctors, the public, the NHS and wider society, it is a relationship that must not be allowed to go on into the future. thedoctor | October 2020 13

05/10/2020 10:18

NEIL MACMILLAN

SMALL: ‘I’ve still got a fever after five months’

Doctors with long COVID Doctors who contracted COVID, and thought the symptoms would be over in weeks, tell Jennifer Trueland about their continuing pain, exhaustion and – sometimes – struggle to be believed

14 thedoctor | October 2020

20200365 thedoctor – p14-17 v3.indd 1

04/10/2020 12:02

NEIL MACMILLAN

professionals they are turning to for help. She is part of ichard Campbell had a demanding job as a consultant rheumatologist in a busy London trust a long COVID Facebook group specifically for doctors in the UK, which has more than 350 members, most at the start of the year. of whom still have symptoms, or who have even In his scant spare time, he enjoyed an active social developed further problems, such as serious heart life, went to the gym several times a week, and had a particular interest in creating complex electronic music, conditions, in the aftermath of COVID-19. ‘The group is very helpful,’ she says. ‘It’s a mixture sometimes involving up to 50 separate sounds. of mutual support, mostly around symptoms and When he developed symptoms of COVID-19 towards how to navigate the NHS with these the end of March, he thought it would be a short period of feeling awful, then symptoms; how to navigate the private ‘I was trying to do back to his old life. But six months later, sector and so on. But there is also he is still suffering – and has yet to discussion about contractual stuff, clinics with my head return to work, let alone anything else. because people are having issues with on the table in ‘I had been looking after probably employers and other things to do with between seeing COVID-19 patients, and working on being off sick. patients’ the medical take where I saw lots ‘Some of us are trying to put of COVID-19 patients,’ explains Dr together some educational resources Campbell, 44. on long COVID – but the problem is ‘I wasn’t severely unwell enough to need to go that we’re all knackered. One of our ideas is to create into hospital, but I was unwell at home for two to some information sheets for GPs and others who may three weeks. I had fever and severe myalgia, and very be coming across long COVID, and also information severe headaches, loss of taste and smell, severe for GPs to give to patients. I think some GPs don’t have vertigo where it felt I was constantly falling backwards, much understanding of long COVID – there’s one poor and severe tiredness. Interestingly, I never had any girl whose GP refuses to write COVID on her sick line respiratory symptoms – I never had a cough and was because she never had a positive test, which is causing never short of breath. her problems with her locum insurance.’ ‘I expected to be unwell for two or three weeks with Breathless and brain-fogged a flu-like illness and get better and go back to work. In Dr Small contracted COVID in April, and, like Dr Campbell, fact, I pushed myself and went back to work after three thought she would soon bounce back and return to weeks, before my symptoms had subsided. I think a lot work. When she attempted to do so, however, even of doctors are used to being able to push themselves trying to do some simple administration tasks meant through difficulties, and that’s what I tried to do – but I probably shouldn’t have. I was trying to do clinics with my she had to go back to bed for days. ‘I’ve still got a fever after five head on the table in between seeing months,’ she says. ‘The symptoms patients. Eventually I realised I needed don’t seem to be going away. Last to take some time off to recover.’ week I tried going into the sea at North ‘I’ve still got Life changing Berwick because I had heard cold a fever after Dr Campbell is one of a growing water could be helpful. I managed five months’ number of doctors reporting five minutes the first time, and it felt continuing symptoms several really good, but then I built it up to weeks and months after contracting 10 minutes, which was a mistake. COVID-19 – a phenomenon usually When I got out of the water I felt called ‘long COVID’. Often affecting young, previously fit everything draining from my body. I was dizzy, and healthy individuals, leaving them with debilitating breathless, really tired, had brain fog, couldn’t find symptoms with life-changing effects, long COVID words. It was utterly draining.’ is emerging as a serious yet largely unforeseen Her own GP has been helpful and sympathetic, she consequence of the pandemic. says, but not everyone has found NHS services so According to Amy Small, a GP in East Lothian, who understanding. For example, Kerry Smith, a salaried is campaigning for better recognition of long COVID, GP in Chichester, has spent around £3,500 of her own money on an MRI and other investigations, and a private there is understandably little in the way of resources consultation with a cardiologist, having hit a brick wall either for doctors who are suffering or for the medical thedoctor | October 2020 15

20200365 thedoctor – p14-17 v3.indd 2

04/10/2020 12:02

CAMPBELL: ‘I felt I was constantly falling backwards’ (photo taken before contracting COVID-19)

ORDYS: ‘It became increasingly obvious that this wasn’t a standard viral illness’

of its lasting effect on people’s health. with local health services. The private tests revealed ‘There are very few figures on how common [long a variety of conditions, including angina, positional COVID is]. If you go on Facebook, even in the UK, there orthostatic tachycardia syndrome, and mild tricuspid are 25,000 to 35,000 people claiming some degree of and mitral regurgitation. symptoms, although it’s hard to tease out how much of ‘My consultant says it’s all sequelae of COVID-19 this is due to long COVID. and he has seen quite a few cases,’ she says. ‘I am to be referred to Charing Cross Hospital urgently so that he ‘We got some really good data out of the sequential can continue my care.’ survey that the BMA has been doing with doctors, which asked some questions about long COVID. We had 5,650 She believes she contracted COVID-19 after seeing people answer the question about a patient who had recently returned whether they’d had COVID, and of that, from China. 12 per cent have had a positive test, ‘The patient had been back for two ‘I thought it would and 16 per cent believe they’ve had it weeks, so the guidelines at the time just be a nasty viral but didn’t have a test because it was were that we would see them infection and I’d early on and tests weren’t available. in the surgery. She had a temperature Of those who reported having COVID, and a cough. get better’ just under 30 per cent said they’d been ‘I’m a very thorough GP, so of left with physical fatigue, generalised course I was very close to her – and shortness of breath, and about 18 six days later I developed symptoms myself. I was quite a fit person – I thought it would just per cent – 270 people – had been left with the brain be a nasty viral infection and I’d get better. But that fog and memory loss and generalised difficulty in hasn’t been the case.’ concentrating.’ Dr Smith paid for private tests after finding local Around a fifth had taken additional sick leave and health services unresponsive. At one point, when her 10 per cent had taken annual leave to give themselves GP sent her to emergency care she went through a more time before returning to work, he adds. ‘So battery of tests but was told everything was normal around 30 per cent of doctors were affected beyond and sent home. ‘I burst into tears – I was at my wits’ the acute COVID.’ This in itself is significant, he says, end; I felt nobody believed me,’ she says. ‘People because doctors are less likely than other professions don’t seem to believe what’s happening because they to take sick leave. ‘Even if this next outbreak takes just the same can’t see it in front of them and that’s the thing I’ve percentage of doctors, we’re looking at huge numbers struggled with the most.’ of people off sick, not just for the [acute] COVID and the Workforce threat quarantine period, but with prolonged symptoms. And David Strain, co-chair of the BMA medical academic all of the people I’ve seen with this have been young staff committee, is researching long COVID as part of – they’ve been under 45. That’s something that really his work as a senior clinical lecturer at the University of needs to be hammered home to the 20-somethings Exeter Medical School. He is also taking a leading role in and 30-somethings that are still going out for nights much of the BMA’s work on COVID-19 more generally – on the town because they think that even if they do and says that there needs to be much more recognition get it, they’re not going to be really affected – because 16 thedoctor | October 2020

20200365 thedoctor – p14-17 v3.indd 3

04/10/2020 12:02

SOURCE: BMA

STRAIN: ‘270 people had been left with brain fog and memory loss and generalised difficulty in concentrating’

of doctors were affected beyond acute COVID

they are the people that are getting this long COVID syndrome.’

‘Drowning in treacle’

The symptoms that have really dragged on have been fatigue – I’m a doctor and I don’t think I really understood what fatigue was until I experienced it, a feeling of just being like your whole body is drowning in treacle, inside and out, and you can’t make your body or your mind function. I’m somebody who, with my job, is used to having a hundred thoughts and making a hundred decisions at any one moment, and I was finding it impossible even to watch Netflix or listen to music. I was just staring into space.’

The BMA has been helping individuals with contractual, sick pay and other employment issues concerning this, he adds, and is also working to ensure long COVID is seen as a consequence of COVID and is therefore considered an occupational health issue. More research is needed, he says, including into similarities with chronic fatigue syndrome, as well as awareness-raising about the public Recovery timescale health implications. All four doctors The Doctor spoke to for this article Abbey Ordys, a salaried GP in Midlothian, became said they had learned from the experience of people ill with COVID-19 at the end of April, and is one of with ME/CFS – particularly around the need to the younger doctors affected. ‘pace’ rather than attempt graded Aged 33, she previously enjoyed a exercise. It has also improved busy working and social life, with a their understanding of this group ‘I was finding it particular interest in yoga, baking and of patients. ‘I think I was always impossible even crafting. Today, she says, she spends sympathetic – now I can be to watch Netflix or an awful lot of time napping. empathetic,’ says Dr Ordys. ‘At the start of week two I Dr Campbell has made a lot of listen to music’ suddenly felt very unwell with progress but is still far from well. ‘I’ve postural tachycardia, chest pains, been building up gradually. I had been terrible feeling and ended up in the trying to exercise but I found that medical assessment unit. I had basic tests which were exercise made me worse, so I’ve been adopting more reassuring – my oxygen level was OK and bloods were of a pacing approach to my symptoms, so when I feel OK, so I continued to recover at home. I expected I they’re coming on, I stop and rest.’ would just recover over a week or so. But it became Today, he has headaches, nausea, and difficulty with increasingly obvious that this wasn’t a standard viral any tasks that require cognitive endurance or periods of illness; it had become something a lot more.’ focus – which are particularly worrying for him because At the end of week three, she tried to go back to of the nature of his work. He also feels that because he work. ‘I managed about two hours before I realised I was contracted COVID-19 so early, it is impossible to know how long it will take to recover fully because there are just not firing on any cylinders and couldn’t work safely. few comparators. ‘Since then, it’s been this ongoing saga of things ‘Previous to COVID-19 I had an extremely busy job, not getting better. There’s been days when I’ve felt I had a very active social life and I was exercising at the reasonable and been able to put on a pair of trainers gym two or three times a week. The worry that I won’t and walk round the block. There have been days and weeks when I’ve just felt awful and spent all day in bed. be able to go back to doing that concerns me.’ bma.org.uk/thedoctor

20200365 thedoctor – p14-17 v3.indd 4

thedoctor | October 2020 17

05/10/2020 10:19

Minds apart The stark and enduring inequality in mental health outcomes between black and white people is being addressed by two psychiatrists who want to tackle decades of unfounded assumptions. Keith Cooper reports

18 thedoctor | October 2020

20200365 thedoctor – p18-21 v2.indd 1

04/10/2020 12:03

here is an awful inequality in healthcare and society with which doctors have grappled for decades to little avail: if you are of black African or Caribbean background, you are more likely to have a bad experience of mental healthcare than if you were born white British. You are treated differently from childhood. The research shows that for bad behaviour, you get the social worker, not the child psychologist, and are more likely to be expelled. As an adult, you have less chance of accessing talking therapies.

If you do, you will face someone with whom you have little in common. You are more likely to be taken to hospital in a police van than ambulance, detained under the Mental Health Act, and end up in the forensic mental health system, with criminals, crushing your chances of getting a job. The cost for patients, their families, the NHS, and to the economy is obvious. This stark and enduring disparity has been studied repeatedly, most recently in 2018 for the Independent Review of the Mental Health Act by Sir Simon Wessely, which admitted ‘little has changed’ in 30 years.

thedoctor | October 2020 19

20200365 thedoctor – p18-21 v2.indd 2

04/10/2020 12:03

structural factors that are long-standing, historical, and cultural, that disadvantage certain groups.’

Structural change

GRAINGE PHOTOGRAPHY

It’s about to be tackled again by a race equality taskforce set up by the Royal College of Psychiatrists, which will be focused on getting things done. So how much of a difference will another initiative make? Shubulade Smith and Rajesh Mohan, the two leading consultant psychiatrists heading it up, believe it can and the time is right. They admit, however, it may take generations to close the gap. For in their sights are ‘People are open those difficult-to-pin-down, to accepting there might be institutional systemic, structural and institutional factors which factors’ have concreted racial inequality into healthcare for so long, as in so many areas of public life. ‘The death of George Floyd in the USA and COVID-19 have allowed people to accept racism isn’t simply about the overt, calling people names in the street,’ says Dr Smith. ‘People are open now to accepting there might well be institutional, systemic and SMITH: ‘Racism isn’t simply about calling people names in the street’

Dr Smith would like an end to all racism but is ‘more realistic than that’. ‘What we want to do is shift things so we introduce some structural change.’ Their taskforce will look at three areas: the college itself, ensuring its own house is in order, the needs of its members, 38 per cent of whom are from BAME (black, Asian, and minority ethnic) backgrounds, and the wider NHS. With so much evidence and so many recommendations out there already, their focus is on getting things done. ‘There has been commission after commission, inquiry after inquiry,’ Dr Smith says. ‘We want to collate recommendations, group them and try to implement them rather than making new recommendations and talking about them again and again.’ Dr Mohan admits structural and systemic factors are as hard to pinpoint as the evidence of their effect is clear. ‘Systemic racism in healthcare is the same as systemic racism elsewhere in society,’ he says. ‘Institutions or bodies have ways of working or systems that inherently disadvantage people in certain groups. Dr Mohan says that the nature of structural racism is not well understood. ‘The systems we are working in have deeply entrenched processes and can perpetuate

factors that can disadvantage certain groups,’ he adds. ‘We have to raise awareness of these systemic structural factors and actively work to address them to make health care systems truly equitable.’ This focus on structural and systemic issues is also informed by a 2019 research paper in Lancet Psychiatry with which Dr Smith was involved. This examined studies of racial inequality since 1970. It found almost half of a sample of 71 papers offered ‘no explanations’ or ones unsupported by the studies themselves. Unsupported explanations included those which entrenched ideas of ‘racial determinism’, that inequalities were due to patients’ lifestyle or cultures. ‘Over the last 35 to 40 years there’s been a propagation of explanations that have been taken as fact but are in fact based on assumption,’ Dr Smith says. ‘It’s amazing and it’s important because it means over the years nothing has changed.’

Experiences of racism Inequalities in mental healthcare cannot be addressed by the NHS alone, of course. ‘That wouldn’t be closing the tap that causes the flood,’ Dr Mohan says. ‘Mental health can be seen as a culmination of various unequal experiences over time.’ Dr Mohan and Dr Smith have, of course, experienced racism inside and outside of the workplace. Dr Smith was born in the UK to Nigerian parents. She

20 thedoctor | October 2020

20200365 thedoctor – p18-21 v2.indd 3

05/10/2020 09:43

‘By simply working in that system you are perpetuating racism’

was subject to name-calling, doubts about her intelligence, questions as to whether she could be a medical student. She considered asking for ‘Dr’ to be removed from her credit card to clear supermarket checkouts quickly. ‘They look at you, look at the card, look at you, look at the card. It goes on for ages.’ After receiving a CBE in the 2019 Queen’s Birthday Honours, a colleague responded: ‘You’ve only got that because you are black.’ Dr Mohan talks of ‘unpleasant experiences’ and of being treated differently because of my ethnic origin’. He arrived in the UK in his late 20s from India, one year off from becoming a consultant but had to start again as a firstyear trainee. ‘I trained until I literally couldn’t train any more,’ he says.

Cultural differences

MOHAN: ‘Systemic racism in healthcare is the same as systemic racism elsewhere in society’

‘You’ve only got that because you are black’

Such experiences put Dr Mohan in a good position to argue for ‘decolonising’ the college’s curriculum and exams for trainee psychiatrists. As in other specialties, international medical graduates are more likely to fail exams than those trained in the UK. ‘They are probably walking into them with a handicap that is unlikely to do with knowledge,’ says Dr Smith. ‘In certain societies, such as Nigeria or certain south Asian societies, it’s rude to look someone straight in the eye; it’s the opposite in Britain and Europe. It’s an important issue for clinical exams, when the actors who play patients give feedback and may mark candidates

bma.org.uk/thedoctor

20200365 thedoctor – p18-21 v2.indd 4

down because they didn’t look them in the eye.’ Dr Mohan believes the college has a good track record on equality to build on. It carried out a gender pay gap review without having to; they’re only required for organisations with more than 250 employees. But what of the seemingly intractable inequality in the wider NHS? How to shift those stubborn, structural, systemic, and institutional scaffolds?

A new framework The solution, or at least the start of one, sounds, frankly, dry and bureaucratic. It’s a management tool – perhaps not the dramatic intervention which the stark effects of racial inequality seem to require. What they’re keen to promote is the PCREF (Patient and Carers’ Race Equality Framework), a recommendation from Sir Simon’s review, in which Dr Smith played a role. The more you learn about PCREF, however, the more it makes sense. It’s a bureaucratic spanner to fix a healthcare bureaucracy which has failed for decades to fix itself. It is being piloted by NHS England/Improvement in Manchester, Birmingham, and London, at the East London NHS Foundation Trust and SLAM (South London and Maudsley) NHS Trust, where they’re employed – Dr Mohan, as a consultant rehabilitation psychiatrist, and Dr Smith, as clinical director for the forensic service. ‘Everyone knows what

the problems are, but people don’t talk about how you get there,’ says Dr Smith. ‘The PCREF is a way of supporting organisations to learn how to meet the needs of their local population.’

Rebuilding trust At the SLAM, they’re beginning by building ‘meaningful connections’ with different communities through charities, churches, parenting, and foster groups. ‘That’s no mean feat, given the history,’ Dr Smith adds. ‘You need to find out who to speak to in every single community. What do they think the issues are? You then develop the competencies to meet the needs of that population, set targets with the local community, move things forward. Monitor. Modify each year until you’ve ironed out problems. It’s no quick fix.’ It could take NHS organisations five years to be classed as ‘competent’, she says, even longer for populations to feel comfortable about using their service. ‘It could be generations before we properly equalise out the system,’ Dr Smith adds. ‘It’s going to depend on people’s willingness to do this. To some extent, we are going to have to take a leap of faith.’ The success of PCREF, it seems, will depend, as with any other measure before it, on the commitment of those behind it. Given the experiences of many in BAME communities, it may just be the leap of faith that is required. thedoctor | October 2020 21

05/10/2020 10:19

EMMA BROWN

Duty-bound Help others in need – a virtue Arvind Shah learned from seeing his father ferry sick villagers to the doctor and which extended to donating his salary to colleagues. Tim Tonkin reports SHAH: ‘I felt from the bottom of my heart that I wanted to do something for my hospital’

or consultant paediatrician Arvind Shah, the ‘I feel it is my duty to give them the knowledge I have desire to ‘give something back’ has always been so that they are equipped to work overseas and make at the centre of his personal and professional life. their pathway for professional progression easier.’ Born and raised in India, where he completed his medical training, Dr Shah came to the UK almost His father’s wish 40 years ago and has since used all the time available Facing challenging circumstances, particularly in early to him to make a difference, not just to his patients, life, is not something unfamiliar to Dr Shah. but to his colleagues at the North Middlesex hospital When he was just five years old his father, a and to students all over the world. successful merchant, took the decision to send him Among the most notable to live with his aunt in the city of Pune achievements of his career is his for the sake of his education, where work with the RCPCH (Royal College he completed school and university of Paediatrics and Child Health) and eventually qualified as a doctor. ‘Anybody that was where he has served as the principal ‘My Dad was very caring and, at ill would come to my regional examiner for South Asia. He that time, was the only person in our Dad and he would was instrumental in launching seven village with a car,’ he says. RCPCH exam centres in India and has ‘Anybody that was ill would come take them to a doctor’ also extended access to the RCPCH to my Dad and he would take them to exams to students in Myanmar and a doctor. That stimulated me towards Nepal. He is now RCPCH regional studying medicine.’ adviser for South Asia. His father continued to inspire An associate professor at St George’s University him and was still urging his son to study hard right in Grenada and an honorary senior lecturer at up until his death. University College Hospital, Dr Shah has spent ‘He wanted me to be a doctor and I always respected more than two decades teaching and working that. Just two days before my final clinical examination with medical students. for paediatrics he passed away,’ says Dr Shah. ‘Whenever I go back to India or Myanmar or ‘I’d been to see him, and he asked why I’d come Nepal and I see the junior doctors there, it reminds reminding me that my exams were the next day and that I had to go for it.’ me of myself,’ Dr Shah says. 22 thedoctor | October 2020

20200365 thedoctor – p22-23 v2.indd 1

04/10/2020 12:04

EMMA BROWN

Choosing Britain

health service and how care in it is delivered. Restrictions on global travel have seen Dr Shah’s He completed his studies and was a gold medallist work administering RCPCH exams suspended, for his graduation year at Bombay (now Mumbai) although he is now working on conducting these University. remotely using an online platform. After several years practising in India, Dr Shah Meanwhile Dr Shah’s workplace and ‘second home’, decided he wanted to develop his career through the North Middlesex hospital, has further training, and in 1983 came to like so many parts of the NHS faced the UK and began working at North ‘At the height of the months of intense pressure. Middlesex hospital. ‘At the height of the pandemic Having never been to the UK pandemic there was there was no time to think or to before, he arrived with just £100 in his no time to think or grieve, one of my nurse colleagues pocket and initially found lodgings at to grieve’ likened it to a war zone,’ he says. the Indian YMCA in London. ‘As a paediatrician, I was not on In addition to North Middlesex he the COVID front line, but I felt from has worked at Addenbrooke’s hospital the bottom of my heart that I wanted to do something in Cambridge and at Great Ormond Street where for my hospital.’ he was selected to go to Philadelphia, USA, as a research fellow. To this end, Dr Shah organised a £9,000 donation Despite being offered the post of associate professor through the Mukul Madhav Foundation to provide 50 meals a day for one month to frontline staff in the USA, he decided he wanted to return to the UK. caring for patients with COVID-19. ‘I had read a lot about the country and came to the He also took the incredibly generous step of UK around the time that the film Ghandi was released and India had just won the Cricket World Cup,’ he jokes. choosing to donate an entire month’s worth of his salary specifically to support the hospital’s ‘During my career I’ve worked in India, in the USA and in the UK, but it was the UK that I came to feel was nursing team. my home.’ Stranded doctors While the UK remains his home, Dr Shah has never As treasurer of BAPIO he supported financial lost touch with his roots and has sought to use his assistance to overseas doctors who had come to experience to support international medical graduate the UK to take the PLAB (professional and linguistic doctors abroad and in the NHS, and serves as the assessments board) examination and been left treasurer of BAPIO (British Association of Physicians stranded following the lockdown on flights. of Indian Origin). Dr Shah says the disproportionate Progress for minorities number of deaths of BAME doctors ‘COVID-19 has also While he is realistic about the and healthcare staff means it is challenges and inequalities BAME essential the issues affecting BAME created a perfect (black, Asian and minority ethnic) and such as access to effective storm of public health staff, overseas doctors in the NHS have and risk assessments and support, are inequalities’ properly addressed in advance of a continue to face, he feels genuine potential second wave of infections. dialogue and progress around these He also believes that, while the issues are now being made. pandemic has ushered in some positive changes to ‘I believe in fairness and I believe in practising equality and diversity not just talking about it,’ he says. working practices such as greater use of technology for remote consultations and tele-education, the ‘I’m glad things are changing, there’s a lot more pandemic has also exposed existing underinvestment awareness about differential attainment, and training on equality and diversity. However, it’s important that in services for public healthcare. we practise these things not just learn about them,’ ‘I do feel COVID-19 has also created a perfect he says. storm of public health inequalities. Despite having affected every part of the world, ‘Public health isn’t just about managing epidemics, it’s also about addressing issues like COVID-19 is just the latest issue to expose many of the health inequalities, childhood death, obesity, inequalities faced by BAME healthcare professionals smoking cessation and breastfeeding, and COVID has and patients. highlighted that these are the core issues we need The pandemic has in just a few months utterly to be working on.’ transformed day-to-day life and the landscape of the bma.org.uk/thedoctor

20200365 thedoctor – p22-23 v2.indd 2

thedoctor | October 2020 23

05/10/2020 10:21

ISTOCK: SUPRABHAT DUTTA

WORLDS APART: People queue to collect everyday essentials from Ramakrishna Mission, Golpark

On two fronts

Continuing our series on how different countries are responding to COVID, the former president of the Indian Medical Association speaks of the sacrifices made by doctors, and the inequalities the pandemic has exposed. In India there are two battles – against the virus, and against a parallel ‘info-demic’ of misinformation. Keith Cooper reports 24 thedoctor | October 2020

20200365 thedoctor – p24-25.indd 1

04/10/2020 12:04

WANKHEDKAR: ‘COVID-19 has shown up the social inequalities in India’

mass movement of millions of migrant workers from industrial towns and ﬁnancial hubs. Many walked thousands of miles on foot with no access to food or water, spreading the virus in their wake. It took two months before special public buses and trains began taking them home. Their arrival sparked another surge. ‘COVID-19 has really shown up the social inequalities in India,’ says Prof Wankhedkar. ‘At the same time as our migrant workers were dying of hunger, there were people buying their own ventilators.’

Doctors attacked COVID-19 cases in India have risen relentlessly to more than six million as a parallel ‘info-demic’ of misinformation spread like wildﬁre, turning many against the healthcare workers risking their lives. So how are its doctors coping with the mammoth task of caring for millions and the public violence? Ravindra Wankhedkar, a surgeon and former president of the IMA (Indian Medical Association), speaks of ‘very real fear’ among its members. At least 382 doctors have died from COVID-19, according to the IMA. ‘Even our younger doctors who form the backbone of our health service are dying,’ says Prof Wankhedkar, who works, in Maharashtra, the hardest-hit province in this nation of vast inequalities. India had been ‘highly unprepared’ for the pandemic, he adds. ‘We’ve had chronic neglect of our public health system since independence in 1947.’ State expenditure on healthcare is barely above 1 per cent of GDP. Its health service is largely privatised and moving towards an insurance-based system. ‘Such systems are not geared up to deal with pandemics and health crisis,’ Prof Wankhedkar says. It entered the pandemic with just six laboratories to do PCR tests and had bought most of its PPE (personal protective equipment) from abroad, he adds.

Powers of arrest The Indian Government took several steps to help healthcare services gear up, including a night-time curfew in March, before cases ascended. It invoked the colonial-era Epidemic Diseases Act of 1897, giving it great powers to arrest and punish citizens and even suspend doctors’ medical licences. Despite much resistance, these powers were used to acquire bed capacity in private hospitals – up to 80 per cent of it in some provinces. Testing labs were massively expanded as its textile industry turned to PPE. An early surge in cases in India was driven by bma.org.uk/thedoctor

20200365 thedoctor – p24-25.indd 2

A huge challenge in India has been the social stigma of COVID-19. ‘Doctors, nurses and paramedics have been asked to leave their homes if they want to work in hospitals,’ says Prof Wankhedkar. They’ve been beaten, their families refused cremations. Hospitals have been vandalised. After lobbying from the IMA, violence against healthcare workers is now a crime. This stigma was fuelled by a bombardment of misinformation early on, spread rapidly through social media, such as WhatsApp, which counts more than 200 million users in India. Crucially, this left many communities without the support of volunteers. It’s something remote areas rely on in times of crisis such as earthquakes or ﬂoods, Prof Wankhedkar says – the ﬂexibility to improvise with limited local resources. ‘Government can’t reach everywhere, so we need active community participation,’ he adds. ‘The fear and stigma totally took that away.’

India at a glance Information correct as of 5 October, 2020

1.3 billion population

6.47 million cases 100,842 deaths

Source: Johns Hopkins Coronavirus Resource Centre/The World Bank

thedoctor | October 2020

05/10/2020 10:20

it happened to me

The joys of monotasking I hate being reprimanded, but I knew that I deserved it. ‘Yes,’ I confirmed to the radiologist, ‘I do understand the potential catastrophic implications of referring a patient with a pacemaker for an MRI scan.’ What upset me was that I was accused of ‘not knowing’ my patient. I knew this patient in depth – I had felt his prostate! I knew that he had a pacemaker. My error hadn’t come from ‘not knowing’. My failure was in trying to do too many things at once. The sets of notes surrounding the computer were evidence of my attempt at multitasking. As healthcare professionals we are masters of multitasking. Consider the times you have held a hand for comfort whilst simultaneously taken a history, considered the differential diagnoses, and clocked the pulse. Only yesterday I was eating my lunch, checking laboratory results and patiently holding the telephone to make a referral. When will we learn that multitasking is neither safe nor effective? Multitasking is a false economy – we try to save time but actually increase the total time expended. I call this ‘intentional multitasking’. Think you can multitask effectively? Try this... Brush your teeth and tidy some clothes at the same time. This is what I find - I spend three minutes brushing the same quadrant repeatedly, dribble toothpaste and saliva on the carpet (which takes two minutes to clean up), and only manage to awkwardly fold one t-shirt. Sometimes your intention is to focus on a single activity but you get side-tracked. This is what I call ‘distraction driven multitasking’.

Consider this: I am writing a complex referral when an email ‘pings’. I check my diary and realise that I need to give my apologies for a meeting. I delete some emails, phone my secretary to order some notes, check whether my colleague can attend the meeting, and get back to the referral. Multiple tasks, multiple distractions, multiplying the risk of error. At home, tidying up after dinner, my powers of concentration are diminished from the day’s work. Yes, even menial tasks need concentration to conquer distraction. I am incapable of focusing on the dishwasher. I scroll through email, send a text, make an internet banking payment. Learn to be conscious of whether you are monotasking or multitasking. To avoid multitasking at your computer, close all applications except for the task in hand. Keep your email closed, or at least turn off the notification ‘ping’. Try checking email at set times of day, and cluster related tasks into set periods. Monotask by giving your full attention to conversation with a colleague or family member, rather than glancing at a screen. When life is so busy we feel compelled to multitask, which makes us achieve less and feel frazzled. Try to master the art of monotasking and you will enhance satisfaction and productivity – and avoid provoking radiologists. Clare Bostock is a consultant geriatrician in Aberdeen. This article originally appeared in the BGS (British Geriatrics Society) Newsletter (issue 77), reproduced with permission

26 thedoctor | October 2020

20200365 thedoctor – p26-27 v4.indd 1

04/10/2020 12:05

the secret doctor

Why is it hard to say ‘it’s not my job’? The cannulation trolley did, to be fair, contain a cannula. One cannula, to be precise: an orange. It also contained four vials of saline (two past their use-by dates), eight clotting tubes, a solitary anaerobic blood culture bottle and, for some reason, a colostomy dressing. This state of affairs is a bit discouraging when you want to cannulate somebody in a hurry. It signals the start o scavenger hunt for connectors, skin wipes, tourniquets and all the other bits and pieces you’ll need. What might have been a quick five-minute job becomes a 25-minute quest. ‘Whose job is it to stock the cannula trolley?’ I asked the charge nurse afterwards. ‘Yours!’ he replied cheerfully. ‘The junior doctors should do it.’ It is the junior doctors who mostly use it, true. And the ward nurses are busy enough without taking on extra tasks. But is this really the best way to make use of the increasingly scarce resource that junior doctors represent? I mean, obviously it isn’t – it scarcely even works as a rhetorical question – but in actual fact that’s frequently the way it ends up. Junior doctors spend a surprising proportion of their day hunting for equipment, portering patients or fixing the printer, at the expense of reviewing ill patients and gaining vital experience. The trouble is, it’s very difficult to protest without giving offence. Do you think you’re ‘too good’ to do menial tasks? Are you

suggesting your time is more valuable than someone else’s? The delicate relationship between young doctors – especially, though not only, young female doctors – and other healthcare staff is only too easily disrupted. As a result, they end up spending much of their time on work that, a generation ago, would have been delegated. Their consultants, on whom this doesn’t really impinge, only start to protest when they find that they’re expected to type their own letters. Any good doctor will, when the occasion demands, clean a trolley, make a bed, dispose of a bedpan or wipe up a spill. If any doctor is spending much of their working day on those jobs, though, you have to ask what they are not doing instead. The same goes for qualified nurses, and anyone else trained and paid to provide a specific skilled service. The health service needs to acknowledge that different staff have different skill sets, and it’s simply not efficient to employ doctors to stock trolleys. Nor does it make for effective training or a satisfying working life. Cleaners, porters and auxiliaries are essential members of the team and should be properly paid and respected, but that does not mean doctors are best used in doing their work.

By the Secret Doctor Search for the ‘secret doctor’ at bma.org.uk @TheSecretDr thedoctor | October 2020 27

20200365 thedoctor – p26-27 v4.indd 2

04/10/2020 12:05

PAUL BLOW

My heart breaks too Words were all she had, but words would never be enough. In the first of two runners-up entries from the BMA writing competition, Revati Naran recalls her emotions as she conveyed some devastating news

ere we all sit, in this tiny room with its pseudo-comfortable chairs and bare walls. Me, in dishevelled scrubs with a pen in my hair, looking too young to be telling you this kind of news. And you, woken in the small hours with words that hide their real meaning like matryoshka dolls. ‘Get here as soon as you can.’ I will stick to the facts, to the bare bones, excuse my pun. I will use numbers, move sequentially. Pause for effect, to let it sink in. I will look you in the eyes when I speak because it is my actions, my team’s actions, that I have to tell you about, to take ownership of. I do not think for one second you are listening to me or understanding because how can you, how can you absorb these words when all that is running through your head is white noise and blankness. You are remembering, perhaps, the time your mother held you after someone broke your heart. How she stroked your hair, promised there would be someone better and then handed you tea in your favourite mug. You are thinking about the rings she was wearing when she came into hospital. The last time you went out for dinner together. Who her favourite couple was on Strictly Come Dancing. Or maybe it is your brother who is in your head – the one who stole food off your plate when he didn’t think you would notice, who snuck you into a gig when you were underage, who shuffled his feet with a choked-up throat when you left for university but would never tell you he misses you, never say out loud that he loves you. I do not know any of this. What I know of them, my patient, is how difficult it was to find a vein to put the cannula into, how three people were trying on both arms, blindly stabbing around. How their eyes were

open when I ran to their bedside, with a nurse already doing CPR. I know that we tried, we kept trying, to undo what their body had done, to restart, re-shock, reboot. I tell you I am sorry. I am so sorry. I wish we had run up the stairs faster. I wish we could have fixed it, I wish this was the way it is on TV. I wish we could have predicted this. I feel sorrow for the fact that we failed to prevent the inevitable but also failed to prepare you, we failed to tell you that this could happen because we didn’t know that it would. This word that I use is inadequate and they all are. I have nothing to say to tell you how I feel for you. Please look at me and believe that I mean it, but that this word is all I have to give you. Please understand that I would like to hold you and let you cry on me so that you might know that I am more than sorry, this word that is a spectrum, but that you don’t know me and I don’t know you and etiquette dictates that I stay where I am. I will not cry in front of you but please know that when I tell you these words, my heart breaks too. That I have to take deep breaths before saying what I know will shatter yours. When I tell you I am sorry, please know that I know and sorrow for what has happened and what is to come for you – the days of waiting, the bureaucracy and the emptiness. This conversation gets more practised and more fluent but is never easier to have. I haven’t enough experience with language to find more eloquent, meaningful things to say and express to you what I feel. Just know that I do. I am sorry, so sorry. Revati Naran is an ST3 in respiratory medicine in London

28 thedoctor | October 2020

20200365 thedoctor – p28-29 v2.indd 1

05/10/2020 07:48

PAUL BLOW

BMA writing competition 2020

thedoctor | October 2020 29

20200365 thedoctor – p28-29 v2.indd 2

05/10/2020 07:48

PAUL BLOW

30 thedoctor | October 2020

20200365 thedoctor – p30-31 v3.indd 1

05/10/2020 10:43

PAUL BLOW

BMA writing

That sorry was meant for you

competition 2020

Alice Bell still feels haunted by an apology she feels she should have made to a patient.

he stood just outside the room, blocking my exit so when I opened the door, hoping to have a moment to process what had happened, I almost walked into her. My damp scrubs stuck to the small of my back. My legs ached. My hands still smarted from the hot water that had washed off the dried blood which had speckled my forearms and trickled inside my gloves to my fingernails. Fatigue and hunger were making me feel nauseous. A buzzer sounded up the corridor. A man walked past, carrying a large silver balloon with a small bear with “Congratulations” on it. I moved aside to let him into the room I had just left. She was tall, her dark hair drawn back, and lips pursed. Almost graceful. Her left hand rested on her left hip through her blue scrubs, whilst with her right hand she formed a wagging finger at my eye level. Her blue eyes looked directly into mine. “Naughty. Tut tut. That was entirely your fault” she said. The fluorescent bulbs glared and reflected off the linoleum floor. The senior midwife stood next to her looking on. “Sorry” I reflexively said, feeling my eyes pricking. I turned to the midwife. “Sarah, please let theatre know we’ve got a case. Possible third degree tear”. Then I had no option but to accompany her to the handover room. “I don’t know what you were thinking pulling down for so long, no wonder she tore” she said. I sat down behind her on one of the chairs, tucking my legs under the desk whilst feeling my lower back sag into the chair. My mouth was dry. I can’t remember what I said in response. Perhaps I said nothing. I remember the feeling as if it was yesterday, ashamed, guilty, exposed. I was ill-equipped to deal with it. I couldn’t formulate a response. Feeling numb, I went back into the room to explain what had happened to the mother. The balloon bobbed cheerfully at the head of the bed. The room

was warm but her new clean white sheets felt cool as I placed a hand on the bed to keep me steady. I could see a pile of bloodied sheets in the corner of the room. The used metal instruments clinked noisily as they were tipped into the bin. The placenta made a wet slapping sound as it was placed in the shining stainless steel kidney dish before being taken to the sluice. Her baby was calm, snuffling and sucking its hand. I can’t remember her name and barely remember her face. I do remember her bewildered look, the exhausted euphoria that comes with having a new baby. The distracted acceptance of the events as I explained them: that when I helped her deliver her baby, she had torn. She signed the consent form. I didn’t apologise. I didn’t apologise. A short time later in theatre, I assisted in repairing the tear. I watched as she meticulously brought tissues together to close the mother’s wound. I helped to hold this suture here and cut that suture there. I helped mop up blood when it obscured a clear view of the skin. I wiped the blood away afterwards and counted the swabs with the scrub nurse. I gave the notes to her so she could write up the work she had done. Later that day, as I was cycling home through the Saturday morning traffic and remnants of others’ revelry the night before, I would think about her comment as we walked away from theatres; patting me on the back, she sarcastically told me not to make the same mistake again because she didn’t want to have to clear up my mess again the coming night. Again, I apologised. I often think about that night shift. It felt seismic in its effect. I think about that mother, who was owed the apology. I think about the apology I gave away so cheaply to someone who didn’t deserve it. And, finally, I think about why I decided to leave obstetrics. Alice Bell is a GP in London and one of the runners-up in this year’s BMA writing competition thedoctor | October 2020 31

20200365 thedoctor – p30-31 v3.indd 2

04/10/2020 20:00

15-17 October 2020 ONLINE AND ON-DEMAND LESS THAN A WEEK LEFT TO BOOK YOUR FREE PLACE Join our fully interactive global virtual event, BMJ Live and take this time for reflection and recovery. Learn how to make changes that can have a huge impact on your clinical practice, your health, and your wellbeing.

Clinical CPD Translate the latest evidence and guidelines into your practice, and earn CPD points for your appraisal.

Career Development Need advice on landing your next dream job, or not sure about your next steps? Get free one-to-one career advice online from skilled professionals who will help you evaluate your options.

Personal development & wellbeing

View the programme and register FREE today at:

live.bmj.com

Portfolio careers

Explore tools, tips and behaviours that will help you build resilience, lead effectively and maintain a healthy work-life balance.

Looking to shape a career with more flexibility? Hear from clinicians who have done things differently and let us help you design your own portfolio career.

Relocation in the UK or abroad

Interactive virtual exhibition

Explore the diverse and exciting places a career in medicine can lead to. Talk to our exhibitors live and attend our dedicated live seminar sessions on relocation.

Access and network with organisations in real-time who are currently recruiting in the UK and abroad. This is your opportunity to ask them those important questions.

KEYNOTE SPEAKERS ANNOUNCED!

Headline Sponsor

Fiona Godlee, Editor-in-Chief, The BMJ Clare Gerada, GP partner, Co-Chair of NHS Assembly, Former Chair of RCGP Council Prerana Issar, Chief People Officer, NHS England

Donâ&#x20AC;&#x2122;t miss out on the must-attend free online global conference for primary and secondary care practitioners of all grades and specialties.

20200365 thedoctor â&#x20AC;&#x201C; p32.indd 1

04/10/2020 12:09