The Doctor, January, issue 27

Tackling the virus – and the anti-vaxxers

Pu sh in gb ac k

The magazine for BMA members

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Issue 27 | January 2021

Kept apart Doctors desperate to be reunited with loved ones Living with COVID A long assault on health and career For want of a bed Deadly delays in sourcing mental health beds

11/01/2021 10:13

thedoctor

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

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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.

Scotland correspondent Jennifer Trueland

The Doctor is a supplement of BMJ vol: 372 issue 8275

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

ISSN 2631-6412

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

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

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In this issue 4-5 Briefing

The prime minister is full of promises for the COVID vaccine rollout but can it be achieved?

Welcome Chaand Nagpaul, BMA council chair Happy new year. This column is my first in this magazine since the approval of the first COVID-19 vaccine in the UK. As I said in December, this is an incredible achievement of modern science.

For most of us in this profession, 2020 was a year of unwelcome superlatives – the pressures were unprecedented, the daily reorganisations and adaptations extraordinary and the exhausting days seemed endless. Doctors absorbed a huge emotional toll as the death rate rocketed and as they treated patients cut off from family and friends as well as colleagues who had themselves fallen ill. They strived to learn new skills and took up new roles in new settings – pouring themselves into caring for their patients without respite, and in full knowledge that they were putting their own health and lives on the line.

Every step of the way – through personal protective equipment failings, test-and-trace shambles, and the disproportionate effect of the virus on our black, Asian and minority ethnic members – the BMA has been a voice for doctors and patients, held the Government to account and driven change.

And, in these coming months, as science has given us hope that this pandemic can come to an end, we will continue to scrutinise those whose decisions chart our path through the pandemic. The vaccination process is a great logistical challenge; we must ensure the Government and NHS leaders do not underestimate those challenges and that staff have the resources and support in place to turn scientific breakthroughs into operational successes.

In this issue of The Doctor we look at some of the most pressing topics for the profession – including discussing the need for the NHS to adapt to doctors who are newly disabled as a result of long COVID and the alarming growth of the anti-vaxxer movement at this crucial moment for society.

This issue of the magazine addresses Government policy – born from Theresa May’s ‘hostile environment’ – around adult dependant relatives and the effect on overseas doctors.

We continue to lead the agenda on the state of mental health services in this country, with an investigation focusing on Birmingham where mental healthcare is described as ‘broken’ and staff feel ‘helpless’.

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

6-10

Deadly delays

Long waits for mental health beds have been linked to patient suicides and yet few trusts have proper plans in place

11

A million volunteers

How Thailand has kept COVID deaths in double figures

12-15

Pushing back

Vaccinating against a swarm of misinformation

16-19

Living with COVID

Two doctors tell of the unrelenting struggle to manage long COVID

20-23

Are your parents at home?

Doctors wanting to move vulnerable relatives to the UK face almost insurmountable barriers

24-25

Extreme initiation

The ‘class of corona’ – the medical students drafted in to battle the virus

26-27

A watershed moment

How the pandemic gives a chance to reflect and an opportunity to change

28-31

Life experience

A new column, the BMA writing competition, and how employer error could have cost a doctor thousands

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briefing

GETTY IMAGES

Current issues facing doctors

An injection of urgency

T

PA

he setting of lofty targets comes easy for Boris Johnson’s government.

During the pandemic there have been promises of world-beating apps and test-and-trace systems, boasts of vast increases in testing capacity and claims of rapid turnaround times for tests and results.

The prime minister’s latest target – a sugaring of the bitter pill of a third national lockdown in his speech to the nation on 4 January – centred around his commitment to vaccinating the most vulnerable among the population by midFebruary.

This is perhaps the prime minister’s most ambitious pledge to date, since the cohort of the population he described – the over 70s, those shielding, those living and working in care homes, and frontline health and care staff – adds up to some 15 million people.

‘If we succeed in vaccinating all those groups, we will have removed huge numbers of people from the path of the virus,’ Mr Johnson said.

He added: ‘Of course that will eventually enable us to lift many of the restrictions we’ve endured for so long.’

The stakes could hardly be higher. And

JOHNSON: Plans to remove huge numbers from path of virus

these are welcome promises. But this is not a Government with a grand history of delivering on them. In the spring and summer, promises of increasing testing were missed and then definitions changed from tests carried out to capacity for tests.

Just this month pledges that schools were safe and would remain open were reneged on within one day of reopening following the Christmas break. Government U-turns have been the rule, rather than the exception.

And the reality is that this, in particular, is a mammoth task. NHS England figures suggest that around 786,000 people were given the vaccine between 8 December and 28 December.

In the first week of January the number had risen, but only by around 300,000. To coin a favourite phrase of this Government, there will be a very pressing need to ‘ramp up’ the process.

‘I do struggle to see how the Government is going to accomplish this,’ BMA medical academic staff committee co-chair David Strain says. He adds: ‘Not because the NHS cannot step up but because of the significant problems getting the vaccine to GPs and to vaccination centres and through the processing that takes the vaccine from a big vat into a deliverable version. These are bottlenecks which may cause problems.’

GPs ready The good news? Primary care stands ready to meet this challenge – and it will not be through

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NAGPAUL: ‘Vaccinating health workers won’t stop them being exhausted’

the failings of GPs if these targets are not met.

BMA GPs committee chair Richard Vautrey adds: ‘This is a process that can be delivered.

GPs are experts in national vaccination. What we need is the vaccine in good supply, to be trusted to get on with it, not tied in bureaucracy and red tape and freed up from some of the more routine things that we do in order to give us time to prioritise this.’

Dr Vautrey says NHS England needs to give practices more freedom to give the vaccine from their own practice sites rather than making people travel to more centralised hubs which may be further away and difficult to get to. He adds: ‘If you are able to have the vaccine in your facility you can give it to patients more effectively and speedily.’

While vaccinating this whole group of people is of great importance it has to be an immense priority to protect the health and social care staff at the greatest risk of contracting the COVID-19 virus and working in warzone-like conditions as they treat rocketing numbers of patients with the condition.

On 6 January the BMA demanded health and social care staff were vaccinated within the next two weeks.

Following the call to action NHS England wrote to system leaders to inform of expedited plans and pledged to have vaccination hubs in all hospital trusts by mid-January. The BMA continues to press for increased urgency.

Protection BMA council chair Chaand Nagpaul said the NHS faced a ‘mammoth task’ and assurances were needed that vaccine supply could keep pace with the target set.

He said: ‘Vaccinating health and care workers won’t stop them being exhausted, won’t stop them feeling the stress and anxiety of not having enough time, or beds, to give patients the care they need. But it will give them protection from this deadly virus and drive down rates of sickness absence and necessary isolating which are leaving services brutally exposed.’

Keep in touch with the BMA online at

instagram.com/thebma

VAUTREY: ‘GPs are experts in national vaccination’

Given the urgency of the situation – at the time of writing there are more than 27,000 patients with COVID-19 being treated in hospitals in England, an increase of more than 50 per cent since Christmas Day – it is easy to forget the remarkable advances of science that have made calls for vaccination possible.

‘This is remarkable science and progress,’ Dr Strain says. ‘The use of the mRNA vaccine is an alignment of stars. It is research ongoing for a long time, projected as a potential, novel, way of producing vaccines but it hadn’t been successful before. It just so happened the technology came good at exactly the time we needed it.’

Read more online – Public health doctors ‘completely shattered’ – Stop ignoring NHS warning lights, says BMA Scotland chair – Making the ‘least worst’ decisions: moral injury in the COVID pandemic – COVID-19: GPs risked their lives – Act now to close gender pay gap, demands BMA – Doctors felt ‘abandoned’ by the Government Read all the latest stories at bma.org.uk/news

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Long waits for mental health beds have been linked to others being seriously harmed.

Research by The Doctor finds much of the NHS lacks even the backstop plans required by law. Keith Cooper reports

Deadly delays K

ierran Fletcher, a father and professional Thai kickboxer in his 20s, had been waiting, bags packed, for 24 hours for a hospital bed when he rushed out of his home and killed Nigel Abbott in a frenzied assault, believing him to be the devil.

Mr Fletcher’s first episode of psychosis had been diagnosed quickly by his GP the previous afternoon. Hours later, an urgent admission had been advised by a psychiatrist.

After considerable effort, his family had persuaded him to be treated.

But there were no beds free in BSMHFT (Birmingham and Solihull Mental Health Foundation Trust) on that night, 26 July 2018. Mr Fletcher instead joined a

queue with 23 other seriously ill patients.

This mental health service, for more than a million people, lacked section 140 beds, a supply backstop which every part of the NHS has been required to have ready for such urgent cases since the Mental Health Act became law in 1983.

While waiting, the care of Mr Fletcher was handed to one of the trust’s five HTTs (home treatment teams).

At that time, they were struggling with up to double the caseloads they could carry and vacancy rates as high as 95 per cent.

Unanswered calls As Mr Fletcher’s condition deteriorated on the day

and evening of the attack, his family called his HTT 60 times. Very few calls connected. There were still no beds at 8pm, his family heard on the last call answered, hours before Mr Abbott was assaulted and killed, as he walked to the pub. Mr Fletcher was later found not guilty of murder by reason of insanity.

This wasn’t the first time England’s second largest city had run out of room and it won’t be the last in Birmingham, Solihull, or much of England, an investigation has found.

The Doctor found that the pressures and risk factors pinpointed by Birmingham and Solihull coroners in this and 10 other deaths which they have examined are

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CRIME SCENE: The street in Sutton Coldfield where Mr Abbott was attacked

ABBOTT: Killed while walking to a pub

‘Deaths are occurring because of a lack of resources’

present in much of England.

The Doctor found waiting times for beds running into weeks, high vacancy rates in HTTs nationwide, and no section 140 backstop supply in much of the country.

The findings reinforce further a point the BMA and other medical bodies have been raising for some time: there simply aren’t enough mental health beds in much of England.

A consultant psychiatrist and clinical director at BSMHFT, whose name is redacted in inquest papers, called mental healthcare in the city ‘broken’ for its ‘weak and incompetent leadership’.

Staff there felt ‘helpless’; they had learned there was ‘no point’ in asking for beds. Its chief mental health legislation officer, a consultant forensic psychiatrist, said services were in ‘massive crisis’ in 2018. ‘Deaths are occurring in Birmingham because of a lack of resources,’ they added.

Unsafe waits The investigation indicates that such sentiments are likely felt by frontline staff elsewhere.

As is depressingly common in mental health care, most

trusts appear unaware of their risks of prolonged waiting times for beds. They just don’t record them.

The Birmingham and Solihull coroners linked 11 deaths in their area in the space of one year to prolonged and fruitless searches for beds. Anthony McCormack, the most recent, took his own life in May 2019, after the longest wait of over a month.

‘Suicide due [to] unavailability of an inpatient mental health bed,’ was the inquest’s conclusion. Anthony Watson died also from suicide in October the previous year, aged 72, after waiting three days, the coroner found.

Despite the risks linked to waiting times, the vast majority of mental health trusts, including BSMHFT, do not record them, according to the 36 FoI (Freedom of Information) responses The Doctor received. Just six did last year; they reported waiting times of up to 29 days.

Hundreds of patients waited more than three days for a bed last year, figures from just four trusts show.

More than 1,300 waited more than 24 hours – the average wait for patients of

Rotherham, Doncaster and South Humber Mental Health NHS Foundation Trust.

Multi-factored assessment The way risks accumulate as acutely unwell patients wait at home for a bed is laid bare in the Birmingham and Solihull coroners’ reports. They show how admitting patients with acute mental ill health often requires the coordination of multiple public bodies, such as the NHS, police and ambulance services, and local authorities.

Each one brings into the mix their own pressures and ways of doing things.

In Mr Abbott’s case, the ‘ambiguous wording’ of one ‘multi-agency memorandum of understanding’ stopped staff from calling police for assistance. ‘They anticipated the police would be too busy,’ the coroner’s report says.

In mental healthcare, admissions are supposed to be coordinated with a ‘clear, joint policy’ agreed by all agencies involved, according to the Mental Health Act code of practice. Yet only four of the 100 CCGs (clinical commissioning groups) which responded to thedoctor | January 2021 07

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Longest waits for a bed in 2019/20 (days)

Sources: FoI requests/coroner’s report

Mersey Care NHS Foundation Trust

South West London and St George’s Mental Health NHS Trust

Northamptonshire Healthcare NHS Foundation Trust

North Staffordshire Combined Healthcare NHS Trust

29

15

7

5

The Doctor’s FoI, knew of such coordinating policies.

Without an agreed way of working together, the potential for confusion and delays mounts as hour-long waits turn to days. It’s magnified further in the NHS when mental health teams are pressured, understaffed, or reliant on agency workers who are less familiar with arrangements than permanent staff.

Deadly delay

‘Services are operating caseloads significantly beyond their recognised capacity’

In Mr Fletcher’s case, he was not prioritised for a bed after his first assessment, the night before the attack, as he should have been.

Ten hours passed before an official referral reached the AMHP (approved mental health practitioner) service for a full Mental Health Act assessment – at 10am, the following morning.

The AMHP’s lunchtime call to the HTT was returned three hours later, at 3.35pm.

Towards the end of the day, Mr Fletcher’s case was closed incorrectly by his AMHP. ‘Longstanding frustration with the challenging environment,’ was the reason she gave at inquest. A second referral had to be made, at 6.01pm.

At 8.06pm, just under three hours before the attack, a bed was still yet to be found.

This pressure on staff working in ‘under-resourced’

teams was pinpointed as a risk by coroners in most of the 11 cases they examined.

‘The HTT, bed managers, and AMHP services are operating caseloads significantly beyond their recognised capacity,’ says the report into Mr Abbott’s death.

Adding to this pressure was BSMHFT’s recruitment problem. All five of its HTTs had unfilled posts at the time of Mr Abbott’s inquest, including in management positions, the inquest heard. The caseload of the HTT in charge of Mr McCormack’s care was five times the size it could handle.

He too had been taken off the waiting list for a bed.

No backstop beds The investigation shows that many other HTTs across England suffer significant difficulties recruiting permanent staff, albeit not on the same scale as in BSMHFT. Vacancy rates in one of its teams hit 95 per cent in the year Mr Abbott was killed, the trust’s FoI response says.

The Doctor found that almost half (48 per cent) HTTs or their equivalent have struggled with vacancy rates of double the national average in the past three years. Camden and Islington NHS Foundation Trust says it is addressing high vacancy rates after seeing them rise in one of its teams from

15 per cent in 2017/18 to 32 per cent last year. Fiftyeight per cent of posts in Dorset Healthcare University NHS Foundation Trust’s connection team were unfilled last year. The average vacancy rate in England for medical and nursing staff is 10 per cent.

In Birmingham and Solihull, many posts in its HTT were unfilled, in part, for the ‘unattractive working conditions’, frontline staff told the coroner.

But perhaps the starkest finding of the investigation is the widespread lack of section 140 backstop beds in the NHS. Section 140 of the Mental Health Act requires all CCGs to have arrangements for beds in urgent situations.

Birmingham and Solihull CCG had been chased for four years to put them in place by the consultant forensic psychiatrist who gave evidence at Mr Abbott’s inquest, the coroner heard.

Concerns about the lack of section 140 arrangements nationally have been raised by the CQC (Care Quality Commission) repeatedly, and by consultant psychiatrist Professor Sir Simon Wessely in his review of the Mental Health Act in 2018. More recently, in May 2020, NHS England urged mental healthcare ‘systems’ to get them in place in anticipation

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of additional pressures from COVID-19.

Lack of arrangements

‘Staff felt helpless and learned there was no point in asking for beds’

The investigation has, however, found that vast swathes of the population of England, some 33 million people, live in areas where their CCGs could not point to their policies for these backstop beds. Of the 100 CCGs which responded, only 12 said they could point to one in place. Six had one in draft. While most CCGs said arrangements were in the hands of the mental health trusts they commissioned, the NHS and the MHA code of practice is clear that they must be involved. Birmingham and Solihull CCG now has a policy for section 140 beds, it confirmed in its FoI response.

Available beds at BSMHFT have, however, decreased since the coroners’ intervention, as the number of patients it sends to other hospitals ‘out of area’ soared by 161 per cent since 2018, the year Mr Abbott was killed.

‘Extremely concerning’ levels of patients waiting for beds have been reported at the trust as recently as October in the trade publication, the Health Service Journal.

Birmingham and Solihull CCG has no plans to increase its ‘bed stock’ in the next three years, its FoI response says.

The CCG had been ‘unable to validate a link between funding and the deaths’, NHS England told Birmingham and Solihull coroners in its response in 2019. In a joint response with the trust, Birmingham City Council, and the West Midlands Police, the CCG says it had in fact ‘exceeded’ the NHS ‘mental health investment standard’

Proportion of population without section 140 arrangements in place

71%

94%

Midlands and east of England

North of England

94% South of England

90% London

Source: Based on responses from 100 CCGs to freedom of information requests. CCGs were asked to supply copies of their policy and/or procedure and/or arrangement for the supply of urgent beds under section 140 of the Mental Health Act 1983.

CCGs without a joint admissions policy in place with their NHS providers, local authorities, and police and ambulance services Total responses 100

96

No joint policy in place

0

Joint policy in draft

4

Joint policy in place

Source: Freedom of information requests. CCGs were asked to supply a copy of any joint policy for admissions, shared with their local authority, providers, police and ambulance service on what to do when a bed cannot be found.

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since its inception.

A spokesperson for BSMHFT says: ‘In light of both increasing demand, and the complexity of patients’ needs we are working hard with our partners to create a mental health system that addresses the demand and capacity issues we are facing.’ It had invested in its HTTs, improved support for crisis cafés, set up a 24/7 mental health helpline, and planned next summer to open a new urgent care centre. ‘This will mean a more timely and joined-up assessment process and fewer delays for people who are experiencing a mental health crisis.’

Legal requirement

‘Severe stresses in bed management’

10

As The Doctor reported in November, bed numbers in many areas of England are expected to fall as demand rises, fuelled by the effects of COVID-19. ‘Severe stresses in bed management’ were predicted in November by the CQC in its annual monitoring report on the Mental Health Act. Without section 140 arrangements, much of the country lacks even the emergency backstop required by law. Struggling – sometimes unable – to keep patients safe at home are the community mental health teams, burdened by everincreasing caseloads.

The battle for more resources from frontline staff might be an old one but it’s one which looks set to grind on for some time in Birmingham, Solihull, and much of England. The awful outcomes for patients and their families will be told by coroners again, until somebody listens.

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How much more tragedy will it take?

Seriously ill patients are being kept from safe beds and treatment until it’s too late, with severe shortages of staff to treat them, says consultant psychiatrist Andrew Molodynski As a society, we should applaud Birmingham and Solihull coroners for pinpointing the risks which arise when mental health services are under-resourced, under strain, and understaffed.

They’ve shone a light into a dark and dank corner of the NHS, they’ve exposed our leaders’ attitudes towards people in mental health crisis. They’ve found multiple reasons which could have prevented another life lost, another family being hollowed out.

They’re reasons which will be wearily familiar to many frontline staff in other parts of the NHS. Despite the rhetoric from politicians and, worse, from those who provide and commission services, patients at severe risk to themselves or others are still being kept waiting for days, weeks, even more than a month for hospital beds. If that’s not bad enough, we found that most of the NHS does not record this data.

The confusing and complicated ‘arrangements’ (one could not call them systems) that open up gaps between police, social workers, and NHS teams are causing distress, infringing human rights, and costing lives. Many home-treatment teams, those expected to reduce hospital admissions in the NHS Long Term Plan, are buckling under workloads. Many run on agency staff, with vacancy rates as high as 95 per cent.

There isn’t even the backstop of section 140 beds in many areas, despite this being repeatedly flagged by national bodies, reviews, and no doubt individual doctors, as in Birmingham and Solihull. Politicians and senior NHS managers are in collective denial. Frontline staff, carers, and those who use services are not, but their voices are not being truly heard. The Government must do more to address these concerns, including meeting with key representative bodies, including the BMA. These tragedies happening up and down our country involve people with one characteristic in common: mental ill-health.

This has now become a civil rights issue, with a group of people identifiable by a particular and definable characteristic being allowed to suffer and let die for want of decent, affordable care.

How many more people need to die before things change?

Andrew Molodynski is BMA consultants committee mental health policy lead bma.org.uk/thedoctor

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REUTERS/ATHIT PERAWONGMETHA

A million volunteers An extraordinary mobilisation of village health workers have helped keep Thailand’s mortality from COVID remarkably low.

Keith Cooper reports

T

hailand is an unlikely success story in the global fight against COVID-19. It became the first country to identify a case outside China.

Since then, however, its approach has grabbed attention and headlines. ‘No one knows what Thailand is doing right but so far it’s working,’ ran one in The New York Times on 17 July, by which time almost 30,000 people had already died with the infection in the UK. By the start of this month, Thailand had still recorded only 65 deaths from the disease.

Volunteer army

stay at home without the need for a new law or system of fines. Most of its recent case have arrived from abroad.

All new arrivals must stay two weeks in quarantine. Thais can stay in free state-run quarantines. Thais and nonThais may also stay at their own expense in Governmentapproved alternative state quarantine hotels.

Any Thais who contract COVID-19 are immediately admitted for free treatment to a hospital or ‘hospitel’, one of several hotels rented by the Government for patients who are not very sick. Foreigners who test positive during quarantine are also admitted to hospital.

So, what has Thailand been doing so right? Two Lockdown eased reasons for its success are its track-and-trace system and Its lockdown started with the closure of massage its army of more than a million village health volunteers parlours, saunas, pubs, bars and boxing stadiums in (pictured above), says Pisonthi Chongtrakul, assistant March, as daily cases rose to a peak of 188. Lockdown professor in the Faculty of Medicine in Chulalongkorn measures began to be eased in May with department University, Bangkok. ‘These are just ordinary people,’ he stores and restaurants opening their doors, followed by says. ‘They conduct home visits, provide schools, pubs, and massage parlours health education, and write reports.’ in July.

That means there is one volunteer for Despite the success so far, Thailand ‘We tend not to every 67 citizens. While some personal saw in early January a sharp increase touch people where protective equipment was initially in in cases and fresh government advice short supply, it had stockpiled N95 to stay at home and close certain we greet them’ masks and anti-viral drugs. ‘As we’ve not public facilities. Doctors had previously had many patients, we’ve had very few expressed concerns about a second staff contract the disease and not one wave, because of a risk of illegal border has died,’ Dr Pisonthi told the Anglo-Thai Society. crossings and a change in public behaviour following a Thai culture is also likely to have played a role, he sustained run of low case numbers last year. adds. ‘We tend not to touch other people where we are ‘The number of people wearing masks is dropping, greeting them. We don’t hug, we don’t kiss.’ Thais greet you can see people gathering without social distancing at instead with a Wai, a slight bow. ‘We also have very few night in Bangkok,’ Dr Pisonthi says. ‘There’s still the threat nursing homes,’ he adds. ‘We have our elderly at home that people will contact the disease, mix, and there will be with us.’ Thais were also willing to wear facemasks and a second wave.’ thedoctor | January 2021

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SIMON GRANT

The rapid development of safe and effective COVID vaccines is one of the great scientific achievements of our times.

The battle now is against the other virus – a social media-fuelled storm of misinformation.

Seren Boyd reports

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Pushing back I

n the shadow of COVID, another pandemic is Professor Dame Parveen Kumar, chair of the BMA’s unfolding; a highly virulent strain, with an alarming board of science, echoes these concerns. ‘We need to act ability to mutate. quickly and firmly against these narratives, and we need This one can turn you into a monkey, render you an to tell people the truth: that immunisation is good for automaton – or convince you you’re invulnerable. you. If you’re offered a vaccination, take it. We have to Misinformation – or, more worrying, disinformation – get the world vaccinated: this is a major pandemic.’ around COVID is nothing new but the imminent prospect Efficacy undermined of mass COVID vaccination has triggered a second wave COVID-19’s vaccination uptake needs to be high of conspiracies, quacks and confusion.

David Strain, who plays a lead role in the BMA’s work on because of its R₀ (reproduction rate). A non-random COVID, has learnt to bite his tongue at the ‘COVID deniers’ vaccination programme, targeting high-risk groups such as vulnerable older people, would need 80 per cent of whose emails flood his inbox after every radio interview the population to be inoculated to be effective, Dr Strain he gives. He is determinedly patient – even after testing points out. A randomised programme would require positive for COVID himself in November. closer to 87 per cent to have the jab.

‘Part of me wants to take them Yet, studies suggest vaccine for a walk round my ward,’ admits ‘Without the hesitancy around COVID-19 is Dr Strain, co-chair of the BMA medical academic staff committee. significant. In a June survey by appropriate trust, ‘Before this all started, having a YouGov for the CCDH (Center for immunisation Countering Digital Hate), one-in-six death on the ward was an uncommon campaigns will not people (16 per cent) said they were occurrence, that would trigger a meet their targets’ unlikely to, or certain not to, get a moment of quiet reflection. Now we are COVID-19 vaccine. A similar number seeing as many in a week as I saw in my had yet to make up their mind. first five years as a consultant.’

In a survey by King’s College London and Ipsos Anti-vaxxers have gone into overdrive, however.

COVID vaccines will change our DNA, implant microchips MORI in July, 22 per cent of 16- to 34-year-olds said they were unlikely to have a COVID-19 vaccine or or sterilise us all, they say. COVID is caused by 5G definitely wouldn’t, compared with 11 per cent of radiation, biological warfare or aliens. It’s a ‘plandemic’ 55- to 75-year-olds. led by Bill Gates, big pharma and the WHO (World Health The fact that coverage rates of immunisation Organization). Or maybe it’s all just an elaborate hoax. generally have been falling ‘dangerously low’ in parts In September, the WHO and UN warned of of the UK has been a concern for several years, the consequences of this ‘infodemic’ being left says Dame Parveen. The WHO recommends flu unchecked. ‘Misinformation costs lives,’ a joint vaccination coverage of 75 per cent of the at-risk statement said. ‘Without the appropriate trust and population – a level not achieved in England since correct information, diagnostic tests go unused, the winter of 2005-06. immunisation campaigns… will not meet their targets, Uptake of childhood immunisations fell again last and the virus will continue to thrive.’ thedoctor | January 2021 13

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KUMAR: ‘We have to get the world vaccinated: this is a major pandemic’

STRAIN: The public health campaign should be science- and health-driven

year, another casualty of COVID-19. MMR coverage fell by as much as a fifth between January and April 2020, compared with the same period in 2019, despite advice that jabs should continue. Although rates stabilised from mid-April onwards, they remain depressed.

Despite this trend, ambitions for COVID vaccination coverage need to be high, says Dr Strain. ‘With COVID, we’re seeing patients in their 40s and 50s dying and young patients, people in their 20s and 30s getting long COVID. We want to get COVID wiped out or near zero, so we have to make this work.’

Rather, the focus has to be on inoculating the vaccinehesitant against the anti-vaxxers. He’s working on a report outlining contemporary threats to health and human rights. Exploring how attitudes are formed – and, by inference, how they can be shaped in public health campaigns – is the focus of a growing body of academic research.

Boosting trust

The University of Stirling’s OPTIMUM study aims to help optimise public uptake of a COVID-19 vaccine by exploring issues such as Anti-vaxxers’ motivations ‘what kinds of messages will resonate ‘Fake news can Meanwhile, anti-vaxxers have been with the public, what information they travel faster and lodge need, which sources they trust’. gaining ground. The CCDH estimates itself deeper than that the biggest English-language antiPredictably, many studies on vaccine vaxxers’ social media accounts enjoy a hesitancy home in on social media, a the truth’ global following of 59.2 million people, fertile breeding ground for conspiracies ‘enough to compromise a future and a space where algorithms vaccine’s ability to contain the disease’. repeatedly expose the doubters to dubious content.

The top 147 accounts increased their following by about A study by King’s College London, based on three 19 per cent in 2019-20. surveys in late May, found that people who used social The anti-vaxx movement is a broad church. CCDH media as a significant source of information about defines four main groups: ‘hate actors’ (eg purveyors of racism), ‘economically-motivated actors’ (eg those selling COVID-19 were more likely to believe conspiracy products), ‘fringe political actors’ (eg those wanting to theories linked to the virus. Importantly, it also found undermine governments or science) and ‘misinformed a ‘statistically significant’ link between believing in citizens’. conspiracy theories and breaking lockdown rules such Julian Sheather, BMA specialist adviser in ethics as going out in public with COVID-19 symptoms. and human rights, says it’s important to differentiate between sub-groups, to be able to address the distinct Social media profit challenges they pose. ‘It’s a complex picture and we have The BMA has been among those calling on the to address different parts of it differently. But this is a Government to devise and uphold binding standards nettle we are going to have to grasp because it’s starting compelling social media companies to prevent the to be so disruptive of health narratives.’ spread of misinformation online.

The urgent need for expedited vaccine roll-out calls CCDH has regularly criticised social media firms’ for a degree of pragmatism. Many anti-vaxxers are so failure to remove misinformation, even when it has ‘dangerously impregnable to information’ that they been reported. It notes that their annual revenue from cannot be persuaded, says Dr Sheather. the ‘anti-vaxx industry’, linked mostly to advertising, is 14 thedoctor | January 2021

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GETTY IMAGES

SHEATHER: A focus on inoculating the vaccine-hesitant against the anti-vaxxers

the Government needs to accept the fact that they can’t estimated at £750m. take political credit for buying 40 million vaccines,’ says Some are exploring more creative, innovative Dr Strain. approaches to fight fake news.

‘It needs to be science- and health-driven and fronted Social psychologist Sander van der Linden and by people like [England’s chief medical colleagues at Cambridge University officer and deputy CMO] Chris Whitty have developed an online game called and Jonathan Van-Tam, who still have ‘Go Viral’. It is designed to stimulate probity and the nation’s trust.’ ‘intellectual antibodies’ because, as ‘The public health The BMA believes improving public Dr van der Linden says, ‘fake news can campaign needs awareness and understanding of travel faster and lodge itself deeper to be apolitical’ immunisation programmes has to than the truth’. run in tandem with widening vaccine The game teaches players availability, increased funding, and how to post fake news and gain targeting specific populations where followers, thereby alerting them coverage is low. Increasing vaccine uptake among NHS to the techniques used to spread misinformation, workers is also important, says Dame Parveen. from manipulating emotions to creating fake experts.

But there is cause for optimism, believes Dr Evidence of participants’ resistance to fake news months Strain. COVID-19 has at least highlighted the role of later has persuaded WHO, Public Health England and the UN to promote the game on their social media platforms. immunisation programmes in public health – and there is one crucial difference between the COVID-19 and MMR vaccines, for example.

Awareness campaign ‘The generation of anti-vaxxers against MMR haven’t Education is important to any public health campaign seen kids going blind or being left brain-damaged promoting COVID-19 vaccination. It must be clear about because there has been sufficient herd the risks associated with refusing immunity,’ says Dr Strain. vaccination, but must also address ‘The one thing In contrast, he says, the outcomes people’s genuine concerns, including from COVID have been widely mistrust of big pharma. even anti-vaxxers publicised, including the large Dr Strain felt the early want is for the number of people who have sadly announcement of the country to get lost their lives, but also the knock-on Pfizer-BioNTech vaccine seven-day back on track’ effects on hospital waiting times, results in November ‘played right provision of other emergency into the hands of the anti-vaxxers’ services such as cancer operations concerned about the speed of vaccine and the extreme pressure that has been placed on development. primary care.

It also fuelled public complacency with lockdown ‘The one thing that, quietly, even the anti-vaxxers restrictions, he suspects. News that Pfizer’s chief executive sold shares worth several million dollars on the want is for the country to get back on track, and if they see vaccination as a route to that, they might just bite same day as the announcement didn’t help either.

‘The public health campaign needs to be apolitical and the bullet.’ bma.org.uk/thedoctor

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EMMA BROWN

The future of doctors who have been struck down by the long-term effects of COVID-19 has yet to be fully explored and planned for. Jennifer Trueland talks to two doctors about their struggle to get back on top

Living with CO T

he early weeks of the pandemic were busy for Nathalie MacDermott.

Specialising in paediatric infectious diseases, and with experience in medical response to disasters and epidemics, she was often called on by the media to share her expertise.

This was on top of her day job, as a clinical academic in training at King’s College London, rotating between clinical and research posts.

Even when she contracted COVID-19 herself, probably from a colleague while on a clinical placement around the end of March, she bounced back relatively quickly, and returned to work after around 10 days, feeling ‘fully recovered’ by day 21. But

then in May she became ill again – and this time the symptoms did not go away.

Worse than that, her condition progressively deteriorated, significantly affecting her mobility (she now has to use walking sticks) and almost every aspect of her life. While she has been able to return to academic work, she has no idea how she will manage when she next has a clinical placement, or how she will finish her training.

Workforce lost Dr MacDermott is one of the growing number of healthcare staff living with a form of what has come to be known as long COVID. Doctors – probably exposed to the virus while at work – have found they are unable to

return to their previous roles sometimes for months after initially becoming ill.

It’s a horrific situation for individuals, but it’s also a major problem for the health service, which is losing a substantial section of the workforce at the busiest time of year, during a global pandemic. Employers are also facing the challenge of how to bring these doctors safely back to work, raising the question of whether a phased return and other processes are sufficiently fit for purpose.

‘Long COVID is an occupational disease and should be seen as such,’ says David Strain, co-chair of the BMA medical academic staff committee, who is playing a leading role in the BMA’s COVID-19 work.

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MACDERMOTT: ‘I can only walk 200 metres now and have developed severe pain in my back’

OVID

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that, but then you do make progress even though it might be very slow. At the moment, everything seems to be going in the wrong direction.’

STRAIN: ‘We don’t know how bad long COVID is going to be’

‘Long COVID is an occupational disease’

‘Everything seems to be going in the wrong direction’

Help at home

‘But I don’t think the NHS understands the scale of the problem yet. We’ve not fully got to grips with how many people this has affected, to what extent, and how long it will take for them to be able to return to work.

‘Are we talking a few extra months? Are we talking something that could be a lifelong commitment with people not going back to work? So, I don’t think people are fully aware, because it would be impossible to be aware because we don’t know how bad long COVID is going to be.’

Prospects unclear He is reassured, he says, that NHS Employers is supportive of helping healthcare workers with long COVID, although he cautions that at the time of writing (December) there has not yet been published policy on this.

Medics such as Dr MacDermott are facing uncertainty, not just about the trajectory of their

condition, but also about their future employment.

Mobility is a particular concern for her.

As well as suffering traditional COVID symptoms, including muscle pain, the second time round she developed problems with her feet, with pain and loss of sensation, and also weakness in her legs.

She has been seeing neurologists and initial MRI and other tests showed a mild neuropathy, but her symptoms have worsened.

‘I can really only walk around 200 metres now and have developed very severe pain in my back. It was affecting my bowel and bladder as well and they have diagnosed a myelopathy due to some form of pathology in my spinal cord.

‘It’s concerning because there’s not been any improvement – it seems like a downward trend. I guess you think when you have a viral illness you have a one-off “insult” and it takes a while to get better from

Dr MacDermott was unable to return to clinical work because of her mobility problems but returned to her academic job in September.

Her university has been very helpful, she says, and her NHS employer accepted that she came under ‘COVID’ sick leave, so there were no issues about docking her pay.

So, where does she think things will go for her now?

‘I really don’t know,’ she says.

‘Right now I really struggle to do things even around the house – I’ve employed a cleaner – so how I return physically to clinical work in the future, I have no idea.

‘But even if I never fully regain my ability to walk, which hopefully won’t be the case, then they will have to put in modifications to make sure I can complete my training as a registrar.

‘And even if I was to work as a consultant they would need to put in modifications to facilitate that, but it’s really hard right now to know what will happen.

‘I don’t even know what’s causing this problem – is it a direct effect of the virus, is it an immune response that the virus has triggered in my body? Who knows what the long-term outlook is?

Hopefully it’s good and it will get better, but I just don’t know.’

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SARAH TURTON

‘My main symptom was fatigue’

JALUNDHWALA: Months of struggle with fatigue

One doctor with long COVID, who has faced debilitating symptoms and a pay cut, is calling on employers to be more proactive

K

‘There are days when I just can’t do it, no matter how hard I push myself’

averi Jalundhwala is losing income and faces an extension of her GP training after contracting COVID-19 at work while on a hospital placement. The uncertainty, on top of debilitating ongoing symptoms, has been very difficult.

‘I became ill on 30 March and had all the usual symptoms, and after a week I felt better and went back to work. I was sent to a COVID ward and worked there for three days while I was still coughing, but I didn’t have fever. Then I got another fever, so I isolated again and then I started really struggling with shortness of breath and that’s been my primary symptom for three months. After that my main symptom was fatigue, which I’m still struggling with now.’

Pay cut Dr Jalundhwala, 28, is doing an extended phased return on a GP placement in the Thames Valley. She had three months sick pay, followed by two months working 60 per bma.org.uk/thedoctor

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cent, and is now working 80 per cent, all remote. ‘I got the full pay while I was on sick leave but then they put me on less than full time pay, so I was paid 60 per cent for two months and now I’m paid 80 per cent. Someone on the Facebook group highlighted to me that I shouldn’t have had my pay cut at all, so I’m following that up with my employers,’ she says.

Losing 40 per cent of income is always hard – especially when you still have around £26,000 in student loans still to pay off. ‘I’m lucky, I’ve got savings and my husband has a good job so we’re managing OK at the moment. But I’ve heard of people who have lost their jobs, which is just terrible.’

She is also concerned about what will happen when she rotates to her next hospital placement, which is due to be emergency medicine – something she won’t be able to do from home.

‘Hopefully I’ll be better, but there are still days when I just can’t do it, no matter how

much I push myself. I think I’ll be working eight-hour shifts but I’m struggling to get in contact with anybody to find out if there’s any flexibility in this. I’ll be going to 60 per cent, so that will be a big cut in pay again.

‘It will also mean more months of working as a trainee, which is fine for me, because that’s just how it is, but it wouldn’t be fine for everybody.’

Out of focus She is finding it difficult to deal with the situation, particularly as she has problems concentrating because of her long COVID. ‘I think it would help if employers were more proactive and when people are sick for a long time, I think they should be reaching out to find out what is happening.

It’s also difficult to find out information, for example what is the situation with sick pay.

Some days I’ve felt I don’t have the energy to do this as well as my work, so obviously I prioritise my work. It’s very difficult all round.’ thedoctor | January 2021 19

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ED MOSS

ntent on Access audio co ion of this the online vers org.uk / feature at bma. thedoctor

AKHTAR: ‘There are people in my position where the outcome is not a happy one’

Doctors wanting to move vulnerable relatives to the UK face almost insurmountable barriers despite being willing to fund their care. Some are left with no option but to leave the country. Tim Tonkin reports

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11/01/2021 09:47

Are your parents at home?

‘I ‘The legal challenge was an extremely depressing experience’

‘I had to tell my trust that I was applying for residency for my mother, and that if I failed the only option I would have was to put in my resignation’

t causes a huge amount of anxiety and distress.

We [overseas doctors] live in a constant state of guilt for not being able to be with our parents when they need you.

There have been colleagues of mine who have lost their parents and have not been able to see them in their last moments.’

This is GP Kamal Sidhu’s blunt assessment of the Home Office’s rules around ADRs (adult dependant relatives), the regulations which dictate how and whether overseas doctors working in the UK can bring older and infirm family members to live with them.

Having previously afforded a more lenient approach, the rules around ADR immigration were tightened considerably in 2012 as part of the then home secretary Theresa May’s socalled ‘hostile-environment’ policy.

Since 2012, foreign nationals looking to bring dependant relatives such as a parent or grandparent to live permanently in the UK, are required to not only prove their relatives require long-term care, but that they are unable to obtain suitable care in their relatives’ home countries.

Dr Sidhu, who is based in the north-east of England, has first-hand experience of this inflexible and often draconian system having sought, so far unsuccessfully, to bring his parents to the UK from India.

‘When I made the decision to come to the UK in 2003, the rules were a lot more

flexible,’ he explains.

‘It was not as difficult to bring parents over here, as long as we were willing to sponsor them. Since 2012 it is next to impossible to bring relatives to the UK.’ Sadly, Dr Sidhu’s case is far from unique.

Families separated Since its implementation, the tougher requirements set for overseas citizens seeking to bring adult relatives to live with them in the UK has had a dramatic effect.

A 2016 Home Office review into the effect of the policy change showed that, while a total of 2,325 applications had been granted between April 2010 and March 2011, this number had fallen to 189 successful applications in 2013 and just 135 the following year.

Dr Sidhu is a member of a joint taskforce comprised of BAPIO (the British Association of Physicians of Indian Origin), APPNE (Association of Pakistani Physicians of Northern Europe) and the BMA, which is set on challenging the existing ADR rules.

In a letter to home secretary Priti Patel, all three organisations have warned that the rules are effectively leading to the permanent separation of older relatives from their children, something that is having ‘a considerable impact on the mental health of our members’.

Dr Sidhu says he knows

of friends and colleagues who have made the decision to leave the UK and relocate to places such as the USA and Australia where immigration regulations concerning family dependants are not as strict.

‘I don’t switch my phone off during the night in case there’s an emergency call,’ he says.

‘You worry at all hours about getting a phone call.

My parents are at that age now where you do expect them to have health problems.

‘Sometimes I wake up in the morning and wonder why I’m continuing with this status quo.

‘You think about going back [to India] but you’re torn between your families, your children live here and go to school here in the UK and you have your career here. You’re faced with essentially having to uproot all of that.

‘There is a huge psychological impact on doctors through this policy,’ he adds.

‘Unless the rules are amended, the UK will continue to be a less preferred destination to overseas doctors than other countries.’

Under stress The threat of overseas doctors quitting the UK owing to the obstacles they encounter when trying to bring their parents to the country, is well founded.

A survey jointly conducted

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MARK PINDER

SIDHU: ‘Since 2012, it is next to impossible to bring relatives to the UK’

‘You think about going back to India but you’re torn between your families’

found that 91 per cent of respondents who had sought and been unable to bring their relatives to live with them, reported feelings of anxiety, stress and helplessness as a result of their predicament.

Sixty per cent told the survey these feelings were having an adverse effect on their working lives, while a staggering 85 per cent admitted they had considered either returning to their home countries or relocating to one with more flexible regulations on ADR immigration.

A year ago, The Doctor reported on the story of Indian-born consultant child psychiatrist Nishchint Warikoo, who had spent years working in the UK, and had become a British citizen in 2014.

After months of battling the Home Office to win the right to bring his mother to the UK, Dr Warikoo concluded that he had no other choice than to

quit his role in the NHS and relocate himself and his family to Australia.

Legal challenge East Midlands-based consultant endocrine surgeon Irfan Akhtar faced a similar situation when he sought to have his mother live with him and his family in the UK. Mr Akhtar explained how his mother, a UK-trained paediatrician, had spent the initial years of her retirement living comfortably in Pakistan.

As she grew older and frail, and with Pakistan generally lacking the kind of community-based social care services seen in the UK, he realised that being separated from his mother was only going to become more difficult and eventually untenable.

When his mother began to develop dementia, Mr Akhtar realised that it was no longer possible for her to live

independently and knew that she would need to come and live with his family.

Despite demonstrating that his mother’s care would be funded privately in the UK and how she could not receive the care she needed in Pakistan, his application was refused.

He challenged the decision, with the resulting appeals process lasting almost two years before finally a court ruling overturned the Home Office’s original decision, allowing Mr Akhtar to bring his mother to the UK. ‘I was one of the lucky ones,’ he says.

‘It [the legal challenge] was an extremely depressing experience at the time and there are so many other people in my position where the outcome is not a happy one.’

False economy Mr Akhtar says he feels the requirements on applicants to prove that bringing an older family member to the UK would not pose a burden to taxpayers are set to an almost unattainably high standard.

He adds that even when applicants, such as himself, are able to fully demonstrate that they have the financial resources to fund any and all of their relative’s care needs, this fact could then be used against them.

‘The counter argument was that if you have money here to support your mother, why don’t you buy her a house in Pakistan and put her there?’ he says.

In its letter to Ms Patel, the BMA, BAPIO and APPNE highlight how the common

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‘The taxpayerburden argument feels quite insulting in some ways’

argument used against applications to bring a dependant relative to the UK on the grounds that doing so would pose a burden to the taxpayer, was based on a false economy.

It adds that not only would the majority of doctors be prepared to cover the costs of their relatives’ care, the punitive rules on ADR immigration risk forcing highly skilled and experienced doctors to consider leaving the NHS. It is an argument Dr Sidhu and Mr Akhtar agree with, and believe is not taken seriously enough by the Government.

‘The parental issue often comes at a stage in your career where you are fairly senior,’ Mr Akhtar says.

‘I had to tell my trust that I was applying for residency for my mother, and that if I failed the only option I would have was to put in my resignation.

‘In my case, I am only one of two consultant endocrine surgeons in the whole of the East Midlands and if I had had to go off [and leave the UK] the effect would have been tremendous.’

‘That [taxpayer burden] argument feels quite insulting in some ways,’ says Dr Sidhu.

‘It overlooks the fact that the country has imported overseas trained doctors that taxpayers here have not funded and secondly ignores the fact that many doctors are willing to give an undertaking committing to ensuring their relatives will not be a financial burden.

‘We need to start looking at those countries that have a far more humane approach to these rules.’

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WARIKOO: Left with no choice but to emigrate to Australia

In its letter to the Home Office, the BMA has made clear that the importance of ending the restrictions around ADR has received additional urgency following Brexit, with European Economic Area nationals working in the NHS also set to now be subject to them, following the end of freedom of movement.

The letter warns that doctors from Europe could join their colleagues from other overseas nations in either leaving the UK or choosing not to come to the country, because of restrictions on bringing family members to come and live with them.

Empathy needed Terry John, who until recently chaired the BMA international committee, says reversing the existing rules around ADR immigration would make a significant difference to improving the lives of overseas doctors already in the NHS, while also making the UK a more attractive destination for future international medical graduates.

‘Choosing to come to the UK to serve in the NHS demonstrates a tremendous

level of commitment,’ he says.

‘It is therefore baffling the Government, which so often talks of its desire to attract the “brightest and the best” to this country, continues to not reciprocate the loyalty shown by overseas staff by taking a more flexible and empathetic approach to the issue of dependant relatives.’

For Mr Akhtar – who describes the successful end to his appeal as like the lifting of a big weight and black cloud from his life – being able to be close to his mother has had a dramatic effect on her and his family’s lives.

‘I flew to get her to the UK, she took her time to settle in the new environment,’ he says.

‘Over time, the change in her personality has been phenomenal, she is more interactive and has built bridges with the grandchildren and feels involved in their development. She manages her walk in the garden and has made a few friends in the neighbourhood.

‘Mum still has her health issues but her approach in managing them is more positive, [and] as a family we feel a lot more stable and are more focused on our children and profession.’ thedoctor | January 2021 23

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Extreme initiation SAHOTA: ‘I felt so alone. There was just this anxious, adrenalised quiet where you feel you’re going to break psychologically before you break physically’

Portrait by paper collage artist Rosalind Freeborn www.paperface.co.uk

‘I can’t tell you what a difference it makes when someone learns your name’

Panic attacks in the toilets, claustrophobic PPE, the relentless hiss of the ventilators, the surreal trauma of watching paralysed people fight for their lives…

Shaan Sahota’s raw, real-life experiences as a junior doctor working in critical care in London at the height of the pandemic are vividly captured in her new play, Under The Mask.

The protagonist, Jaskaran, is an FiY1 (foundation interim year one), whom COVID has catapulted prematurely into her medical career. In fact, Dr Sahota had been an FY1 for six months when she was redeployed from surgery to ICU in mid-March 2020. But she felt just as overwhelmed as her central character.

‘There was virtually no one in the hospital, no families, and my patients were all paralysed: they’d never even looked me in the eye,’ says Dr Sahota. ‘I felt so alone. There was just this anxious, adrenalised quiet where you feel you’re going to break psychologically before you break physically.’

Dr Sahota was commissioned to write the audio-play after Tamasha theatre company read a blog she had written for The Guardian. To build intensity and realism, she interviewed several FiY1s for the project. The immersive soundscape is based on recordings made in ICU with a virtualreality 3D microphone.

For Dr Sahota, the biggest adjustments were finding herself in

a role for which she was unprepared emotionally. Her day to day was ‘small and tedious and humbling’.

Administering eye drops, proning patients, emptying catheters. Countering racism with courtesy when patients demanded to see a ‘white doctor’. She was the only FY1 who stayed in ICU when the cohort were given the option to move on.

Partly through the catharsis of writing, she realises that the pandemic pushed everyone out of their depth. And she learnt that small things really matter.

‘When you’re depersonalised in this pile of PPE, I can’t tell you what a difference it makes when someone learns your name. When someone sees you as a person, not just a pair of hands, it really motivates you.’

Among all the existential questions the work raised and the play explores, Dr Sahota found one particularly challenging: ‘Do I only want to be a doctor because I expect people to get better?’

Most of her patients died.

‘Through COVID, the whole world has had this confrontation with death and suffering. I had a painful encounter but I don’t wish not to have seen it. You have to see all of life, including the ugliness, and say yes to it all.’

Interview by Seren Boyd Under the Mask is a co-production between Tamasha and Oxford Playhouse and will be on tour from 23 March 2021.

For more information: https://tamasha. org.uk/whats-on/

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Drafted in early from medical school, the ‘class of corona’ faced a once-in-a-generation crisis. Two doctors have captured their experiences, in very different ways

KOOMSON: ‘These doctors took a bold step’

‘Some of the doctors reported feeling “impostor syndrome’’’

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COVID-19 has caused an array of disruption, uncertainty and drastic reform of the systems we once knew. One group of doctors all too familiar with this were the final-year medical students who were fasttracked to become doctors.

At the Princess Alexandra Hospital in Harlow, around 20 doctors started work in May in these circumstances, with many more new doctors starting early in other trusts around the country.

Although often described as ‘drafted in’, it was their own choice whether they took up the posts.

However, talking to them, it is clear they felt a considerable degree of pressure, from their own sense of duty and a prevailing climate where everyone was doing their bit.

A new type of job required a new title – FiY1s (foundation interim year one) doctors officially, but also known by some as ‘doctors by default’. This was one of several terms, such as ‘class of corona’ or the ‘COVID cohort’, which some of the doctors regarded as a kind of badge of honour, and others found condescending.

So, what were their experiences and how did they feel? We sent open, qualitative questionnaires around the cohort to find out.

Naturally, there was a great deal of anxiety. Starting out as a doctor is stressful enough, but there were specific COVID challenges to add, such as the fears of PPE (personal protective equipment) shortages, and the risk

of infecting loved ones. The constant use of military language by the media – ‘battling’ the virus, working on the ‘front line’ – may have been meant to inspire but it tended to provoke concern instead.

Support came from wellness inductions, developed by the NHS, medical schools and foundation programmes and many engaged with and benefited from these.

Some of the doctors reported feeling ‘impostor syndrome’, familiar to many who qualified before them. But again, this was probably exacerbated by the conditions set by the pandemic. The working environment was unfamiliar even to their experienced colleagues, and they had come to it through an unorthodox and premature rite of passage.

Some doctors look back on the experience positively. But we may have to wait some years for the answers on how this cohort was affected and find out whether they were adequately supported.

It will be interesting to compare them with those who waited until August to start their foundation jobs at the normal time. These doctors took a bold step, and we owe them our continuing attention and care.

Original qualitative research was conducted

by Albert Koomson (foundation year 1 doctor) and Adeel Abbas Dhahri (specialty registrar) at the Princess Alexandra Hospital NHS Trust in Harlow, Essex

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SARAH TURTON

BELL: ‘As a woman, I felt frustrated that I was having to choose between caring for my family and doing a job for which I have trained for years’

A watershed moment Through the stress and upheaval of COVID-19, working and personal lives are being changed forever. London GP Alice Bell gives The Doctor her account of coping with a pandemic and what it means for her, her family and the world’s future

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SARAH TURTON

A

and a second child to look after, I made the decision to s a GP, I would have expected to see a great continue my maternity leave as planned, to allow myself many changes to my working life during the to be part of a refreshed workforce in time for a possible coronavirus pandemic. second wave.

However, having spent the entire period to date on Admittedly, one might feel I am fortunate to not have maternity leave, I have been viewing some aspects worked during the pandemic and to of the pandemic from the sidelines, not have been on the front line when whilst experiencing other aspects some were, and others tragically lost first-hand. their lives. Part of me does regret that I have not been part of the systemic ‘I was very conscious I will never be able to say that I was changes within the NHS and have not of a dilemma there when the seismic shifts within witnessed the rationing of healthcare within me’ our healthcare system took place that has occurred at the cost of and when the well-oiled cogs of the coronavirus: the stalled cancer referrals, gargantuan machine suddenly slowed and indeed all hospital referrals. and changed gear.

I have, however, been able to experience lockdown as patients have, looking after two children, for a portion of it only being able to leave the Opportunity for change The other part of me, the mother, feels grateful that I house for an hour at a time with them, and crucially, at was able to look after and protect my family during this its peak, not knowing the end point. time. But as a woman, I felt frustrated that I was having Having replaced the rigid routines of daily GP to choose between caring for my family and doing a job surgeries and meetings with the daily routines of early for which I have trained for years. parenthood, the indefinite nature of lockdown proved Sometimes a crisis becomes an opportunity for quite challenging. change. The pandemic has accelerated the progression In March, when my social media was rife with of telemedicine and other integrated technology, pictures from Lombardy intensive care units with but let us not forget the recent challenges that the patients ventilated prone, and fellow doctors advising medical profession faced even before the pandemic us to beware as this was coming to the UK, the sense of muddied the water: chronic underfunding of the NHS; panic was palpable. an undermining of professional identity among doctors after the imposition of the junior doctor contract; Initial panic and the loss of trust from patients that we all felt after My husband, who is also a doctor, was pulled off his Harold Shipman. research into a central London teaching hospital that As we now face the prospect of local lockdowns and was acting as a super-surge centre. There was a definite more restrictions, and I face the prospect of returning sense of war spirit and a dawning realisation that our to work, there is a dawning realisation lives were about to change. that we will all feel the repercussions Among clapping for carers, rationed of this pandemic in our personal and pasta, and rainbows appearing at professional lives for years, possibly every home’s window, he started to ‘We will feel decades, to come. go into work, while I stayed at home. the repercussions for The road ahead is fraught with The sense of panic and fear within years to come’ anxieties. Let us hope the positives us dissipated on his return from the that have come out of the pandemic wards, as the known enemy appeared can continue to be borne out despite less scary than the media portrayal the inevitable economic downturn, the which seemed to play heavily on fear. need to raise taxes and to continue austerity to fund the A calm can-do attitude permeated with the understanding that this condition offered no diagnostic Government bailout schemes. uncertainty, that there was only one treatment available We must brace ourselves for the increased health at the time, and that this sometimes failed despite the needs of a population who have been unable to best efforts of all staff involved. maintain their chronic health conditions, their As the pandemic and lockdown unfurled, I was very mental health, and their worrying cancerous conscious of a dilemma within me: I had skills which growths, whilst together we all adjust to the new could be useful in this pandemic, but I was choosing to normal way of life. remain at home. With a young baby, nursery closures, Alice Bell is a GP in London thedoctor | January 2021 27

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PAUL BLOW

When the lights go out A story of grief and simple kindness by Louise Wiseman, highly commended in the BMA writing competition

T

he sky across the city is dimming down for dusk as I look out from the labour-ward window.

I knock on the door to the private room, standing in my anaesthetic greens. I feel the plastic mould of my clogs momentarily ground me, static to the floor.

I walk in towards the bed as the midwife nods towards the mother. I see the beauty of the last days of pregnancy in the bloom on her face, the Rubenesque bulge of her tummy with child. Then I look in her and the father’s eyes and see the raw, red swelling of tears spent. She is looking at me but through me, blunt and desperate.

I sit on the mint-green NHS bedspread and look in her eyes.

‘I am so sorry…’ I introduce myself. She and her husband nod, silently. I talk through risks and effects.

With shaking hands, she signs my prepared clipboard consent form.

I scrub my hands at the sink and stand motionless while the midwife gowns me up. My size seven-and-ahalf gloves, prepared and ready to fit, lie open on the sterile table. We have a well-rehearsed routine. We are a team, the midwife and I. Our familiar, superficial chit chat usually masters and soothes the frantic time away. Today we work together in silence, packs are opened and paper is smoothed.

The mother is positioned and I start my quiet patter.

‘A little scratch my darling.’ In the fray of intense clinical encounters, I have learned to create intimacy in the face of fear with each patient. Patronising to some. Natural and essential to me.

The teen in the car crash – I cradle her head and say, ‘it will be OK my darling’.

The septic child with veins collapsed – ‘just a little scratch sweetheart’.

Five years later the midwifery team will call me ‘darling’ and ‘sweetheart’ as they rapidly prep me for my own emergency section. I will treasure the over-familiarity. The future mother I will become,

will cradle her children’s faces and litter the dialogue with ‘sweetheart’ and ‘darling’, natural and essential.

‘Just a bit of pushing sweetheart until we find the space.’

There is no space in this room. It is permeated by a dense fog of grief and longing. My epidural needle is wide and deep, I find what I need and quickly finish my well-rehearsed procedure. Normally time is of the essence. Today, we have all the time in the world in this room, and yet we have none.

Everything clean, everything perfect and I turn the mother round to use my meds to create comfort.

There is no comfort from this pain.

I sit on the bed. I take her hand after removing my gown and gloves. My hands are still powdery from the latex. ‘I am so sorry.’ My eyes are glazed with tears.

The father thanks me, looking at me but through me.

I leave the room for the mother to have her dead baby, my epidural working. I go to sit in the warm, familiar midwifery office, the TV murmuring and the chocolate biscuits open.

My favourite midwife is sitting knitting. Booties and hats for tiny stillborn babies. She knits when there is peace within the unpredictable nights. She has shown me babies in little boxes for parents to view. Lost treasures. Little darlings and sweethearts. Hand and footprints on cards to put away in memory boxes that may never be opened.

This baby is not tiny; she is full term. The mother and father have a long night ahead. The midwife sees my wet eyes as I watch her knitting needles click together.

I feel helpless, humbled, unworthy of her comfort as she looks straight at me.

‘I am so sorry, sweetheart, that I had to call you to this.’

Louise Wiseman is a former GP and freelance medical writer

28 thedoctor | January 2021

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PAUL BLOW

BMA writing competition 2020

bma.org.uk/thedoctor

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

A basic error by an NHS employer could have cost a doctor thousands of pounds, but some determined work by a BMA employment adviser rescued his financial security There are specialties in which there is a severe shortage of doctors, and so it makes sense that those willing to train in them are given a little extra help when they need it.

One source of help comes from pay protection. This applies, in certain circumstances, for career-grade doctors wanting to return to training. To qualify, they need to have at least 13 months’ continuous service in the same nationally recognised career-grade post at the point immediately prior to re-entering training, and to move immediately from that to a hard-to-fill training programme.

In this case, the doctor met the conditions.

He was a specialty doctor returning to training to become a GP. His problem arose from the incorrect use of one word by his former employer. It described him as a locum in correspondence with his new employer, leading it to conclude wrongly that he lacked the necessary continuous service.

It was a simple mistake by the employer, and so it should have been easy for them to correct. But in the months leading up to the doctor starting his new job, it took a considerable effort from a BMA employment adviser to resolve the matter.

When the doctor got in touch with the BMA, it was two months before he was due to start

his new job. He had already tried to raise the issue with his manager, and although they offered verbal support, little had been done.

This is where the persistence and expertise of the employment adviser came in. She sent the doctor’s contract to the new employer, which made it crystal clear he was not a locum.

Almost two weeks passed so she chased the old and new employers. Another two weeks passed, and she chased again. A succession of calls and emails to which a doctor in a full-time position would find it difficult to commit the time and energy.

Confirmation arrived just before the doctor was due to start his new job. Without the pay protection, his salary would have been more than £6,000 lower.

Terms and conditions are complex, and HR departments make mistakes, but what this illustrates is the brick wall that doctors so often face when they are trying to correct something incredibly simple – in this case his basic employment status.

The doctor said he had been very stressed, as it would have been difficult for him financially to be in a training post without salary protection.

He added: ‘BMA membership is necessary, and I would recommend it for every practising doctor in the UK.’

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Your BMA In the first of a new series of columns, the BMA representative body chair and deputy pass on how they have been working for BMA members and how you can join the conversation and improve doctors’ working lives I believe the most important aspect of my role as representative body chair is to be the servant of the ordinary doctor – to be as accessible as possible to all members of the BMA, and all of the profession.

I want to understand the issues that matter to doctors from all backgrounds and all walks of life.

The experiences I’ve had in my personal life and career give me a platform to try to represent as many people as possible.

I am a vocational doctor and I love being a GP. But I’m also a mum and I think work/life balance is important.

I’ve been a campaigner and have driven change: from fighting against the introduction of student loans to working on the rollout of the New Deal, the shorter working week for doctors on the ground.

I’ve also campaigned around tax-deductible childcare for doctors, having myself struggled to make ends meet and to go out on call while juggling the care of twoand three-year-old children.

And one of the life experiences that really sticks with me is being a student from a comprehensive school when eight in 10 of my undergraduate peers were privately educated.

Widening participation will always be a crucial priority for me.

I am the first junior doctor and woman of colour to be elected in this role.

It’s taken 188 years for someone like me to be in this position. When you think about the diversity of the NHS and the membership we represent, this isn’t good enough – and there is no doubt it has taken a long time for people from minority and junior backgrounds to get elected into these positions.

There is often a misconception among members that the people in leadership roles in the BMA don’t work on the front line and therefore are not representative, but that’s not true. I am a full-time, clinical doctor, working as a paediatric respiratory registrar, on the front line alongside my role as your deputy chair of the representative body.

I’m here to tell you that times have changed. There is nothing stopping anyone from stepping up and taking these roles – nothing to stop you taking a leadership position in the BMA so you can use your experiences to represent your colleagues. And your BMA will support in this role.

Nothing would make me feel prouder than other people like me – people who haven’t felt represented before, or people who have felt their clinical roles or their backgrounds would hold them back.

I stood for this position on a manifesto of ‘challenge and change’ and I promise to represent you as best as I can so the BMA can live up to those words.

BMA representative body chair Helena McKeown

BMA representative body deputy chair Latifa Patel

In the coming months we will use this column to share our experiences, to discuss the work we are doing at the BMA on your behalf and, we hope, to encourage as much dialogue between ourselves and our members as is possible.

We want to know the issues that matter to you so we can represent you to the very best of our abilities.

This is not an empty pledge, this is a direct call for us all to come together because that is how the BMA can create better workplaces, improve your terms and conditions and improve patient safety and care.

There is, ultimately, only one way we can represent you properly, and that is if you tell us and your BMA what you need. We will be as accessible as possible – please contact us directly at rbchair@bma.org.uk We will listen to you and use your experiences to shape our work.

Helena and Latifa

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