The Doctor, issue 23, July, 2020

The magazine for BMA members

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Issue 23 | July 2020

Without a trace Why poor planning and budget cuts are putting the Government’s testing programme at risk

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

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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.

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 iStock

The Doctor is a supplement of BMJ vol: 370 no: 8253 ISSN 2631-6412

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In this issue 4-5 Briefing

Junior doctors freed up to pursue careers, returning doctors left in limbo, and calls to investigate China’s organ trade continue to grow

Welcome Chaand Nagpaul, BMA council chair As this magazine lands on doorsteps across the country the Government’s measures to ease lockdown are sending a message that the worst of this pandemic is over – that this crisis is behind us.

But the features in the July issue of The Doctor suggest that is far from the case: in intensive care departments across the country exhausted staff are readying themselves for further waves of infection, in our towns and cities public health experts are drawing up plans to deal with further outbreaks varying from the manageable to the catastrophic.

Also in this issue of the magazine we speak to doctors working in areas of natural beauty – with waves of tourists expected to arrive in the coming weeks and months. The concerns these doctors have should be held by us all. It is imperative there is absolute clarity on the public health measures that must be adhered to, to minimise spread of infection. The Government must ensure the public know what is safe and what is not safe to do.

The Government is understandably keen for the public to return to more normal lives and to get the economy moving but public health and the healthcare system must remain at the heart of every decision made – and the BMA will continue to make the voices of our members, healthcare workers and patients heard.

Raising concerns alone is not enough, however. We must have constructive solutions to many questions this pandemic asks of society and we will use the experience and expertise of doctors to influence better decisions from national policy makers.

In this issue of the magazine we discuss the need for greater capacity and flexibility in critical care, for transport services to move patients and staff between hospital sites and for vital consideration of the wellbeing of doctors who have done remarkable, and exhausting, work to protect the public during this pandemic. It is crucial doctors have the resources they need to respond to further outbreaks.

In an in-depth feature with input from doctors from Birmingham to Shetland we outline the failures of the Government’s test-andtrace strategy.

If society is to return to normality, a functioning, comprehensive test-and-trace strategy is key. Failure to deliver this could have a devastating effect on the NHS and our society.

6-11

Intensive cares

COVID-19 has placed a heavy burden on intensive care doctors and their specialty must emerge from the pandemic better resourced for the long term

12-13

Tourist trap

Floods of summer visitors, coupled with poor Government guidance, have left doctors in beauty spots fearing a second spike

14-17

COVID on our minds

The pandemic’s severe effect on mental health – in a country where services could barely cope before it

18-23

A hidden threat

Confidence in test and trace has been hit by cuts to budgets and a lack of transparency

24-25

Above and beyond

A GP sets up a number of life-saving initiatives

26-28

Lack of cover

Poor planning threatens the supply of face masks

29

On the ground

How local BMA reps won justice for junior doctors working long hours without proper reward

30-31

Baptism of fire

The BMA’s chief executive on how COVID-19 has transformed the association

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briefing Current issues facing doctors

CHISHOLM: ‘A veil of secrecy hangs over China’s transplant system’

Pressure builds to investigate organ trade Concerns about China’s illegal trade in prisoners’ organs for transplant surgery have been raised by doctors for years, most recently following our investigation, At What Price? in The Doctor this year.

BMA medical ethics committee chair John Chisholm called for an ‘open and independent’ investigation of allegations that such unethical practice continues at scale following our review of the evidence.

These concerns were brought to Parliament last month by Labour MP for St Helens South and Whiston Marie Rimmer at a meeting of the Medicines and Medical Devices Bill scrutiny committee.

‘The BMA calls on the Government to reconsider their position … and to use their influence with the international community to ensure that a full, proper investigation takes place,’ she said.

While Chinese doctors admit tens of thousands of organs were taken from prisoners before it was outlawed in 2015 – and a voluntary system set up – illegal ‘organ trade gangs’ still operate, they say. The Independent Tribunal into Forced Organ Harvesting from Prisoners of Conscience in China, however, concluded last year there was ‘no evidence’ that ‘organ harvesting’ at scale from prisoners had stopped.

Restrictions to liberty in a prison environment make it highly unlikely prisoners are truly free to make independent decisions about donating their organs.

Ms Rimmer called unsuccessfully for an amendment to the Medicines and Medical Devices Bill to ensure medicines supplied in the UK meet ‘basic human rights standards with regards to how organs have been obtained in their development and manufacture’.

‘I have tried every nook and cranny to do anything I can to stop this practice,’ she said. ‘I do not want to risk our health service or our country’s reputation.’

In response, health minister Jo Churchill pledged to ask the Foreign and Commonwealth Office to review its position on the ethics of China’s transplant system.

‘A veil of secrecy hangs over China’s transplant system,’ Dr Chisholm concluded following our review of the evidence. ‘In these circumstances, I believe it essential China agrees to a thorough, open and independent investigation of these allegations, commissioned by a reputable body, such as the World Health Organization.’

HELP AT HAND: Thousands of doctors offered to return to fight COVID-19

Called up but not needed It seemed like anything was possible.

At the end of March, the GMC granted temporary registration to almost 36,000 doctors who had given up their registration or licences to practise in the previous three years.

Thousands of doctors indicated a willingness to return, with health secretary Matt Hancock saying they had ‘risen to the call of the nation’s needs’.

It was a once-in-a-generation opportunity for the NHS. On a sea of goodwill, it could gain expert and experienced doctors, some of whom may wish to stay beyond the pandemic.

This, in a health service acknowledged to be chronically short of medical staff even during normal times.

It seems sad, therefore, that there are increasing numbers of stories of doctors whose talents were not used.

One of them was GP Sandra McIntosh who had retired from general practice in 2017, having been a partner in Scotland for 30 years. When her registration and licence to practise was restored, she was living in London.

She was keen to help.

So, all she had to do was join the England GP Performers List… There was a form. She filled it in and was told she would be contacted in two days.

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Juniors freed up to pursue careers

Two weeks later, the same form arrived again. She filled it in. Another six weeks passed before NHS England rang and – with precisely seven minutes’ notice – asked her to have all her documentation ready for viewing via an online link.

She managed this, and a few days later a GP from NHS England contacted her. She was asked how much learning she had done. Not much, given that she had fully retired three years previously.

Surely this would apply to the majority of those contacted. In any case, that was the last she heard from them.

She said: ‘I’m sorry and a bit disappointed about the process.

Why ask us to volunteer and then not offer us work?’

She was glad the NHS had not been overwhelmed, although, as many have pointed out, this was only because of the mass cancellation of elective work.

The other way the NHS survived – as doctors in their thousands have told successive BMA surveys – is that they are working unsustainable hours and putting their mental health at risk.

Each of them would have been grateful to have a former colleague offer a helping hand. It seems a huge missed opportunity.

Keep in touch with the BMA online at

Career paths do not always make for easy navigation. While some individuals are blessed with knowing from the outset of their professional lives which specialty they will pursue, others find that getting to where they want to be can take a little more time.

Changing from one specialty training route to another has historically disadvantaged those junior doctors who have elected to do it by requiring repetition of shared elements of curricula.

But following years of lobbying by the BMA junior doctors committee, a landmark decision means that trainees will no longer have to repeat training for competency sign-offs they have already gained, thereby avoiding unnecessary delays to their career progression.

BMA junior doctors committee chair Sarah Hallett said the agreed guidelines from the Academy of Medical Royal Colleges meant that junior doctors would be able to pursue their desired specialty, while reducing duplication and receiving recognition for all of the training they had undertaken.

She said: ‘Increased flexibility has benefits for both doctors and their patients. Many junior doctors change their minds about their specialty or develop different interests and priorities throughout their training which can often lead to a change in training programme.

‘The accreditation of previous training upon entering a specialty ensures that training is appropriately recognised, and these competencies don’t need to be repeated which not only respects the prior knowledge of the junior doctor but also personalises and streamlines their training experience. It also encourages retention of these doctors in the workforce, and ensures they are able

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HALLETT: ‘Increased flexibility has benefits for doctors and patients’

to progress through their training in a manner that recognises their experience.’

Increased flexibility in training has been a priority of the BMA during negotiations following the 2016 junior doctor contract dispute.

A greater emphasis on work/life balance and the need for increased flexibility in training among junior doctors has become increasingly evident in recent years.

The UK Foundation Programme 2019 F2 Career Destinations Survey found that 40 per cent of respondents said they had changed their minds about what specialty they would pursue following foundation training.

To read the full guidance, search for ‘Guidance for flexibility in postgraduate training and changing specialties’ at www.aomrc.org.uk

Read more online Call to maintain workplace improvements Call to extend overseas doctors’ visas Training accreditation boost for juniors Call for USA to reconsider leaving WHO Read all the latest stories at bma.org.uk/news

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NEIL HALL – POOL/GETTY IMAGES

Intensive cares Intensive care has coped magnificently, but at great personal cost to staff.

Peter Blackburn hears their experiences, and why there must be better resources for a specialty running constantly close to capacity even before the pandemic

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ED MOSS

‘I

put myself into that position and I just wonder how they coped.’ After months of seemingly endless working hours, exhausting night shifts, energy-sapping protective equipment and fundamental reorganisations in care and services, Jagtar Pooni is still thinking of others.

Asked to reflect on how he, colleagues and services coped with the first brutal wave of the COVID-19 pandemic, Dr Pooni, an intensive care consultant in the West Midlands, immediately thinks of the patients and their families.

Dr Pooni says: ‘It [working in this crisis] has heightened everything. Even as I speak to you now I can picture certain patients who have got better and other patients who have not and I am getting emotional and upset now reflecting on this time.

‘The most distressing thing is the relatives who were unable to visit – these poor people could not visit their loved ones in hospital, and many of them died in the following days and weeks without family present. I can’t imagine what they must have been going through in this situation.’

Stress and isolation For many of these patients these were not short periods of time alone, accompanied only by the doctors and nurses trying to stretch their care and compassion across as many people as possible in a profession used to giving much more one-to-one focus.

Many occupied intensive care beds, supported by mechanical ventilators, for 50 days or more.

Dr Pooni, who has isolated himself from family and feared for his, and their, safety every day, adds: ‘It was a personal inconvenience and difficulty for us, but in no magnitude does it compare to the families and relatives waiting at home. When I reflect on things, I push aside the challenges and the everyday stress and the final conclusion is this

is the most distressing thing I have witnessed.’

It says an awful lot for Dr Pooni and the profession that his thinking is so fundamentally selfless – but now the worst of the first surge of demand has passed it will also be important to focus on the profession.

The weeks and months since the pandemic arrived in the UK have been relentless and brutal for doctors working in intensive care.

For the future of the service, its workforce and patients – particularly in the uncertainty of this new disease and any potential further peaks – this remarkable time is a period from which lessons must be learned, and quickly.

The first issue at hand is that staff are not only exhausted but may be grieving and feel bereaved having withstood a wave of additional trauma during the crisis.

Dr Pooni says: ‘You could and can see the effect on staff, you could witness it.

The situation here was the staff were stressed and crying and upset because of the large workload and the processes that we had – although we were doing the best we could – that in the system we were not providing the best care for patients and patients’ relatives.’

It is an issue Julian Bion, professor of intensive care medicine at Birmingham University, is seeking to address.

Professor Bion explains: ‘Sitting down and talking to a family in person, being able to put your arm around somebody, feels better – less bad – than trying to communicate over the phone and saying we can’t get your father or son better and that they are going to die. Doing that over the phone is extremely hard. To do it on such scale here is a different matter entirely. You end up with bereavement on both sides. There may be – I think there will be – consequences from the pandemic in terms of anxiety, depression, burnout, and staff sickness.’

POONI: ‘The most distressing thing is the relatives who were unable to visit’

‘Staff were stressed and crying and upset because of the large workload’

‘When there is a death you want to be able to come out of that with a capacity to move forward’

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GLOVER: ‘There is an issue in terms of people not having taken the opportunity to recuperate’

BION: ‘There will be consequences from the pandemic’

Disrupted lives

Listen to staff

For Paul Glover, intensive care consultant in Northern Ireland, the toll has been obvious – with difficulties having pervaded every area of life for staff on the front line. ‘Our routines are different, the structures of our weeks have been changed, there has been disruption to work lives and home lives with children not at school, partners having to work from home and all sorts of other issues. It is all contributing to the pressures people are feeling. I think there is an issue in terms of people not having had or having taken the opportunity to recuperate following the first phase.’

Professor Bion is keen to use reflective learning to help staff cope with what they have been through. For the last three years he has been developing a reflectivelearning programme and toolkit and he has applied for National Institute for Health Research funding to test whether this can improve resilience and recovery for staff, and care for patients across the health service.

The toolkit provides staff with multiple methods for learning from their experiences – and focuses on learning when things go wrong as well as when they go right, a ‘key part of learning’.

Professor Bion says: ‘When there is a death or something goes wrong you want to be able to come out of that with a capacity to move forward, to create a better future.

That is what reflective learning does when done well and that is a key part of mitigation.’

The exhaustion of doctors after this relentless period on the front line is a significant problem, too, though – particularly with potential future waves of COVID-19 looming and the spectre of a possible rise in demand related to patients staying away from healthcare, or being unable to access it, during the pandemic.

BMA consultants committee deputy chair Simon Walsh says: ‘What I’ve been seeing and hearing from my colleagues around the country and where I work in London is just all about exhaustion.

‘When the pandemic first hit the UK doctors and all other healthcare workers did their absolute utmost to keep services going while dealing with lots of critically ill patients with COVID-19 and have been exposed to quite an unknown level of risk as well, particularly in the early weeks with all the questions around PPE – that combination of massive workload and very large numbers of very unwell patients but also that sort of stress of the unknown risk to your colleagues, yourself and your families at the end of the day.

‘The most important thing that trusts can and must do is listen to their staff and the groups that represent them because there are lots of things that will be different locally that are concerning doctors and other healthcare workers. One of the things that will be a common theme will be having flexibility in carrying over annual leave and having a reasonable discussion about how doctors who have done excessive amounts of shop-floor, hands-on, clinical work are given time to do their SPA work for reappraisal and revalidation.

‘We also need to be mindful doctors have given their utmost to the point of harming their own health – physically and mentally.

They need to be given flexibility in terms of leave and to have flexible working patterns going forward.’

Dr Glover adds: ‘Sustainability is a massive issue. What is quite clear is that the effort that was put in is not sustainable and it can only be delivered for short periods of time and to do that it is imperative that processes are put in place to allow staff to recover.’

There may be few genuine positives to take from the pandemic but if little else the

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BANERJEE: ‘To focus solely on increasing ventilator capacity has been wrong’

WALSH: ‘Staffing needs to be at the centre of everything’

importance of intensive care – well resourced, properly staffed and genuinely valued – must surely be the defining conclusion.

Second wave Intensive care doctors told The Doctor they believe the Government has made funding available for expansion of departments potentially equating to 150 per cent of current capacity in certain areas – but the Department of Health ignored several requests for clarification on this – and there are reports that capacity in London is to be increased more permanently, in case of future waves of illness.

But what is the importance of increased capacity?

Professor Bion says the NHS is usually running too close to, or rather above, capacity – while recognising that intensive care capacity in this country has increased in recent years.

‘It’s true the UK has always had fewer resources for intensive care specifically than comparable developed affluent countries such as the USA, Switzerland, Germany and France.

But there has been a major increase in intensive care resources during the last 10 years; they have tended to be concentrated in the larger centres which probably makes sense.

‘It copes reasonably well – but it’s tight as the whole of the health service is. The health service tends to run at 90 per cent occupancy most of the time but that is measured at midnight and doesn’t reflect what it feels like during the day – it is usually more like 120 per cent. There is always pressure on scarce resource.’

Many doctors believe more capacity is needed to allow flexibility and respite from demand.

Dr Glover says: ‘The pandemic has highlighted the importance of critical care in a functioning healthcare system and it

is a service that frequently runs at 90 per cent capacity. When you run at that level of capacity it’s insufficient to sometimes meet demands in normal times let alone when a pandemic takes things into a different area altogether.

‘A fire extinguisher is still very useful when you don’t have to use it – that’s the comparison. We need to accept we need to have spare capacity in critical care to meet peak demands.’

However, the argument isn’t just about beds and ventilators. Staffing is crucial.

Dr Walsh says: ‘It is a really complex area – there has been a lot of redeployment of staff to help us get through the first peak of it but going forward trusts are trying to re-establish elective work and normal business because we need to find a way to continue that important work. It means rapid reconfiguration plans are being made and instigated in trusts. My worry is that in a lot of these discussions staffing is the appendix at the end, but really that needs to be at the centre of everything. Trusts may need staff to move site, move area, take on new ways of working and coming out of this excessively stressful time staff need to be at the centre of this conversation.’

‘The UK has always had fewer resources for intensive care than comparable countries’

Preventive measures Some doctors would argue that the best way to respect and value the sacrifices made by intensive care doctors and to protect their future is to focus not purely on ventilators and bed numbers but to have a properly coordinated effort to stop the spread of the disease before people end up in intensive care with, ultimately, quite high fatality rates.

Ami Banerjee, associate professor in clinical data science at University College London and academic cardiologist, says: ‘I think the whole debate has been framed wrongly. We’ve been from the beginning talking about ITU or ventilator capacity only. My own research has

‘We need to be mindful doctors have given their utmost to the point of harming their own health’

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shown that we could have and should have focused our efforts on early suppression and early lockdown. To focus solely on increasing ventilator capacity when not focusing on the upstream bit has been totally wrong in my view. We were forced to scramble to find extra capacity when we had actually seen in other countries in Europe what happens if you don’t manage the infection rate.’

Dr Banerjee – who urged the Government and national health leaders to place clinical academics at the heart of its future planning in continuing to tackle this pandemic – adds: ‘We’ve proven that with a lot of strain we coped – every facility around the country has been coping but it came at a cost and it was an unnecessary strain created by lack of forward planning. Evidence based policy is a word thrown around with reckless abandon but there was a massive lack of that here.’

It’s certainly not all about capacity. And there may be some much bigger questions to answer: Can hospitals continue to be structured as they are in the COVID-19 world with facilities stretched trying to provide safe spaces for people with and without the virus? Should the whole hospital estate be reconfigured?

As Dr Pooni says: ‘Imagine a situation on a critical care unit where you have COVID patients but you now have patients who don’t have COVID but have other critical illnesses and are at risk of developing COVID. We try to cohort patients, isolate patients, put them inside rooms and section off critical care units physically, but it is difficult and ultimately decreases our capacity as there are beds and spaces we can’t use. There are great challenges as to how we do this and where we look after these patients.’

Sharing resources These are huge questions which will need serious care and attention. In the meantime, what can be done?

The Doctor understands a group of leading intensive care professionals are in negotiations to extend specialist intensive care transfer systems, operated in some patches of the country which see patients or specialists moved between hospital sites, extended across the country.

This could be crucial. Professor Bion says: ‘We haven’t had satisfactory transport

systems to share resources between centres and the coronavirus has further highlighted the need for a transport system which we have been saying since I was a junior doctor.’

Ultimately, giving this remarkable group of doctors the working environment they need, and the time away from it that they need, will require serious discussions, investment and change.

But while those discussions will be required, for intensive care specialists such as Dr Pooni the focus will always be on care – and he, and colleagues, will do their best to be ready for whatever comes next.

‘We have learned from everything that has happened. We have learned and processed, we have the care pathways, the new staffing structures, the hospital organisation and the non-ITU staff trained and people aware of the risks. We have so much in place that if a surge comes tomorrow, we could cope with it.

‘But that’s the non-emotional side. Staff on the critical care unit are exhausted. Having learned from all those experiences they would be able to deal with the situation, but they are exhausted and they need to rest.’

‘Staff are exhausted and they need to rest’

Wellbeing resources during COVID-19 Some of the external sources of support the BMA suggests for doctors include: HealthSHIP – Medical student volunteers offer to help NHS key workers with non-clinical services such as childcare and groceries NHS Staff support line – Confidential staff support line, operated by the Samaritans, for when you’ve had a tough day, are feeling worried or overwhelmed, or maybe you have a lot on your mind and need to talk it through Frontline 19: free online wellbeing support – Mental health and emotional wellbeing support service set up by therapists to support frontline staff

For a full list, visit bma.org.uk/covidwellbeing

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Tourist trap Floods of summer visitors have led doctors in beauty spots to warn of a second spike in COVID-19 infections. A lack of clarity in Government guidance only makes it harder for those trying to prevent infection. Seren Boyd reports

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itting on a beach or heading for the hills is blissful escapism from the monotony of lockdown – and day trippers in their thousands are descending on beauty spots and rural idylls.

These seasonal visitors are the lifeblood of rural economies but, this year, locals have mixed feelings about their return. At worst, they fear tourists could bring COVID-19 along with their paddleboards and bicycles and turn host communities into incubation areas for a second spike.

Lucy-Jane Davis, a GP registrar who chairs the BMA South West regional council, says communities are braced for an onslaught of visitors – and a potential health crisis.

She likens the situation to waters receding from the coast before a tsunami.

‘In the south-west, there’s a feeling that the water is still sitting out there somewhere and we’re wondering when it’s going to hit. It may well be the real impact of COVID locally comes in the next few months.’

In her corner of Devon, local peculiarities make a mockery of social distancing.

There are sheltered coves 12

reached by narrow paths creating ‘pinch points’, narrow streets in quaint villages, the ever-present threat of showers sending people diving for cover in the same olde tea shoppe.

Cornwall has a resident population of about half a million – and five million tourists in a normal year.

As with other areas of outstanding natural beauty, the south-west has an older demographic, weaker transport links and more limited NHS infrastructure.

Cornwall has one major acute hospital, with a limited number of ventilated beds.

As the background infection rate is still high, and robust test and trace processes remain elusive, Dr Davis worries a second peak would overwhelm local health services.

‘We only need a tiny outbreak relative to the number of people who might come to visit to put the entire system under huge strain,’ she says.

Lack of guidance Day trippers have returned to these tourism ‘honey pots’ before local amenities have reopened. The

continued closure of public toilets has meant nasty surprises for litter-pickers, and the combination of carefree visitors and a lack of lifeguards has proven dangerous. When two coastguard helicopters scrambled to the aid of three ‘tombstoners’ seriously injured after diving off Durdle Door in Dorset, thousands of people had to be corralled on the beach to clear landing spaces.

Dr Davis has been busy convening discussions between regional clinical commissioning groups and other stakeholders such as chambers of commerce, who all share one concern: the lack of Government guidance on how to manage the anticipated crowds.

What they do know is that Exeter’s Nightingale Hospital is scheduled to open in the first week of July. Health secretary Matt Hancock told Parliament on 23 June that Exeter’s Nightingale had ‘more flexible uses than the previous Nightingales’, which could include tackling winter pressures. But the south-west has had winter pressures for many years, and while the Nightingale may well be able

DAVIS: The real impact of COVID locally may come in the next few months

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to deliver extra capacity, it was not conceived for that reason. It was conceived for COVID patients, and the fact the Government is continuing with its construction when the Nightingale in London, for example, has been mothballed, leads doctors to question whether there are serious concerns for a growth in infections.

‘Clearly somebody is thinking that there might be a need for it,’ says Dr Davis.

These concerns are not confined to the south-west.

The Lake District tourist board has tempered its usual enthusiastic welcome for adventure-seekers, with alerts about car-park restrictions and guarded messaging about receiving visitors ‘when the time is right’.

Matlock in the Peak District, where Peter Holden is a GP, is a magnet for the motorcycling fraternity and recent weekends have seen large gatherings with ‘not a lot of social distancing going on’. He’s also concerned about ‘some quite atrocious’ driving he attributes to ‘atrophied driving skills’, and cyclists’ reluctance to recognise that cars are reclaiming the road again.

This national park receives more than 13 million day visitors a year.

Sense of exhaustion Dr Holden shares locals’ concerns about the risk to care homes and about the lack of personal protective equipment in the event of a major outbreak.

Yet he has fewer concerns about the robust local health system being able to cope than about health professionals’ ability to sustain punishing schedules amid mounting backlogs.

‘We’re all utterly exhausted and even if we knew that COVID-19 was dead today and never coming back, we could not deliver “normal” again for many months,’ says Dr Holden, a member of BMA council. ‘We need time to regroup, we need a break.’

But, for Dr Holden, transmission risks have to be set against concerns over the lockdown’s effect on health, wellbeing and the economy, especially for seasonal workers not covered by the furlough scheme – a balance Dr Davis also recognises.

Dr Holden’s call is rather for openness and transparency from the Government.

‘Locals are worried about importation but they also want sound information and honesty so they can make up their own mind about risk,’ he says. ‘There’s a feeling the Government is not levelling with people.’

With the easing of lockdown to allow holiday accommodation, hotels and restaurants to reopen, due in England on 4 July, tourism hotspots are likely to draw ever-larger crowds.

The BMA is launching a public campaign including an infographic offering tourists practical advice such as packing a first aid kit and remembering to bring prescription medicines. It has also produced a document outlining basic principles for tourists, accommodation and service providers and local authorities to consider, including having plans in place should holidaymakers or staff develop COVID-19 symptoms.

‘I’ve lived in a city-centre, one-bedroom flat and I know how much people must crave having a break,’ says Dr Davis. ‘But we need to be sensible about how to make that safe. The best public health crisis is the one that doesn’t happen.’

SUN SEEKERS: Crowds gather on Bournemouth Beach, Dorset

‘We only need a tiny outbreak relative to the number of people who might come to visit to put the entire system under huge strain’

‘There’s a feeling the Government is not levelling with people’

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COVID on our minds The pandemic is likely to have a severe impact on mental health, in a country where services could barely cope before it.

Jennifer Trueland reports

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s much of the world moves slowly out of lockdown and health services begin to reshape into what will pass for a kind of normality, one thing is clear – the mental health consequences of the pandemic are immense and will be long-lasting.

In the UK, specialist services and primary care alike are dreading what some are calling a ‘tsunami’ of mental illness caused directly or indirectly by COVID-19.

What makes matters worse is that it comes at a time when mental health services, pre-pandemic, were already buckling under the levels of demand, coping with the effects of recession, and desperately needing additional resources and, of course, enough staff to run them.

So how will services cope with the current and upcoming crises – and will there be any positives, or learning to be taken from the pandemic?

‘The first lesson is that it’s best not to be in this position in the first place,’ says Adrian James, who has just taken up post as president of the Royal College of Psychiatrists. ‘If you’re already playing catch-up, when a crisis hits then you’re in a much less good position to deal with it.’

He is anticipating a huge increase in demand: this includes from people who have experienced a degree of trauma as a result of having COVID-19, people who have been bereaved owing to the pandemic, and those with pre-existing mental illness who haven’t been able to access treatment in a timely way.

‘There’ll be people with depression and anxiety who won’t have been coming forward to see their GPs, so there will be untreated mental illness which we also know tends to get worse and worse and then present much later with a greater need for input,’ he warns.

support | protect | represent

Widening inequalities

The BMA is calling for action to ensure that mental health services are properly funded and equipped to meet the anticipated increase in demand and to make access easier for everyone who needs it.

The association’s paper, Beyond Parity of Esteem: COVID-19 and mental health in England, warns that the pandemic is likely to have a negative psychological impact on the population, with some people developing a mental illness for the first time, while others with existing problems could find their symptoms worsening.

The BMA warns that prior to COVID-19, services were often unable to provide all patients with the services they needed because of a lack of resources – and is concerned that the likely increase in demand will make that position worse.

It also says the pandemic’s effect on population mental health could widen existing inequalities in society if attention is not paid to the specific vulnerabilities of certain groups and demographics.

The BMA also wants better preventive measures to look after the mental health of the population and the workforce.

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‘If you’re already playing catch-up, when a crisis hits then you’re in a much less good position to deal with it’

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JAMES: ‘We need at the very least the extra funding that’s been promised’

Declining access to care

health services is set to increase, and our research Andrew Molodynski, national mental health lead for shows people with mental health problems already the BMA consultants committee, and a consultant have been struggling to access the support they need psychiatrist in Oxford, says that while demand is in primary and crisis care. Many services turned to already beginning to pick up, he worries about the digital support, but 1.9 million people do not have effect in the medium and long term. This includes digital access, which serves to deepen existing health ensuring that people can access care. inequalities. Mental health services ‘I still believe that the majority need to be equipped to support those of people who get as far as mental who have fallen through the net ‘We cannot health services get safely looked during the pandemic.’ underestimate the after – yes, things are sadly more long-term effect this Overcrowded and deprived stretched and less humane than will have on people’s Primary care is also bracing itself to they used to be, particularly in the cope with an upsurge in demand from crisis care sector, but the system mental health’ patients with mental health needs – is going to come under even more indeed, according to Southampton GP strain and there will be even more of a and BMA council member Alex Freeman, it’s already problem in terms of human rights and access. Getting proving a challenge. to services is going to get more and more difficult, ‘It’s tough, it’s really tough. [Specialist] mental unfortunately.’

On a positive note, specialist services have been health services are running, but a lot of the mental innovating – not just by using video consultations, but health issues that we’re seeing in general practice also in having ‘walking’ appointments in the open air, are what you might call the lower level issues which which is safer and requires less or no PPE (personal normally wouldn’t access specialist mental health services,’ she says. protective equipment). Services are linking in better ‘We’re seeing people presenting with a lot of with voluntary groups and stronger relationships have anxiety, sometimes with depression. been building between different parts We’re seeing a lot of people who have of the local health and care economy.

‘We’re seeing people been doing their best to survive in Vicki Nash, head of policy and often very difficult circumstances – campaigns at the mental health presenting with a lot have quite a deprived population charity Mind, wants action. ‘This of anxiety, sometimes we that we cover. We’ve got families pandemic has been as much a mental with depression’ that have been stuck indoors in health emergency as a physical health overcrowded situations where emergency,’ she says. ‘As we look children haven’t been able to go out forward, we cannot underestimate to play because they’ve got no access to the outside, the long-term effect this will have on people’s so they’re finding life pretty tough at the moment. mental health.’

We’re also having a lot of presentations of people who It is positive, she says, that mental health has been feel that they are at risk from COVID-19 even though part of the national conversation around COVID-19, they’re not deemed to be at high risk, according to the but she adds: ‘We know existing demand for mental 16 thedoctor | July 2020

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FREEMAN: ‘We’ve got families that have been stuck indoors in overcrowded situations’

MOLODYNSKI: ‘Things are more stretched and less humane than they used to be’

definitions, but who are being pressurised to go back to work and are contacting us because they don’t feel they’ll be safe there, and that’s causing them a lot of anxiety as well.’

Patients who are frontline workers, including in the health and care sector, are feeling the pressure – many of them are exhausted as well as worried and anxious, she adds. Bereavement and grief are also issues.

‘We’re going to be dealing with the fallout from this for years,’ says Dr Freeman. ‘In my area we weren’t hit as hard as for example parts of London, but we’ve had some patients die from COVID and their relatives find it quite difficult to cope because they don’t want their loved one to be a statistic. It’s tough doing bereavement calls at the moment mainly because people are saying, “well we can’t have a proper funeral” and they’re finding those initial stages very difficult – and what happens immediately postbereavement is actually quite important for people and they’re being prevented from doing what they feel they would be doing under normal circumstances.’

Practices are already taking steps to help manage the anticipated rise in needs, including directing patients where appropriate to resources such as online CBT (cognitive behavioural therapy), she says.

But she adds that more resources will have to be put into mental health services to help cope with demand in primary and secondary care.

Dr James also says more resources are needed, and is calling for money already promised in England’s Long Term Plan to be delivered and front-loaded.

‘We want to make sure the Government hears a clear message that we need at the very least the extra funding that’s been promised, but we need more down the line, and we need to empower clinicians and patients to work in innovative ways. There have to be some positives from COVID-19 and we do need to bring them out, but there will be negatives we have to look at as well.’

support | protect | represent

Doctors under stress

Doctors are reporting increased levels of work-related mental health conditions as a result of the COVID-19 pandemic, a BMA survey has found.

Nearly half said they were suffering from depression, anxiety, stress, burnout, emotional distress or another mental health condition relating to or made worse by their work; this was made up of 31 per cent who said it was worse during the pandemic, and 13 per cent who said they were suffering but it was no worse than before.

More than four in 10 of those who responded (42 per cent) said they had had to access NHS wellbeing support services provided either by their employer or a third party.

Many of those taking part in the tracker survey also expressed a lack of confidence in their ability to manage patient demand as normal NHS services were resumed. Just over half (53 per cent) said they were ‘not at all confident’ or ‘not very confident’ about managing demand in their own department or practice, while 61 per cent were not at all or not very confident in the ability of their local health economy to do the same. There was even less confidence in their ability to manage demand in community settings such as care homes – with 23 per cent saying they were not at all confident and 44 per cent saying they were not very confident.

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SIMON GRANT

Failings in Government planning, cuts to budgets, a lack of transparency, and, in England, a reliance on the private sector has battered doctors’ confidence in the test and trace system. Peter Blackburn reports

‘T

his disease is still killing people – we are now around where we were just before lockdown and we are seeing significant outbreaks in countries such as Germany where lockdown has been released.’

Ask Justin Varney, director of public health for Birmingham, why an adequate test-and-trace system is important, particularly with no vaccine available, and the answers are as clear as politicians often wish theirs are; this virus has not gone away, another wave of infection varying from manageable to catastrophic is likely and with another wave could come a further entrenchment of inequalities in society.

Until early June there was no comprehensive, functioning test-and-trace system running across the UK. In the early days of the pandemic, local public health teams – decimated by austerity – had attempted to keep pace with numbers but soon ran out of capacity.

And even in those areas of the country where local relationships and access to university facilities meant continuation was possible, a lack of lab capacity, far more available in Germany for example, hindered progress and national strategy was lacking.

Perhaps most damningly of all, successive Governments have been accused of having made a choice not to have the capacity to deal with this sort of pandemic.

Speaking to The Doctor, the former health secretary and now chair of the Commons health and social care select committee Jeremy Hunt says: ‘The main mistake was that we focused our preparation on pandemic flu rather than a SARS-like virus, all our

thinking was geared to the way flu-type viruses behave – that there was no need to increase PPE [personal protective equipment] stocks or testing capacity.

‘I think that was where the mistake was during the period I was health secretary. I think in terms of test and trace the evidence from all over the world shows the more localised the approach, the more successful – in Germany the corona detectives and the role of local government in Korea, it’s highly localised.

‘We chose not to have that capacity because our mindset was a flu pandemic where the virus spreads so quickly that after a certain level of transmission you don’t try to isolate people any more and you accept that. It was contain, delay and mitigate and that is not the approach Korea, Singapore or Germany took.’

But these decisions were not the only problems contributing to a failure to test and trace to suppress infection and manage this pandemic. The 2012 Health and Social Care Act split public health from the NHS and left it in local authorities vulnerable to massive spending cuts and decimating capacity and expertise for exactly this sort of situation.

Soon overwhelmed Public health medicine consultant and BMA public health committee member Penelope Toff says: ‘Over several years there has been decreased local and public health laboratory capacity and increased fragmentation in the public health system, so that although at the beginning of this pandemic there was contact tracing going on, by the middle of March the numbers of cases were just too high for that to be a feasible approach at the scale required. thedoctor | July 2020 19

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Birmingham Mail

VARNEY: ‘We need a very honest discussion about the inequalities within society’

TOFF: ‘We don’t need to use the private sector for public health capacity’

‘What we heard from the Government was, “that’s Expertise ignored the phase we were in and now we’ve moved on to the Yet even now with test and trace at the top of the next one” but the reality is that most of the countries Government’s strategy – easing lockdown and paying which have dealt very much better with COVID-19, for adverts on people’s television sets about the continued to do contact tracing at the necessary scale importance of the project – this is a process beset to make it successful, along with other measures like with problems. The first two weeks of statistics made self-isolation and social distancing.’ available suggest at least a third of people are not In a turn of events that would be welcome if the providing their contacts to contact tracers and the circumstances were not so tragic, the Government has ‘NHS’ test-and-trace system in England only reached pumped around £300m into local public health teams around 10 per cent of the people the Office for National to do their part in test and trace and crisis planning.

Statistics calculated were infected.

In Birmingham that equates to around £8m – which Not only that but much of the process has been comes after several years of cuts totalling £5m in contracted out to private firm Serco in a multimillionDr Varney’s team. pound deal – and professionals on the ground are But money alone isn’t enough. As Professor Jim reporting a lack of transparency and delays in receiving McManus, vice president of the test results.

Association of Directors of Public BMA deputy council chair David ‘Most of the countries Health, wrote recently: ‘While the Wrigley says: ‘It just makes doctors sigh which have dealt additional funding of £300m for with disbelief that you can struggle better with COVID-19, local councils is welcome, delivering to deliver successfully on previous these plans will require much more contracts but then be handed further continued to do than money – a fully operational NHS deals at such an important time. It contact tracing’ test-and-trace service, high-quality beggars belief that this is continuing and timely data flows, the right levels when you could utilise NHS staff, NHS of capacity in all parts of local government and the services and NHS laboratories to do this work.’ health and care system, and strong national impetus to Dr Toff adds: ‘We don’t need to reinvent the wheel – promote the public health messages that we all know we don’t need to use the private sector for public health save lives.’ capacity simply because there hasn’t been sufficient The Government has publicly made test and trace a investment in what we have in the public sector. The priority – as Professor McManus has stated it should be. expertise and knowledge of how to control outbreaks In England the idea is that if you develop coronavirus and stop them spreading and becoming epidemics symptoms and test positive for the disease you will is there in local authority public health with support from PHE health protection units but it has not been be contacted and asked to log on to a website where personal details, places you have visited and names adequately used and resourced. Furthermore, the of those you have been in contact with should be expertise of those on the ground with this experience submitted. Close contacts will then be contacted and was not input into government plans from the told to stay at home for 14 days, even if they don’t beginning.’

Rupert Soames, chief executive of Serco, told the have symptoms. The Government has suggested the scheme will be ‘world beating’. press his firm’s work in setting up the test-and-trace 20 thedoctor | July 2020

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HUNT: ‘It was contain, delay and mitigate and that is not the approach Korea, Singapore or Germany took’ WRIGLEY: ‘Private contractors struggled to deliver successfully on previous contracts but were then handed further deals’

as the Francis Crick Institute and Oxford University offered their expertise and resources (such as PCR machines and trained personnel) to help increase Private sector reliance testing capacity, but these offers were ignored.

The Government in England’s approach to dealing with Mr Hunt told The Doctor he had no problem with the pandemic has relied on the private sector in many the ‘ideology’ of contracting private firms but felt areas – a contract of undisclosed value was secured by a more localised approach and utilising available Deloitte, one of the ‘big four’ consultancy firms, to set expertise might have been more helpful. He says: up and manage a network of 50 off-site testing centres. ‘I think you would have some of these coordination The firm is responsible for managing logistics across issues regardless, but local authorities know their these sites as well as booking tests, sending samples to areas extremely well and can coordinate the testing laboratories and communicating test results. Deloitte and the tracing part of the programme much more nominated companies such as Serco, Sodexo, Mitie, easily if things are more highly localised. I have always G4S and Boots to staff and manage the day-to-day wondered whether we should have involved local running of the testing sites and those unable to access authorities earlier, with a more strategic process.’ the testing sites are advised to request And doctors and public health home-testing kits that are produced leaders have told The Doctor they ‘There has been and processed by diagnostics face difficulties in delays of test results, decreased capacity company Randox and dispatched by a significant lack of data availability and increased Amazon. A network of ‘lighthouse’ and regular communication failures laboratories was established by the between Serco, Public Health England fragmentation in the Government to process the test nationally and local teams. public health system’ samples. And Deloitte was handed There are concerns about a lack of further responsibility for coordinating transparency, too. At a hearing of the these labs, located in Milton Keynes, Glasgow, Belfast health and social care committee in June Baroness Dido and Cheshire. A fifth lab is managed by Cambridge Harding, chair of NHS Improvement and NHS England University and the pharmaceutical companies and the Government’s test and trace tsar – smiling GlaxoSmithKline and AstraZeneca. These labs were – repeatedly told the committee figures for how the designed to cope with testing on a mass scale, process was going were not yet available or validated. processing 75,000 tests of the Government’s The Doctor asked Mr Hunt what Baroness Harding’s 100,000 target. approach said of the Government’s in general.

Meanwhile, 44 NHS labs were, according to a former Mr Hunt says: ‘I do think if there was more senior figure at the World Health Organisation, Anthony transparency from the outset we would have had a Costello, left ‘underused’, clinical staff in the NHS were more effective national response. The best example of concerned that the development of a parallel system that is the secrecy around SAGE – we didn’t know who encouraged competition in supplies and reagents the members of SAGE were or what advice was being required – effectively reducing the capacity of existing given at the start of the crisis. And it is clear some of NHS labs – and it was also reported that in the early the advice was wrong. stages of the pandemic, leading scientific centres such ‘In January SAGE was giving two options of either system was ‘extraordinary’ amid suggestions the contract should be cancelled.

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iStock

MURPHY: ‘We rapidly set up teams to respond’

Scottish mainland were one of the worst hit areas in the early days of the pandemic – and quick-thinking local experts acted swiftly to enforce a local lockdown and introduce a speedy test-and-trace system, with people drafted in from various NHS departments to phone around and tell people to self-isolate if required. Cases dropped very quickly and the virus has been quiet since.

Dylan Murphy is lead GP at the Lerwick Health Centre in Shetland. He says: ‘We had an early cluster of cases before social distancing was a thing – and before there was any testing. There was quite a lot of work at that point and we rapidly Flawed app ‘The expertise and set up teams to respond.

The problems run even deeper. The knowledge of how to ‘We were quite reactive – Government has planned for a contactcontrol outbreaks and I remember the schools up here, for tracing app that can enable digital instance, shut a week before they did contact tracing on a much larger scale stop them becoming anywhere else and similarly in primary to be the centrepiece of its project. epidemics is there’ care we were having discussions It was first announced on 5 May but saying we’ve looked ahead of the has since been deemed flawed, and a curve and need to make decisions. We would be more new version does not appear likely to arrive for some proactive saying you shouldn’t be going out in public months. with these symptoms.’

This is concerning for two reasons. In addition to reducing burden on those individuals employed to carry out ‘face-to-face’ contact tracing, digital contact Nipped in the bud tracing is a crucial tool for stemming any potential A rural part of Wales, Ceredigion, also had success with spread though interactions in pubs, restaurants, shops its own reactive measures. An initial flurry of cases in and on public transport where contact details are not this coastal county led to the local authority taking readily available. Moreover, digital contact tracing action – setting up a ‘homemade’ and in-house test, is better able to distinguish the type of interaction track and trace system. that takes place between two individuals, measuring Speaking to Wales Online, the man responsible for proximity and length of interaction, thereby reducing the system, the local authority’s corporate director Barry the margin of error inherent in asking somebody to Rees, feared slow reactions and slow test results would remember who they have seen and the nature of each mean an increase in the spreading of the virus. He said: interaction.

‘We short-circuited that loop and didn’t wait for their Some small pockets around the country have had test results to come back before taking action. We were success though – largely by acting quickly and with able to send a note down to our contact-tracing team to relative independence from national policy makers and gather more information. If they’re showing symptoms their central command and control strategy. then there’s almost the presumption of a positive test The Shetland Isles to the far north-east of the and that guides the advice we give to them.’ extreme lockdown or herd immunity with shielding for the vulnerable – they didn’t model track and trace and I think we may see that as a major oversight. But none of us knew it wasn’t being modelled because it was all kept secret. This should have been run in public like the way the Bank of England is and how the monetary committee vote, for example. If we had that transparency around SAGE, scientists up and down the country would have been able to scrutinise what they were saying.’

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iStock

‘Local authorities know their areas extremely well and can coordinate the testing and tracing’

prioritising a centralised approach was thought to be More recently, in Scotland, a system called NHS test a sensible idea. and Protect is now in place. Between 28 May and For Dr Varney there are a number of other crucial 7 June 2020, 741 contacts were traced from 681 areas, too. COVID ‘pre-hab’, or the education of people positive tests for the virus – an average of 1.5 contacts who could be susceptible to the virus and helping them per case. Northern Ireland was the first part of the UK to make the best decisions to keep themselves safe is to bring in contact tracing. Contact tracing started in crucial. And, perhaps most of all, public health teams Wales on 1 June and is called ‘test, trace, protect’. now in local governments need the support, backing It seems that with the will and the local expertise, and confidence to do their jobs. test and trace can be achieved in small pockets where He says: ‘The public health grant local efforts are led by local experts that funds me and my team is due to – and there may be lessons from the run out at the end of March 2021 so Government to learn from this. Frankly, ‘If there was more there is no certainty to our future at the lessons for the Government look transparency from the all – the Government needs to make likely to be forming quite a long list: outset we would have a clear statement that the money we a lack of preparation for this sort have been given for this process is part of pandemic; an unwillingness to had a more effective of the baseline of the grant for the next quickly strengthen public health national response’ three years so we have security for the teams decimated by cuts; a continued future in this COVID world.’ reliance on private companies; and And – as crucially as anything – urgent action on the little action on the fragmentation of services are all inequalities this disease highlights is needed, with test issues which are slowing progress. Add on top of that and trace in place to protect as much as possible. poor messaging and communication and it is little He says: ‘We need a very honest discussion about wonder the UK’s statistics around this pandemic look the inequalities within society and substantial efforts on among the world’s worst. the living wage and tackling racism and discrimination.

It can be done – but we have to stop talking about Empower local areas Regardless of the failures, test and trace continues to be inequalities like they are an interesting topic and consider them to be a crisis such as climate change of vital importance – for public health and in returning that we have to turn around.’ to a more normal society. So what should be done?

At the time of The Doctor going to press local For Dr Toff the issues are clear: data and resources outbreak plans were being finalised across the country must be made freely available to those working on with directors of public health drawing up their the ground, the turnaround of test results needs to be responses to further waves of infection. In Birmingham, quicker and public messaging about the continuing risks Dr Varney’s team is ready to surge from 22 to 70 people made much more prominent in government messaging. and a massive project of community engagement And for Dr Toff and public health professionals is already unfolding. Doctors and experts across the around the country, the empowering of local areas country will be hoping their efforts mean any further is key too. Few know their local populations as well wave comes under the manageable category, rather as public health specialists embedded in those than the catastrophic. communities – it’s challenging to understand why thedoctor | July 2020 23

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EMMA BROWN

RAYMOND: ‘I had visions of things that I wanted to achieve’

Above and beyond GP Sharon Raymond has served not only her own patients during the pandemic, but has set up a number of potentially life-saving initiatives. Tim Tonkin reports dio interview Listen to an au d online by with Dr Raymon bove and searching for ‘A a.org.uk beyond’ at bm

C

OVID-19 has challenged the NHS like no other public health emergency in living memory.

Faced not only with overwhelming levels of patient demand from those struck down by the virus, doctors have also had to contend with scandalous shortages in protective equipment, shortfalls in staffing and drastic changes to their day-to-day operations.

Time and again doctors and other healthcare professionals have not only risen to these challenges in the battle against the pandemic but demonstrated levels of ingenuity and determination in responding to the unfolding crisis.

London out-of-hours GP Sharon Raymond is one such doctor.

Dr Raymond, who is also a lead in London for integrated urgent care, devised and co-founded CCR (Covid Crisis Rescue), a voluntary initiative which since March has spearheaded a number of programmes in the capital designed to support doctors and patients during the pandemic.

‘I had a couple of visions of things that I wanted to achieve in terms of services,’ she says.

‘It wasn’t happening via the powers that be like

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EMMA BROWN

to probes because there is a risk with COVID of silent hypoxia … so it’s really important to have these probes to see objectively what is happening to oxygen levels.’

To combat this risk while minimising the need Taxi scheme CCR was formed on 21 March by Dr Raymond and trained for patients to unnecessarily journey to and from hospitals and other healthcare settings, Dr Raymond lawyer Alex Adams in response to the difficulties GPs hit upon the idea of a loaning service incorporating were facing in getting hold of adequate supplies of PPE (personal protective equipment). the assistance of motorbike couriers and the Royal Using charitable donations raised online, CCR was Free hospital. able to source a range of PPE such as masks, gowns, Patients in isolation can request an oximeter which visors and gloves and, to date, has distributed more is then delivered directly to their home. Once they’ve than 30,000 such items. been used, probes are returned to the Royal Free Since then, it has expanded into a number of other hospital where they are sterilised, checked and stored areas including partnering with a taxi firm to set up a ready to be sent out to the next patient in need. dedicated ‘COVID cab service’ for patients.

Dr Raymond says the probe-loaning service, which Patients attending COVID-19 ‘hot hubs’ are often covers the whole of London, has now been extended required to stay in their cars while they to places outside the capital such as are assessed or tested by staff in PPE. Kent and Bradford.

‘There was a Dr Raymond says this means homeless ‘We’ve got about 200 volunteer limited capacity for people and those without access to bikers who are willing to deliver probes ambulances, with personal vehicles can face problems 24/7 within one hour and 30 minutes when attending these sites. of a request being made direct to a some taking more This lack of access to personal patient’s doorstep or care home,’ than two hours’ transport also means that doctors are she says. having to make home visits or resort ‘While there has been recent NHS to ambulances at a time when operating on razor-thin guidance [for clinicians] on how to use oximeters it’s margins in terms of time and resources. important that the infrastructure is in place so that ‘I noticed in the course of my clinical work that there people can get hold of them, and I hope that this was a limited capacity for ambulances with some at service extends nationally to address that.’ times taking more than two hours to reach a patient Going strong when it would normally take 18 minutes,’ explains While social restrictions imposed by the national Dr Raymond. lockdown have started to be eased, Dr Raymond and ‘There are some patients who could potentially get CCR have lost none of their impetus. to hospital without needing an ambulance but who Following the Government’s announcement on did not have access to personal transport.

5 June calling for all staff across primary and secondary ‘I approached a cab firm and, after drawing up a care sectors to wear face coverings at all times, CCR was standard operating procedure, we now have the first able to donate 10,000 masks to 50 GP practices across cab service running throughout London.’ the country.

Using donations to CCR, cabs participating in the Looking to the future, CCR is hoping to work with scheme have been fitted with protective screens public health and rough sleeper services in the City and PPE, costs of journeys for patients unable to of London to run a pilot scheme aimed at testing afford them are also covered by donated funds. homeless people for the virus with the use of rapid Probe loan point-of-care tests.

Perhaps CCR’s most ambitious project to date, however, Dr Raymond will also be looking to launch a has been an oximeter loan service to patients, including telephone-based, peer-support service called those self-isolating, to allow remote monitoring of their ‘In your shoes’ for doctors at risk of burnout as a result oxygen levels. of the pandemic.

‘We were ordering these probes in and sending them ‘I find it hard to keep up with myself,’ she jokes. out but after a delivery of several hundred of these ‘[However] we can’t sit back. People have got needs probes, I realised that once given out it might take a and the situation is fluid and it’s about being able to while to obtain more given the strain on medical supply react quickly.’ chains,’ she says.

To find out more about CCR, visit www.justgiving.

‘I felt so strongly that we need to have more access com/crowdfunding/coronavirus-fightback clinical commissioning groups and NHS England, so I decided to set up these services myself.’

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ED MOSS

Lack of cover Haphazard Government planning has threatened the supply of face masks and left some doctors relying on donations.

Tim Tonkin reports

MILES: ‘We are asking patients to wear face coverings but are not mandating it’

‘The Government has failed to plan properly for these changes’

T

hroughout the world, masks and face coverings have arguably become the defining symbol of the COVID-19 pandemic.

While the advice from bodies such as the World Health Organisation as to whether or not healthy members of the public should use masks has evolved over time, the need for face coverings and PPE (personal protective equipment) in hospital and other healthcare settings has never been in doubt.

Indeed, much of the debate has centred around either the scandalous shortages or the inadequate quality of masks and other protective equipment, as the NHS has battled to stay on top

of the outbreak.

The announcement by health secretary Matt Hancock last month that all hospital staff in England would be required to wear surgical masks at all times, and irrespective of whether they were in a clinical environment, should therefore have been an unequivocally welcome one.

However laudable the intention, hard questions were soon being asked about how such a sweeping decree had been reached without any apparent consultation or even prior notification of employers or the medical profession.

Further questions about the extreme short notice given to trusts, just 10 days from the announcement to the implementation date, and the

logistics of meeting the new requirements soon followed.

Frustration with the lack of consultation and coordination in ushering in the new regulations was expressed by organisations such as NHS Providers and the BMA. ‘It is clear the Government has failed to plan properly for these changes which are now in effect and have left providers of NHS services confused and unprepared for how this will be implemented on the front line,’ says BMA council chair Chaand Nagpaul.

‘It is imperative that we do all we can to prevent the spread of infection in healthcare settings, so that patients and visitors can attend hospital and GP practices without fear of

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ED MOSS

NAGPAUL: ‘The Government has left providers of NHS services confused and unprepared’

WRIGLEY: Relied on mask donations from local retailer

contamination. The wearing of masks by staff and face coverings by the public will be key to enabling this.’

‘Adequate supply’

‘The wearing of masks by staff and face coverings by the public will be key’

Commenting last month, the Department of Health and Social Care has insisted it possesses an ‘adequate supply’ to meet the increased demand, adding that more than eight million masks had so far been delivered across England.

It confirmed that, under the new guidelines, hospital staff should wear masks in all areas of their workplace including break rooms but added that staff are permitted to remove masks to eat and drink as long as they adhere to social distancing.

This guidance also applies to primary care settings with GPs and pharmacists encouraged to wear masks when in waiting-room areas and where space constraints prevent social distancing.

Under the Government’s guidelines members of the public are ‘strongly urged’ to wear masks when attending hospital or GP surgeries, but ministers have made clear that patients who present without face coverings should not be denied treatment and that

hospitals should provide them with masks if necessary.

BMA council deputy chair and Lancashire GP David Wrigley, however, says his practice had been left scrambling to secure sufficient supplies of masks and was largely able to do so thanks to a donation of several hundred masks from a local retailer.

‘Given the last-minute announcement by Government, it left us in a very difficult situation with regards to face coverings for patients,’ he says.

Access to masks The BMA has called for the wearing of face masks by members of the public attending GP surgeries to be made compulsory and made clear that it is the Government’s responsibility to ensure the public can readily access masks for their own use, warning that hospitals and other healthcare settings cannot be expected to provide protection for staff and patients.

It is a position shared by Oxfordshire GP partner Helen Miles who, like Dr Wrigley, says there is no way her practice can cater for all patients when it comes to masks.

‘We are asking patients to wear face coverings but are not mandating it. We are also not mandating masks for staff when they are not in patientfacing roles and instead we are encouraging social distancing,’ she says.

‘We don’t feel we’ve got enough PPE to be able to give patients medical-grade masks, so if they turn up without a face covering then what do you do?’

She says the practice has been promoting the use of masks to its patients, and that the response and uptake of this has been broadly positive.

‘If a patient is coming to a COVID-19 clinic then we provide them with a surgicalgrade mask from the outset, but there’s just no way we’ve got supplies to be providing masks for every patient.’

Access to PPE for GPs and smaller healthcare providers is provided by an online portal. Practices are limited to ordering a single combined pack of PPE containing 100 type IIR masks, 200 aprons and 200 pairs of gloves, which are delivered within 48 to 72 hours.

Dr Miles feels, however, that this one-size-fits-all approach may not prove adequate under the new guidelines, thedoctor | July 2020 27

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iStock

‘We don’t feel we’ve got enough PPE to be able to give patients medicalgrade masks’

IZAGAREN: ‘Having colleagues in masks takes away a lot of the information’

particularly given that some practices’ PPE needs are much greater than others.

‘Things are better now than they were at the outset of the pandemic when we were relying on local dentists to supply us [with masks] or we would have run out without doubt,’ she says.

‘As each week goes by, we are seeing more and more patients face to face, so usage is going to be going up. It seems nonsensical to have a system whereby, whatever the size of your practice, you get the same amount of PPE supplied.’

Meeting the supply and demand of masks is not the only challenge now facing the NHS as a result of the new guidelines.

Surrey-based specialty trainee 5 in paediatrics Fizz Izagaren is deaf and relies on lip-reading in her day-to-day work and life.

She says that, while her trust has been supportive of her needs, the increased use of masks since the start of the pandemic has been challenging.

‘Having colleagues in masks takes away a lot of the information I would get in terms of communication so it’s very much about finding strategies to overcome the fact that lip-reading isn’t there,’ she says.

She says that while colleagues would be willing to lower their masks to talk when not around patients, emergency medical situations where everyone is wearing face coverings are particularly challenging.

‘Now that wearing masks is compulsory whether you’re in the corridor or the

canteen it is going to be really challenging,’ she adds.

The Government’s guidance allows exemptions from wearing masks for those with certain disabilities or who rely on lip-reading or other facial cues for communication. However, more must be done to develop alternatives to standard face masks too so that disabled people, their carers and those around them can minimise risks of infection.

For example, for its part, the BMA has endorsed calls for the introduction of transparent masks so that those who rely on facial cues for communication can do so without having to compromise their and others’ safety.

Dr Izagaren has been helping to lead a campaign for transparent masks to be made available to the NHS and the general public, as part of efforts to raise awareness of the effect of face coverings on the deaf community.

Having written to the Parliamentary health committee chair Jeremy

Hunt and NHS England chief executive Sir Simon Stevens about the effect of masks, Dr Izagaren says she was delighted to learn the NHS had agreed to a forthcoming pilot scheme using transparent masks imported from the USA. ‘It’s a misconception that face masks just impact on deaf people,’ she says.

‘Older patients with dementia if they don’t have the right sensory input, because they aren’t wearing their glasses or hearing aid, are more at risk of developing delirium,’ she adds.

‘It changes their behaviour and you may end up with a patient who you can’t communicate with because they are scared and unsure of the environment they’re in and this could be further exacerbated by the use of masks.’

To read more about the Government’s guidance on face masks in clinical settings, search for ‘COVID-19: infection prevention and control’ at www.gov.uk

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

Thousands of junior doctors are working longer and more anti-social hours during the pandemic. But one major employer failed to show them anything like the goodwill or flexibility that they have brought to tackling COVID-19 A group of junior doctors from foundation year 1 to specialty trainee 3 were given less than 48 hours’ notice that the medical work schedules and rotas were going to be changed.

They simply arrived at work to be told they would be working more long days, faced a huge increase in weekend on-call, and an increase in nights. All leave was cancelled.

Pay for the extra weekends would only be at the basic rate despite their colleagues receiving locum rates for similar work.

They felt let down by their employer, and also tired and demoralised. At least one registrar had gone on sick leave with stress.

The hospital had failed to consult or seek to agree changes with the trainees before the new rotas were introduced – totally against basic and established practice in employment relations. This requirement was written explicitly into the agreement which was soon afterwards signed by the BMA and NHS Employers. The agreement does allow for greater flexibility during this exceptional time but says clearly that employers should ‘continue to work in partnership with trainees and accredited trade union representatives when developing new patterns of working’ and ‘discuss proposed new patterns of work with affected trainees’.

The trainees got the BMA involved, which gathered details of those affected and quickly organised a meeting with the HR director.

This first meeting was not very helpful.

The employer said it had researched the pay arrangements at neighbouring hospitals and concluded it had come up with a fair deal.

The only offer was the additional 15 per cent weekend allowance for working more than one in two weekends, as per the existing junior doctor contract, but no extra pay for the additional hours worked.

The ‘research’ did not amount to much, given that in the very hospital where the meeting took place, there was a glaring inconsistency. Doctors in emergency departments had been treated very differently. They had been given the chance to volunteer for additional hours at the rates payable for those hours – rather than all being basic pay – and additional weekends to qualify for locum rates.

The BMA spoke to the trainees affected and confirmed this was not acceptable.

Its representative said there had been no consultation, that there was a clear and unfair disparity in terms and conditions and that goodwill across the trust was adversely affected.

She was successful. It was agreed that all pay was to be at the appropriate rate, all additional weekends were to paid at locum rates, and that they would qualify for the 15 per cent allowance if they worked more than one in two weekends. It meant hundreds of pounds of extra pay for the trainees and – just as importantly – a recognition that those giving exceptional service deserve a little respect from their employers. thedoctor | July 2020

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MATT SAYWELL

Baptism of fire It’s been quite a year for Tom Grinyer as the BMA’s new chief executive.

He describes how the pandemic has caused the association to work in different ways and help more members

GRINYER: ‘It’s been hugely democratising’

W

hen Tom Grinyer arrived at the BMA a year ago as the new chief executive, he could not have imagined what the association would be looking like now.

An increased membership, high media profile but the buildings in London, Edinburgh, Cardiff and Belfast almost empty. The 500 BMA staff working at home, blessing and occasionally cursing the technology which is enabling the association to carry on its work during the greatest public health emergency in living memory.

Mr Grinyer says the organisation has had to respond quickly to the pandemic as the different aspects of it became apparent, at times on a daily or hourly basis. From when there were some in government saying the approach should be based on herd immunity, to the scandalous shortages of PPE (personal protective equipment), to the concerns with testing, easing the lockdown, wearing face masks in public, and a dozen other issues.

He says this has been achieved by bringing together staff and members for regular, briskly paced online meetings. ‘What’s been crucial is bringing together doctors from across the branches-of-practice chairs, chief officers, subject matter experts, with staff from all levels of the organisation to coordinate our response.’

New working practices Mr Grinyer says this is not only efficient but – in an organisation which has historically been at times accused of being rather hierarchical – ‘it’s been hugely democratising because everyone is in an equal-sized square’ on the screen.

Just as the profession is doing, he says the BMA needs to look at what might be the positive legacy of the changed working practices. It’s not necessarily going to be a return to exactly the same situation.

‘We want to take the best, we want to take the learning, we want to take what works,’ he said.

The pressure to change will not come solely from a review of the different working practices, but from financial realities. While the BMA has welcomed several thousand new members during the crisis, it has also seen a severe drop-off in its events and learning and development income.

‘We are going to have to start a debate about what we do and how we do it better; as one member of staff said to me although we are further apart, we have never been closer together,’ he says. This might include online meetings being the norm rather than faceto-face, given that they have generally been thought to work well.

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BMA support to members, January to May

19,000 new cases

34,000 calls

3,200 web chats

Standing up for members

‘What’s been crucial is bringing together doctors from across the branches of practice’

‘Although we are further apart, we have never been closer together’

While there may be uncertainties ahead, one definite is that the BMA is probably busier than at any other time in its history. The figures for member support are striking. Between January and May, there were 19,000 new cases opened to support members, a 19 per cent increase on the same period last year. There were 34,000 calls (up 10 per cent) to the BMA’s support team, 12,500 emails (up 44 per cent) and 3,200 web chats (a 16 per cent increase).

Members expect the BMA to do a job for them, and often to take robust action on their behalf. Mr Grinyer says: ‘I’m really proud of the role we play – the muscle of the trade union, the solutions of the professional body. At a time when the issue of PPE was at its height, we were damned right to be raising that at the highest level. We also needed to support members so opened our support 24 hours, seven days a week.

‘As one BMA council member said, “if not us, who?”. All the other organisations out there, they may be campaigning organisations, but we have to hold that member’s perspective, negotiate as a trade union, guide as a professional body and get traction with the Governments of all our four nations, and still have that conversation the day after as well.’

With a background in civil service unions and medical royal colleges he is proud of the trade union and professional sides of the BMA – two facets it has had for decades and which have sometimes led members to feel they have to favour one side over another. But the pandemic has helped to dispel misconceptions that, the trade union side was ‘practical’ whereas the professional one somewhat more abstract and theoretical. He says he has received, for example, a great deal of praise for

12,500 emails

the robustness and practicality of the BMA’s ethics guidance.

Freedom to speak up Mr Grinyer arrived at the BMA during another very challenging time. Daphne Romney QC had been asked to conduct an independent review following reports of sexist behaviour by members.

The report spoke of the need for ensuring diversity and gender balance, for robust action to be taken against harassment, discrimination and bullying, and for a culture where bad behaviour could be called out.

Among many recommendations, Ms Romney said every committee member should undergo training in areas such as diversity, equality and anti-bullying.

He says: ‘This report was a backdrop to my appointment, and as soon as we received it I wanted to get out there and get on with tackling what was in it.’

Mr Grinyer points to the extensive training which has taken place, the wide-ranging debate around behaviours and the recent appointment of Mary Walsh as the BMA’s first freedom to speak up guardian.

What the Romney report spoke to was a change in the BMA’s culture. What she or anyone else could not have predicted is how profound that change in culture would be, thanks to the arrival of a certain virus.

He says the BMA has had to be fast, cohesive and effective, and that while it will always have more work to do in tackling discrimination in all its forms it has risen to the challenge. Keeping this legacy, once its exceptionally hard-working members rid Britain of the virus, will no doubt be his key priority.’ thedoctor | July 2020 31

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